Audit Project Odense Research Articles

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study.

Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs). This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes. A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements. A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025. This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention. DERR1-10.2196/60099.

Audit of Antibiotic Dispensing in Community Pharmacy (Happy Patient Project)

Dispensing and prescribing antibiotics is inappropriate in many of the countries in the European Union, including Spain, and a threat to the population's health. To tackle the growth of antimicrobial resistance, the Happy Patient project was set up under the sponsorship of the European Commission. O ascertain the characteristics of dispensing antibiotic therapy in Spanish community pharmacies.To compare the variability between different Spanish community pharmacies. The Audit Project Odense® methodology was used to find out how antibiotics were dispensed in community pharmacies. Pharmacists taking part were asked to record for five consecutive days between the months of February and April 2022 the actions performed during the dispensing of oral antibiotics for human use and for the treatment of acute infections. A total population of 573 patients (59.9% female) of all age groups were interviewed. The patients were 83.6% aware of the purpose for which the antibiotic was prescribed and the most requested antibiotic was amoxicillin followed by amoxicillin with clavulanic acid.In 15% of dispensations, a triple safety check was completed: interactions, contraindications and allergies. The pharmacist rarely contacted the prescriber but when she did, the prescriber altered the prescription.In 62.3% of cases, information about the duration of treatment was provided and amoxicillin with and without clavulanic acid was the antibiotic dispensed for which most warnings about side effects were issued. In 24.6% of dispensations there was no advice given at all. In 81.7% the pharmacist agreed with the prescribed treatment. This audit can be a starting point to improve clinical practice and reduce antibiotic resistance. It highlights the need for safety checks in regard to the use of antimicrobials and suggests verifying dispensing to correct errors that may jeopardize the safety and effectiveness of antimicrobial therapy.

Developing a Tool for Auditing the Quality of Antibiotic Dispensing in Community Pharmacies: A Pilot Study

The European Centre for Disease Prevention and Control describes the community pharmacist as the gatekeeper to the quality of antibiotic use. The pharmacist has the responsibility to guard safe and effective antibiotic use; however, little is known about how this is implemented in practice. To assess the feasibility of a method to audit the quality of antibiotic dispensing in community pharmacy practice and to explore antibiotic dispensing practices in Greece, Lithuania, Poland, and Spain. The Audit Project Odense methodology to audit antibiotic dispensing practice was adapted for use in community pharmacy practice. Community pharmacists registered antibiotic dispensing on a specifically developed registration chart and were asked to provide feedback on the registration method. Altogether, twenty pharmacists were recruited in four countries. They registered a total of 409 dispenses of oral antibiotics. Generally, pharmacists were positive about the feasibility of implementing the registration chart in practice. The frequency of checking for allergies, contraindications and interactions differed largely between the four countries. Pharmacists provided little advice to patients. The pharmacists rarely contacted prescribers. This tool seems to make it possible to get a useful picture of antibiotic dispensing patterns in community pharmacies. Dispensing practice does not seem to correspond with EU guidelines according to these preliminary results.

Health alliance for prudent prescribing and yield of antibiotics in a patient-centred perspective (HAPPY PATIENT): a before-and-after intervention and implementation study protocol

BackgroundExcessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections.Methods/designHAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit.DiscussionHAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics.Study registrationEU Health programmes project database https://webgate.ec.europa.eu/chafea_pdb/health/projects/900024/summary; date of registration: 1 January 2021.

How to improve practice by means of the Audit Project Odense method.

How to improve practice by means of the Audit Project Odense method.

C-reactive protein cut-offs used for acute respiratory infections in Danish general practice.

BackgroundGPs can use the C-reactive protein (CRP) point-of-care test (POCT) to assist when deciding whether to prescribe antibiotics for patients with acute respiratory tract infections (RTIs).AimTo estimate the CRP cut-off levels that Danish GPs use to guide antibiotic prescribing for patients presenting with different signs and symptoms of RTIs.Design & settingA cross-sectional study conducted in general practice in Denmark.MethodDuring the winters of 2017 and 2018, 143 GPs and their staff registered consecutive patients with symptoms of an RTI according to the Audit Project Odense (APO) method. CRP cut-offs were estimated as the lowest level at which half of the patients were prescribed an antibiotic.ResultsIn total, 7813 patients were diagnosed with an RTI, of whom 4617 (59%) had a CRP test performed. At least 25% of the patients were prescribed an antibiotic when the CRP level was >20 mg/L, at least 50% when CRP was >40 mg/L, and at least 75% when CRP was >50 mg/L. Lower thresholds were identified for patients aged ≥65 years and those presenting with a fever, poor general appearance, dyspnoea, abnormal lung auscultation, or ear/facial pain, and if the duration of symptoms was either short (≤1 day) or long (>14 days).ConclusionMore than half of patients presenting to Danish general practice with symptoms of an RTI have a CRP test performed. At CRP levels >40 mg/L, the majority of patients have an antibiotic prescribed.

Introducing point-of-care ultrasound in Danish general practice—elucidating the use through a medical audit

Point-of-care ultrasonography (PoCUS) is increasingly used across the medical field. PoCUS is also being implemented in general practice despite a lack of clinical guidelines and training programs for general practitioners (GPs). This study aimed to elucidate the employment of PoCUS by Danish GPs following a short training program. Thirty GPs were enrolled in a short ultrasound training program and taught how to perform 22 selected scanning modalities. In the following 3 months, the GPs registered all performed PoCUS examinations according to the Audit Project Odense method. After 5 months, the GPs were invited to participate in an evaluation seminar, where questionnaires were distributed. During the registration period, 1598 patients were examined with PoCUS. A total of 1948 scanning modalities were registered, including 207 examinations outside the taught curriculum. The majority of the ultrasound examinations were performed within 10 minutes (89%), most were considered to be conclusive (87%) and/or to increase diagnostic certainty (67%), whereas one in four examinations entailed a change in patient management. Most GPs attending the evaluation seminar continued to use PoCUS and found the scanning modalities included in the course curriculum relevant in their daily work. The GPs found several indications for performing PoCUS following the attendance of a 2-day basic training program. The majority of examinations were registered to be conclusive and/or increase diagnostic certainty. However, few GPs used PoCUS on a daily basis and not all examinations were registered to have an impact on patient care.

Danish GPs’ and practice nurses’ management of acute sore throat and adherence to guidelines

Sore throat is a frequent presentation of acute respiratory tract infections in general practice. Though these infections are often harmless and self-limiting, antibiotics are frequently prescribed. In Denmark, practice nurses manage an increasing part of patients with acute minor illnesses. We aimed (i) to investigate Danish practice nurses' and GPs' management of patients presenting with a sore throat and (ii) to explore to what extent management is according to current Danish guidelines. A cross-sectional study was conducted during winter 2017, involving GPs and practice nurses in Danish general practices. Patients with a sore throat were registered according to the Audit Project Odense method. A total of 44 practices participated with the registration of 1503 patients presenting with a sore throat. Most patients had a strep A test performed, especially when managed by a practice nurse (84.6% versus 61.8%, χ2 = 90.1, P < 0.05). In total, 40.6% of performed strep A tests were not according to guideline recommendations. Antibiotics were prescribed for about one-third of patients, regardless whether managed by a practice nurse or a GP (χ2 = 0.33, P = 0.57). However, 32.4% of these prescriptions were not in line with Danish guidelines. Patients with acute sore throat were managed similarly by GPs and practice nurses, apart from a higher use of strep A tests in patients seen by practice nurses. Importantly, this study demonstrated that there is still room for improvement of the management of these patients in Danish general practice.

Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: Comparison between Denmark and Iceland

Objective: To compare the appropriateness of antibiotic prescribing for upper respiratory tract infections (URTIs) in two countries with different prevalence of antimicrobial resistance: Denmark and Iceland.Design: A cross-sectional study. Settings and subjects. General practitioners (GPs) in Denmark (n = 78) and Iceland (n = 21) registered all patients with URTI according to the Audit Project Odense (APO) method during a three-week period in the winter months of 2008 and 2009.Main outcome measures: Appropriateness of antibiotic prescribing in patients with URTI in Denmark and Iceland.Results: A total of 1428 patients were registered (Denmark: n = 1208; Iceland: n = 220). A majority of patients in both countries were prescribed antibiotics, and only a minority of the prescriptions could be classified as appropriate prescribing. In general, Icelandic GPs more often prescribed antibiotics (Iceland = 75.8% vs. Denmark = 59.3%), but Danish GPs had a higher percentage of inappropriate antibiotic prescribing for sinusitis, and Icelandic GPs for pharyngotonsillitis. No differences were found for acute otitis media (AOM). The different antibiotic prescribing patterns between Denmark and Iceland could not fully be explained by different symptoms and signs among patients.Conclusion: Icelandic GPs have a higher antibiotic prescribing rate compared with Danish GPs, but the percentage of inappropriate antibiotic prescribing is highest in Denmark for sinusitis, and in Iceland for pharyngotonsillitis.Key pointsWithin the Nordic countries there are marked differences in antimicrobial resistance and antibiotic use.Iceland differs from Denmark by a higher antibiotic prescribing rate and a higher prevalence of antimicrobial resistance.The majority of antibiotics are prescribed in primary care and most often for upper respiratory infections (URTIs).Only a minor amount of antibiotic prescriptions for URTIs can be classified as appropriate; inappropriate antibiotic prescribing is higher in Denmark than in Iceland for sinusitis and the opposite for pharyngotonsillitis.The different antibiotic prescribing patterns between Denmark and Iceland cannot be fully explained by different clinical criteria among patients.

Antibiotics and near-patient testing: Differences in habits between physicians completing or discontinuing a medical audit

Background and Aim: Respiratory tract infection (RTI) is a common reason for consulting primary health care. Antibiotic prescribing for RTIs varies among physicians indicating that national guidelines are not always adhered to. The aim was to study if antibiotic prescribing and use of near-patient tests were different among physicians who complete an audit registration and those who discontinue their participation. Method: A prospective cohort study where physicians participated in an APO (Audit Project Odense) process, making an audit registration for every appointment with a patient who had a respiratory tract infection during 4 weeks in 2008 and 4 weeks in 2009. Between the registrations, a limited educationally oriented intervention was made. 18 Primary Health Care Centres located in three counties in southern of Sweden with 77 primary health care physicians participated. When comparing proportions the Chisquare test was used. Mann Whitney U-test was used when comparing independent groups and Wilcoxon’s signed-rank test was used when comparing dependent groups. Results: Of the 77 physicians, 38 participated only at baseline (group 1) and 39 participated in both registrations (group 2). The overall use of CRP near-patient tests was 37% in group 1 and 28% in group 2 (Chisquare p pharyngitis/tonsillitis, antibiotics were prescribed to 45% in group 1 and to 12% by group 2 (Chisquare 0.003). Conclusion: In conclusion, this study showed that physicians, who were more inclined to complete audit participation, used near-patient tests and prescribed antibiotics more correctly, according to the national guidelines for respiratory tract infections, than physicians who discontinued the participation. To achieve a rational use of antibiotics, near-patient tests and prescription of antibiotics must be used according to guidelines.

Can the APO method be used for measuring soft data?: A pilot study

Objectives. The aims were to develop auditing according to the APO (Audit Project Odense) method for measuring soft data, exemplified by a holistic view, and to test the instrument. Design. A descriptive study of the development of an APO chart and a test registration. Setting. Primary health care, Blekinge County, Sweden. Subjects. Ten general practitioners (GPs) were invited to transform categories of the concept of a holistic view obtained in an earlier study, into 30 variables on an APO registration chart. The participants chose to study different kinds of knowledge as aspects of holistic care. Main outcome measure. An APO registration chart and test of the instrument. Results. After three meetings the group had drawn up an APO registration chart supplemented with Likert scales. A pilot audit was performed. Eight doctors registered 255 consultations. In assessment of the patients’ problems, factual medical knowledge was important in 83% of the cases, familiarity in 53%, and a capacity for judgement in 36%. In decision-making factual medical knowledge was used in 88% and capacity for judgement in 58%. A holistic view was necessary for the outcome in 43% and valuable in 25%. The GPs used the Likert scales in a majority of the cases. Conclusions. In this first step in developing an instrument, the results indicate that the APO method could be an alternative for studying what happens in the consultation, and the occurrence of an abstract phenomenon such as the use of different kinds of knowledge as part of a holistic view.

Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT)

BackgroundExcessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries.The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina).Methods/DesignHAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPs'surgeries.To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period.DiscussionHAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs' diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.

A multifaceted intervention according to the Audit Project Odense method improved secondary prevention of ischemic heart disease: a randomised controlled trial

No single quality improvement instrument has proved consistently effective, but multifaceted interventions are believed to have the greatest impact. However, only little is known regarding what combinations are likely to be successful. To evaluate the impact of a multifaceted intervention strategy combining GP registrations, outreach visits and feedback, targeting secondary prevention of ischemic heart disease in general practice. A randomised controlled trial including 28 GPs in Ringkjøbing County, Denmark. Half of the GPs received outreach visits and feedback on their prescribing of heart disease drugs. Evaluation was based on registration of consultations with patients suffering from ischemic heart disease. The intervention had a statistically significant impact on prescribing of lipid lowering drugs [odds ratio 1.59; 95% confidence interval (CI) 1.00 to 2.53] and acetylsalicylic acid (odds ratio 2.54; 95% CI 1.21 to 5.31). An intervention strategy combining outreach visits, feedback and GP registrations is a promising way of improving the quality of preventive treatment in general practice.

Respiratory tract infections in Greenland: results of an audit project

Objectives. To elucidate and improve quality of diagnosis and treatment of respiratory tract infections in Greenland. Study design. All district medical officers and nursing staff in the Greenlandic coastal health services were invited to participate in the study. Twenty-five district medical officers and the nursing staff from nine districts completed the project and registered in a 3-week period 1,163 contacts involving respiratory tract infections. Methods. Self-registration according to the Audit Project Odense (APO) method on a simple APO registration chart. All contacts involving respiratory tract infections were registered with regard to sex, type of contact, contact form, infection focus, diagnosis and treatment, origin of infection, antibiotic treatment, choice of antibiotics and possible sick-leave. Results. Of the 1,163 registered contacts lung infections represented 26%, throat infections 22% and otitis media 16%. Paraclinical tests were performed in 32% of the cases, 47% of the cases were treated with antibiotics, in 2/3 of the cases with penicillin V. The use of paraclinical tests was somewhat lower and the use of antibiotics was higher than in Denmark. Conclusion. The study showed that it is possible to carry out an APO audit in Greenland, and that there was a moderate difference in the diagnosis and treatment between Greenland and Denmark. An increased use of paraclinical tests may result in quality improvement.

Methodological problems in comparing audits from the Nordic countries. A critical review of results from audit on Nordic general practitioners' management of patients with psychiatric problems

In 1998, an audit on psychiatric problems in general practice was conducted in four Nordic countries. Five-hundred-and-sixty general practitioners participated and made registration according to the Audit Project Odense method. This paper describes the methodological problems related to international differences in the organisation of health care, recruitment of general practitioners and the registration of contacts. Nordic differences in this audit gave rise to inspiring discussions at national meetings, but methodological problems remain to be resolved if the results are to prove useful in scientific reporting.

Long-lasting improvement in general practitioners' prescribing of antibiotics by means of medical audit

Objective - To evaluate the usefulness of medical audit of GPs' antibiotic prescription habits. Design - Medical audit according to the APO method. Registration of antibiotic prescriptions for respiratory tract infections during a 3 year period. Intervention with courses, visits to the laboratory, and distribution of recommendations concerning diagnosis and treatment of respiratory infections. Setting - 24 Danish GPs in cooperation with Audit Project Odense (APO) and Department of Clinical Microbiology, Odense University Hospital. 207 GPs acted as controls. Main outcome measures - Changes in the number of antibiotic prescriptions and in the penicillin/broad-spectrum antibiotic ratio. Results - The proportion of antibiotic prescriptions was reduced during the investigation period, but a similar reduction was found in the control groups. Only for acute sinusitis was a lasting decrease not found in the control groups recorded. The penicillin/broad-spectrum antibiotic ratio increased in the intervention group (1.33 in 1992, 1.94 in 1993 and 2.70 in 1995). This increase was significantly higher than in the control groups. The change was seen for acute sinusitis, bronchitis, and pneumonia, but not for acute otitis media or acute tonsillitis. The changes induced from 1992 to 1993 were maintained or increased from 1993 to 1995 although the educational measures had stopped. Conclusion - Medical audit according to the APO method is a useful tool for inducing and maintaining desirable changes in GPs' prescription habits.

Medical audit changes physicians' prescribing of antibiotics for respiratory tract infections

Objective - To reduce the prescribing of antibiotics in respiratory tract infections (RTI). Design and subjects - The Audit Odense model for registration and quality development was used for RTI. Twenty general practitioners registered their consultations for RTIs during 4 weeks in February-March (n=1124) and November-December (n=926) in 1995. Diagnosis, choice of antibiotics and diagnostic tools were registered. In between the two registrations an active intervention took place. Consultations for RTIs among 25 physicians (who had not participated in any intervention or follow-up discussion) served as a control. Setting - General practice in southern Sweden. Outcome measures - Prescribing of antibiotics before and after an intervention. Results - The proportion of patients not receiving an antibiotic increased from the first to the second registration in both groups, in the intervention group from 45 to 55% (p<0.001) and in the control group from 36 to 40% (p=0.0298). The reduction was most evident in patients diagnosed with tonsillitis and bronchitis. This was in concordance with an increase in the use of desktop diagnostics (Strep A and CRP). Conclusion - These results indicate that it is possible to achieve a change in the utilisation of antibiotics in the treatment of RTIs and that the Audit Project Odense (APO) model could be a valuable tool.