Effective Stewardship Research Articles

Impact of a Community Pharmacy Pharmacotherapy Follow-up (PTF) service in patients using opioid analgesic

The use of prescribed major opioid analgesics (fentanyl, tapentadol, morphine and oxycodone and combinations) for non-cancer chronic pain is fraught with risks that may generate Negative Medicine Outcomes (NMO). Among the factors associated with these risks, those related to the patient's characteristics and aberrant behavior, the treatment conditions, and the prescription health settings should be evaluated with the aim of minimizing unsafety during the health care process. The present study addresses, from a community pharmacy, the analysis of Drug Related Problems (DRP) and Negative Medicine Outcomes (NMO) in patients using these major opioid analgesics while it aims to demonstrate the role of pharmaceutical care interventions in promoting safety during the use of these molecules. A three step Pharmacotherapeutic Follow-up (PFT) protocol was designed to prevent, detect, and solve DRP and NMO associated with the use of opioid analgesics. 74.6% of the patients used opioid analgesics to treat musculoskeletal pain. Polypharmacy with benzodiazepines (61.9%); antidepressants (57.1%) and antiepileptics (30.2%) was detected in patients using these opioids. The Morisky-Green Adherence test revealed that 30.2% were nonadherent. It was observed, with statistical significance, that in all patients (63), the impact of the 14-week PFT supervised by the community pharmacist achieved an overall reduction in the prevalence of DRP and NMO. While the reduction in the number of DRPs reached 66.7%. Community pharmacies are a strategic point to promote and implement effective opioid stewardship due to both their central role in healthcare services and frequent interaction with patients.

First global report about the prevalence of multi-drug resistant Haemophilus influenzae: a systematic review and meta-analysis

BackgroundIn recent decades, the prevalence of antibiotic resistance is increasing in Haemophilus influenzae (Haemophilus influenzae), which poses important challenges to global health. This research offers a comprehensive meta-analysis of the global epidemiology of multi-drug resistant (MDR) H. influenzae.MethodsIn this study, we conducted a meta-analysis based on PRISMA checklist. Electronic databases including PubMed, ISI Web of Science, Scopus, EMBASE, and Google Scholar were reviewed using keywords related to H. influenzae and antibiotic resistance. Eligible studies were selected based on stringent inclusion and exclusion criteria. Then, data from these studies were analyzed using the Comprehensive Meta-Analysis (CMA) software.ResultsOf 375 retrieved articles, 16 met the inclusion criteria. These studies were conducted from 2003 to 2023 and analyzed data from 19,787 clinical isolates of H. influenzae. The results showed different levels of resistance of H. influenzae to different antibiotics: ampicillin (36%), azithromycin (15.3%), ceftriaxone (1.4%), etc. The global prevalence for beta-lactamases producing H. influenzae and MDR H. influenzae was measured 34.9% and 23.1%, respectively. The prevalence rate of MDR H. influenzae was higher in Asian countries (24.6%) compared to Western regions (15.7%). MDR H. influenzae had the highest prevalence in meningitis cases (46.9%) and the lowest prevalence in acute otitis media (0.5%).ConclusionsThe prevalence of MDR H. influenzae has been increasing worldwide, especially in Asian regions. This highlights the urgent need for monitoring and implementation of effective antibiotic stewardship programs globally.

Selection of new pathogens during antibiotic treatment or prolonged antibiotic prophylaxis in orthopedic surgery

In orthopedic surgery regarding open or infected wounds, both the current antibiotic therapy as well as the perioperative antibiotic prophylaxis, may select new pathogens leading to iterative debridement and changing the antibiotic regimens targeting more resistant microorganisms. The risk of finding new and more resistant pathogens is relatively high (5%-15%) and exceeds the incidence of primary surgical site infections (SSI) after elective orthopedic surgery with primary wound closures. Based on a narrative review of the current scientific literature, we summarize mechanisms and associations of such a pathogen selection by therapeutic or prophylactic agents and focus on the importance of an adequate initial debridement and on an effective antibiotic stewardship.

Analyzing the relationship between socioeconomic deprivation and outpatient Medicare Part D fluoroquinolone claim rates in Texas.

Only a few studies have assessed the relationship between deprivation and excessive antibiotic use. In Texas, antimicrobial prescription rates are particularly high compared with the rest of the US. This study analyzed the association between local area socioeconomic deprivation and providers' fluoroquinolone claim rates among beneficiaries 65 years and older in Texas. This ecological study utilized provider- and area-level data from Medicare Part D Prescribers and the Social Deprivation Index (SDI) repositories. Negative binomial regression models were employed to evaluate the relationship between provider- and area-level characteristics (prescriber's gender, specialty, rural-urban community area, beneficiaries' demographics, area-level population, and SDI) and fluoroquinolone claim rates per 1,000 beneficiaries. A total of 11,996 providers were included. SDI (IRR 0.98, 95% CI 0.97-0.99) and male providers (IRR 0.96, 95% CI 0.94-0.99) were inversely associated with claim rates. In contrast, several factors were associated with higher claim rates, including non-metropolitan areas (1.04, 95% CI 1.00-1.09), and practices with a high proportion of male (IRR 1.12, 95% CI 1.10-1.14), Black (IRR 1.05, 95% CI 1.03-1.07), or Medicaid beneficiaries (IRR 1.15, 95% CI 1.12-1.17). Effect modification was observed between SDI and rurality, with higher SDI in non-metropolitan areas associated with higher claim rates, whereas SDI in metropolitan areas was inversely related to claim rates. Lower fluoroquinolone claim rates were observed among Texas Medicare providers in metropolitan areas with higher SDI. Conversely, higher rates were observed in rural areas with higher SDI. More studies are needed to understand the underlying causes of this variation and develop effective stewardship interventions.

Digital transformation and data ecosystem: implications for policy actions and competency frameworks

The article discusses EU policy for digital transformation and the associated development potential. The article aims to critically analyse the current progress of the operationalisation and implementation of the relevant policies. It is followed by the recognition of the challenges that can contribute negatively to the necessary strategic objectives and obstacles that may hinder reaching the policy goals. In particular, a significant obstacle may be a major deficiency of adequately prepared experts ready to work in new roles in a dynamically developing data ecosystem. A remarkable example is the role of the Data Steward. This role is essential for fostering the rapid development of the data ecosystem in the EU. We propose creating a universal competence framework for Data Stewards to streamline human resource allocation. The article proposes a basic outline of the necessary skills and competencies ensuring effective data stewardship.

Comparison of CSF Lactate and Serum Procalcitonin in Diagnosing Pyogenic Meningitis

Background: Meningitis, a potentially life-threatening inflammation of the meninges, poses diagnostic challenges, particularly in differentiating bacterial meningitis (BM) from other forms. The identification of effective biomarkers is crucial for accurate diagnosis and treatment. Objective: This study aimed to evaluate the diagnostic utility of cerebrospinal fluid (CSF) lactate levels and serum procalcitonin (PCT) in distinguishing BM from tuberculous and viral meningitis. Methods: Conducted at the Neurology Department of Pak Emirates Military Hospital from February to May 2023, this observational study included 55 patients, with a mean age of 44.03 years. Patients were selected based on clinical signs and symptoms of meningitis, with those having received prior antibiotic treatment excluded. CSF and serum PCT levels were measured, and statistical analyses were performed to compare these biomarkers across different meningitis etiologies. Results: Of the 55 patients, 30 (54.50%) were diagnosed with BM, 15 (27.30%) with viral meningitis, and 10 (18.20%) with tuberculous meningitis. The mean CSF lactate level in BM patients was 9.36 ± 7.95 mmol/L, significantly higher than in non-bacterial cases. Similarly, serum PCT levels were markedly elevated in BM patients (24.05 ng/ml ± 39.82 ng/ml). The study found a strong correlation between elevated CSF lactate and serum PCT levels with the diagnosis of BM (P < 0.05). Conclusion: CSF lactate levels and serum PCT are reliable biomarkers for diagnosing BM. Their elevated levels in BM patients compared to those with tuberculous or viral meningitis can assist in accurate and timely diagnosis, contributing to improved patient outcomes and effective antibiotic stewardship.

Data Stewardship – Austrian National Strategy and Alignment

Within the FAIR Data Austria project, supported by the Federal Ministry for Education, Science, and Research (BMBWF), a national strategy has been established to advance the creation of tailored Data Stewardship solutions for the Austrian context. The strategy, formalized as a toolbox, delineates various Data Steward models, corresponding competencies, and accessible training resources. Despite the crucial role of Data Stewardship in supporting data-driven scientific research, Austrian universities encounter challenges in its implementation. Issues include lack of consensus on the skills, roles, and responsibilities of Data Stewards, coupled with insufficient funding for these positions. This article explores these challenges and emphasizes the importance of addressing them to promote effective Data Stewardship within the Austrian academic landscape.

Utility of Vizient Clinical Data Base as a benchmarking tool for laboratory stewardship programs

Abstract Establishing an effective laboratory stewardship program across healthcare systems to improve patient care has been of growing interest. Despite general guidelines from various organizations, clear definitions for these laboratory-based quality measures, and associated benchmarks, are still lacking. Hence, we utilized Vizient® Clinical Data Base (CDB) as a tool to benchmark our institution against U.S. News and World Reports’ Honor Roll (USNW) healthcare organizations 2021-2022. We focused on inpatient laboratory testing with specific targets including mean laboratory resource units used per patient per day to obtain an overview of our institution’s overall performance, daily basic metabolic panel and CBC test ordering patterns across various service lines, and C-reactive protein (CRP) to erythrocyte sedimentation rate (ESR) order ratios compared to USNW hospitals. As one of the five institutions with the highest mean laboratory resource units used per case per day (12.7) from January 1, 2021-January 31, 2022, we investigated this further to identify tests driving this result. Of all the laboratory tests ordered, blood gas was identified at the 99th percentile compared to peers. Stratifying by service, we found cardiac surgery (17%), general medicine (15%), pulmonary/critical care (11%), neonatology (10%) and transplant (9%) services at our institution were the major contributors to blood gas orders. Investigating daily laboratory test orders (BMP, CBC) showed that our institution was at the 46th and 71st percentile overall, respectively. Further CBC analysis showed that general medicine (28%) and oncology (11%) services were the major contributors for the test volume and highest total resource units used per quarter in 2021. Assessing CRP to ESR ratio depicted that our institution’s ratio of 2.2 was lower compared to USNW hospitals’ average of 2.9, meaning ESR is likely overutilized. In conclusion, Vizient CDB can be used as a resource for benchmarking laboratory utilization patterns. It can be helpful in developing road maps and prioritizing interventions for lab stewardship programs. This study identified a general overuse of laboratory resources at the hospital compared to peers, and identified some intervention targets including blood gas testing and ESR.

Acinetobacter baumannii: assessing susceptibility patterns, management practices, and mortality predictors in a tertiary teaching hospital in Lebanon

BackgroundAcinetobacter baumannii is a major nosocomial pathogen capable of causing life-threatening infections. This bacterium is highly resistant to antibiotics and associated with high mortality rates. Therefore, this study aimed to evaluate A. baumannii's susceptibility patterns to antimicrobials, assess the appropriateness of the initiated antimicrobial therapy, determine the mortality rate, and identify predictors associated with mortality.MethodsA retrospective observational study was conducted among patients infected with A. baumannii at a university hospital in Lebanon through the revision of medical records. Kaplan–Meier survival analysis and log-rank tests were used to analyze time-to-mortality. Binary logistic regression was performed to identify predictors of mortality.ResultsThe records of 188 patients were screened, and 111 patients with A. baumannii infection were enrolled. Almost all isolates were resistant to carbapenem, and 43% of the isolates were extensively-drug resistant. Almost half of the patients received initial inappropriate antimicrobial therapy (n = 50, 45.1%). The 30-day mortality rate associated with A. baumannii infection was 71.2% (79/111). The time to mortality in patients who received inappropriate antimicrobial therapy (5.70 ± 1.07 days) was significantly shorter than in those who received appropriate antimicrobial therapy (12.43 ± 1.01 days, P < 0.01). Binary logistic regression revealed that inappropriate antimicrobial therapy (adjusted odds ratio [AOR] = 16.22, 95% CI 2.68–9.97, P = 0.002), mechanical ventilation (AOR = 14.72, 95% CI 3.27–6.61, P < 0.001), and thrombocytopenia (AOR = 8.82, 95% CI 1.12–9.75, P = 0.003) were more likely associated with mortality.ConclusionsA. baumannii exhibits an alarming mortality rate among infected patients. Thrombocytopenia, mechanical ventilation, and inappropriate antibiotic administration are associated with mortality in patients infected with A. baumannii. The prompt initiation of appropriate antimicrobial therapy, infection control measures, and effective stewardship program are crucial to reduce the incidence of A. baumannii and improve the treatment outcomes.

Bacterial abundance and antimicrobial resistance patterns of uropathogens among pregnant women with asymptomatic bacteriuria: Association with glycemic status

ObjectivesAntimicrobial resistance (AMR), a growing global menace, poses a significant threat to maternal and fetal health. Gestational diabetes mellitus (GDM) causes double trouble in pregnancy, increasing the risk of a variety of infectious morbidities while also raising the possible association with AMR. Asymptomatic bacteriuria (ASB) is a common problem in pregnancy, but little research has been done to date explicitly examining the relationship between GDM and ASB and yielded conflicting results. Even fewer studies have specifically examined the relationship between GDM and AMR in women with ASB. Retrieving the most recent information on the disease burden, the range of causative pathogens, their patterns of AMR, and associated risk factors in pregnant women is crucial to stop the exponential rise in AMR in pregnancy and improve maternal and neonatal outcomes of infectious morbidities. Hence, this study was planned to investigate the association between glycemic status and the contemporary bacterial profile, antimicrobial resistance(AMR), and associated variables among pregnant women with ASB Study designThis prospective, hospital-based, cross-sectional study was conducted among 320 pregnant women; divided into two groups, GDM and non-GDM. Data regarding sociodemographic and clinical characteristics were collected using a structured questionnaire. Clean-catch midstream urine samples were investigated for the presence of significant bacterial uropathogens and their AMR pattern was determined using recommended culture methods. ResultsWe found ASB in 46.25% of study participants with significantly higher occurrence in the GDM group. Dominant isolates were Escherichia coli followed by Klebsiella pneumoniae. AMR was noted in 51.35% and multidrug resistance(MDR) in 23.65% of isolates. Overall AMR, MDR and higher degrees of AMR were higher among uropathogens isolated from the GDM group as compared to the non GDM group, although the difference was not statistically significant. ConclusionThe high occurrence of ASB in pregnancy along with substantially high AMR in this study suggests the need for effective infection control and stewardship programmes. By defining the association of ASB and AMR with hyperglycemia, our study calls for the exploitation of this potential association in halting the pandemic of AMR and in improving the management of infectious morbidities, thus in-turn alleviating their undesired maternal and infant outcomes.

1274. Long-term Sustainability of Improvements in Antibiotic Prescribing for Inpatient Skin and Soft Tissue Infections after Implementation of Local Treatment Guidelines

Abstract Background Institutional guidelines for the management of inpatient skin and soft tissue infections (SSTIs) were implemented at an academic public safety-net hospital in 2009. This led to an immediate and marked decrease in unnecessary use of broad-spectrum antibiotics and durations of therapy. The objective of this study was to determine if these changes in prescribing have been sustained over time. Methods This was a retrospective review of patients hospitalized with cellulitis or abscess at Denver Health Medical Center between July 2016 and August 2022 (maintenance period). Case identification and data collection methods were identical to those used in a previous publication describing pre-intervention (January to December 2007) and intervention (July 2009 to July 2010) period data. The main outcomes were the proportion of patients exposed to an antibiotic with broad-spectrum gram-negative or antipseudomonal activity and the median duration of therapy. Results A total of 186 patients from the maintenance period were included for comparison with those from the pre-intervention (n = 169) and intervention (n = 175) periods. In the maintenance period, the median patient age was 41 years and 74% were male. The most common comorbid condition was injection drug use (27%). Overall clinical characteristics were similar between the three periods. The proportion of patients exposed to an antibiotic with broad gram-negative activity was 66% during the pre-intervention period, 33% during the intervention period, and 27% during the maintenance period. The proportion of patients exposed to an antibiotic with antipseudomonal activity was 28%, 18%, and 16% during the pre-intervention, intervention, and maintenance periods, respectively. The median total duration of therapy was 13 (IQR 10-15), 10 (IQR 9-12), and 8 (IQR 7-10) days in the pre-intervention, intervention, and maintenance periods, respectively. Conclusion Reductions in use of broad-spectrum antibiotics and durations of therapy for inpatients with SSTIs were sustained 12 years after implementation of a local treatment guideline. These findings add to the evidence that local guidelines are an effective antibiotic stewardship tool and demonstrate that resultant improvements in prescribing can be sustained over prolonged periods. Disclosures Timothy C. Jenkins, MD, Basilea: Clinical events adjudication committee

Airborne laser scanning to optimize the sampling efficiency of a forest management inventory in South-Eastern Germany

Effective forest stewardship relies on comprehensive field-inventories describing forest resources. Increasing demands for data and indicators that improve understanding of climate change impacts, timber production, and ecosystem processes make access to robust field inventories crucial. A trade-off between cost and statistical efficacy exists however, necessitating that practitioners be familiar with the spatial and structural composition and variability of their management areas. Remotely sensed data, like airborne laser scanning (ALS), can improve data availability and sampling efficiency. In this study, we simulate sampling approaches and provide an indication of the benefits of incorporating ALS-derived auxiliary data. We evaluate the ability of sub-samples from an existing field-inventory to accurately estimate ALS structural metrics. Additionally, we explore data-driven approaches to allocate new field plots, reducing bias and improving accuracy. The Monte Carlo simulation compared the local pivotal method (LPM), Latin hypercube sampling (LHS), and simple random sampling (SRS) at a variety of sample sizes. Precision and variability measures were used to comparatively assess the efficacy of sampling method and sample size. Results demonstrate the value of ALS as an auxiliary dataset, with LPM and LHS achieving sampling efficiencies over SRS of up to 88.6% and 94.3%, respectively. By applying the adapted Latin hypercube evaluation of a legacy sample (AHELS) algorithm, we reduced the mean average percent deviation (MAPD) by over 20% between sample measures and wall-to-wall ALS metrics. These methods can aid practitioners in planning cost-effective and statistically rigorous forest inventory campaigns, particularly in determining where to re-sample within an existing plot network.

Why local antibiotic resistance data matters – Informing empiric prescribing through local data collation, app design and engagement in Zambia

BackgroundControl of antimicrobial resistance (AMR) relies on local knowledge and local intervention implementation. Effective antibiotic stewardship requires locally-suitable prescribing guidelines. We aimed to use a novel digital tool (the ZARIApp) and a participatory approach to help develop locally-relevant empiric antibiotic prescribing guidelines for two hospitals in Lusaka, Zambia. MethodsWe produced an AMR report using samples collected locally and routinely from adults within the prior two years (April 2020 – April 2022). We developed the ZARIApp, which provides prescribing recommendations based on local resistance data and antibiotic prescribing practices. We used qualitative evaluation of focus group discussions among healthcare professionals to assess the feasibility and acceptability of using the ZARIApp and identify the barriers to and enablers of this stewardship approach. ResultsResistance prevalence was high for many key pathogens: for example, 73% of 41 Escherichia coli isolates were resistant to ceftriaxone. We identified that high resistance rates were likely due to low levels of requesting and processing of microbiology samples from patients leading to insufficient and unrepresentative microbiology data. This emerged as the major barrier to generating locally-relevant guidelines. Through active stakeholder engagement, we modified the ZARIApp to better support users to generate empirical antibiotic guidelines within this context of unrepresentative microbiology data. Qualitative evaluation of focus group discussions suggested that the resulting ZARIApp was useful and easy to use. New antibiotic guidelines for key syndromes are now in place in the two study hospitals, but these have substantial residual uncertainty. ConclusionsTools such as the free online ZARIApp can empower local settings to better understand and optimise how sampling and prescribing can help to improve patient care and reduce future AMR. However, the usability of the ZARIApp is severely limited by unrepresentative microbiology data; improved routine microbiology surveillance is vitally needed.

Approach to diagnostic evaluation and prevention of invasive fungal disease in patients prior to allogeneic hematopoietic stem cell transplant.

In recent years, advancements in the treatment landscape for hematological malignancies, such as acute myeloid leukemia and acute lymphoblastic leukemia, have significantly improved disease prognosis and overall survival. However, the treatment landscape is changing and the emergence of targeted oral therapies and immune-based treatments has brought forth new challenges in evaluating and preventing invasive fungal diseases (IFDs). IFD disproportionately affects immunocompromised hosts, particularly those undergoing therapy for acute leukemia and allogeneic hematopoietic stem cell transplant. This review aims to provide a comprehensive overview of the pretransplant workup, identification, and prevention of IFD in patients with hematological malignancy. The pretransplant period offers a critical window to assess each patient's risk factors and implement appropriate prophylactic measures. Risk assessment includes evaluation of disease, host, prior treatments, and environmental factors, allowing a dynamic evaluation that considers disease progression and treatment course. Diagnostic screening, involving various biomarkers and radiological modalities, plays a crucial role in early detection of IFD. Antifungal prophylaxis choice is based on available evidence as well as individual risk assessment, potential for drug-drug interactions, toxicity, and patient adherence. Therapeutic drug monitoring ensures effective antifungal stewardship and optimal treatment. Patient education and counselling are vital in minimizing environmental exposures to fungal pathogens and promoting medication adherence. A well-structured and individualized approach, encompassing risk assessment, prophylaxis, surveillance, and patient education, is essential for effectively preventing IFD in hematological malignancies, ultimately leading to improved patient outcomes and overall survival.

Impact of Irrational Use of Antibiotics Among Patients in the Intensive Care Unit on Clinical Outcomes in Sudan.

Intensive Care Unit (ICU) is a specialized ward where critically ill patients are admitted to provide intensive health care Inappropriate antimicrobial therapy (AMT) and high mortality rates were documented in the ICU. The influence of irrational use of empiric antibiotics on clinical outcomes in ICU patients is not well studied in Sudan. This study aims to determine the rational use of antibiotics and its impact on clinical outcomes among ICU patients. Using data collection form, a retrospective longitudinal study was conducted among ICU patients at Omdurman Military Hospital, Khartoum State. Patients admitted from January 2019 to December 2019 were included in the study. Patients who stayed in ICU < 48 hr were excluded. Appropriateness of AMT is assessed using culture sensitivity test (CST) and the American Society of Infectious Diseases (IDSA) guideline. Among 102 patients, 54.9% male, one-third of patients developed nosocomial infections, 80.4% received empiric therapy with broad-spectrum antibiotics. The CST is done in 19%, and 43% patients are prescribed inappropriate AMT. Inappropriate AMT is associated with recurrent infections 38.4% (p=0.028) and high mortality 33.8% (p=0.014). Overall mortality rate 63.7% ICU patients. Elevated mortality in nosocomial 57.8%, decreased with inappropriate AMT in 21.6% patients. Significantly higher mortality rates 90.7% among uncontrolled infections (p<0.001), 80.6% nosocomial infections (p=0.001), and 76.7% renal compromised (p=0.002). Empirical AMT reduces the frequency of nosocomial infections, which has an impact on mortality. Inappropriate AMT is significantly associated with uncontrolled infections and lower mortality. Implementing a restrictive infectious control system and effective stewardship programs in hospital ICU wards is recommended.

Enhancing Surgical Outcomes: A Critical Review of Antibiotic Prophylaxis in Orthopedic Surgery.

The postoperative burden remains significant due to the possibility of prolonged hospitalization, escalated healthcare costs, and patient distress caused by postorthopedic surgicalsite infections (SSIs). Orthopedic surgery is likewise faced with a significant challenge posed by these conditions. A positive association has been observed between the presence of postorthopedic SSIs and heightened susceptibility to adverse health outcomes, along with elevated rates of morbidity and mortality. Systemic antibiotic prophylaxis (SAP) reduces the risk of acquiring an SSI. Closed fractures, open fractures, arthroplasty, and percutaneous fixation each possess distinct attributes that impact the data and antimicrobial therapy. When implementing SAP, it is crucial to strike a delicate equilibrium between maintaining effective antibiotic stewardship protocols and preventing the occurrence of SSIs. This practice effectively prevents both the incidence of negative consequences and the emergence of antibiotic resistance. The objective of this study was to examine the existing literature on the use of surgical antibiotic prophylaxis in orthopedic surgery and explore the potential consequences associated with the inappropriate administration of antibiotics.

An Overview of Data Management in Human Subjects Research.

Research studies generate data in various forms. Data can be quantitative or qualitative. Research involving human subjects requires protection of data to ensure privacy. Various regulations and local policies need to be followed to ensure data security. Data management plans are critical for effective data stewardship and include details plan on data collection, management, storage, and formatting. This paper will review data collection tools, data security strategies, file management, data storage, government regulations, prepping data for analysis, reference management, and file management.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Opioid Prescribing by Emergency Physicians: Trends Study of Medicare Part D Prescriber Data 2013-2019

BackgroundEmergency physicians play a critical role in mitigating the opioid epidemic in public health. ObjectivesTo analyze the prescribing of emergency physicians for opioids among Medicare beneficiaries enrolled in the Part D program from 2013 to 2019. MethodsWe conducted a retrospective, cross-sectional, descriptive analysis of Medicare Part D prescriber data, focusing on opioid claims between 2013 and 2019. The primary outcome variables evaluated included proportion of opioid claims, trends of the most prescribed opioids, cost of opioid claims, and days’ supply per claim. ResultsA total of 63,586 emergency physicians were identified over the study period. Opioid prescription by emergency physicians decreased from 14.45% to 11.55%, and the cost spent on opioid drugs declined by 50%. The use of drugs such as hydrocodone-acetaminophen and oxycodone-acetaminophen declined substantially, whereas tramadol and acetaminophen-codeine prescription increased. The opioid prescribing rate and days’ supply also decreased. ConclusionsThe decline in traditional opioid agents such as hydrocodone-acetaminophen was partly offset by an increase in opioids like tramadol, which carry additional potential adverse events. Opioid prescribing rate, average days’ supply, and cost of opioid drugs significantly decreased from 2015 to 2019, after a spike in 2015. All regions observed a decrease in emergency physicians, but opioid prescribing rates varied across regions. These trends highlight successful opioid stewardship practices in some areas and the need for further development in others. This information can aid in designing tailored guidelines and policies for emergency physicians to promote effective opioid stewardship practices.

Information provision by non‐government actors in the Australian National Disability Insurance Scheme: A key market stewardship function in social care quasi‐markets

AbstractThe use of quasi‐markets for the delivery of social care continues to grow internationally. This has presented considerable challenges regarding governance and stewardship of these markets, to ensure they meet policy goals. To date, both scholarship and practice on quasi‐market stewardship have mainly focused on the role of government. However, non‐government actors can also play important stewardship roles. For effective stewardship, there needs to be integration between government and non‐government actors in the system, not just a top‐down approach. This paper explores the stewardship role of non‐government actors in the Australian National Disability Insurance Scheme (NDIS) with a focus on the role of information provision as a key market stewardship function. Findings show non‐government information providers play important stewardship roles that increase choice and control for citizens, enhance market sufficiency, diversity, and innovation, and support other actors in the system. We argue for a shift in the conception of market stewardship as primarily a government activity and recommend the market stewardship actions of non‐government actors be better acknowledged, funded, and ‘joined up’ with the market stewardship role of government to enable social care quasi‐markets to operate more effectively.Points for practitioners Information provision by non‐government actors is a key market stewardship function in social care quasi‐markets. Market stewardship needs to be the responsibility of a much greater range of actors than government alone. A framework for ‘distributed stewardship’ can help join up the stewardship actions of non‐government actors with those of government to support information flows for more effective stewardship.