General Medicine Practice Research Articles

Exploring the motivations, challenges, and barriers for implementing evidence-based veterinary medicine (EBVM) in general practice

An evidence-based veterinary medicine (EBVM) training resource, ‘EBVM Learning’, was created in 2015 and updated in 2019. Following feedback from users, it was decided that a more concise practitioner-focused version was needed. Seven online focus groups, with a total of 22 veterinary practitioners, explored the motivations of practitioners to engage with EBVM. They considered the challenges and barriers to implementing EBVM in practice, and specific supportive measures they felt would increase adoption of EBVM in practice. Participants identified time, support from colleagues and management, and accessing and appraising evidence as being the most important challenges and barriers to the use of EBVM in general practice. However, the value of EBVM was appreciated, and there was an appetite amongst the participants to utilise more EBVM to inform their clinical decision-making. At a workshop attended by experts in EBVM, educators and practitioners, the results of the focus groups were presented and discussed to inform the development of a new online training resource. This study has been used to produce ‘EBVM for Practitioners’, to attempt to reduce some of the barriers and challenges faced by practitioners and support them in increasing their use of EBVM. Further work by the leaders in the veterinary profession will be needed to expand and improve the quality of the evidence base on which EBVM relies, and to ensure practitioners have the skills, access, and motivation to utilise it.

Fostering clinical research in general practice and family medicine. Selected abstracts from the 93rd EGPRN conference Halle, Germany, 14–17 October 2021

Fostering clinical research in general practice and family medicine. Selected abstracts from the 93rd EGPRN conference Halle, Germany, 14–17 October 2021

Clinician Confidence in Managing Ophthalmological Presentations: A Model for Collaborative Post-Graduate Training in Ophthalmology

Clinicians working in emergency medicine (EM), general practice (GP) and general medicine are frequently expected to review, assess and manage those presenting with ophthalmic complaints. They are in many instances the gatekeepers to accessing secondary ophthalmological care services. Often these clinicians have received only undergraduate teaching on ophthalmology and infrequently utilise their skills with ophthalmological equipment such as fundoscopes and rarely a slit lamp. Due to this, clinician confidence in managing ophthalmological issues is often poor.

Primary Care Aspects in the German Coalition Agreement 2021

Despite statewide rising numbers of family physicians during the last legislative period, their overall health care providing capacity has declined, mainly due to their working part-time. In the legislative period starting in 2021, this trend appears likely to continue. The German Health System Advisory Council foresees the number of general practitioners (GPs) who will have to be replaced by the next federal election in 2025 as exceeding 26,000. This results in a need for political action to sustain the primary care workforce. We conducted a content analysis of the coalition agreement 2021 between SPD, Greens and FDP with regard to explicit and related topics of GP care. A mixed inductive-deductive classification of the included text passages was used to thematically structure the results. A total of 34 relevant text passages were identified between pages 8 to 139 of the coalition agreement. Family physician care was explicitly addressed only once, when the planned abolition of budgeting was discussed. Other proposals which affect family physicians work included reduction of bureaucracy, prevention, or easier access to medical care for disadvantaged groups. Other passages of the coalition agreement regarding security of medical supply, included demand planning, innovative healthcare models, and cross-sectoral care. One focus of the coalition agreement was on digitalization. It mentions e. g., a digitization strategy for the healthcare sector, telemedicine services, and the electronic medical record, including opt-out possibility. Other assessed passages included projects to facilitate research or climate change and health. Despite the lack of mention of family physicians in the coalition agreement, many projects relate to the work of family physicians. Some of the ideas mentioned have also already been written down by the German Society for General Practice and Family Medicine (DEGAM) in its positions on the future of general practice, digitization or climate change and health. The planned projects in the coalition agreement have the potential to strengthen health care by family doctors and also make it more attractive for young doctors. However, further measures may be necessary to maintain GP care in the short and long term.

Special Report: Measurement-Based Care—Using Data to Augment Psychotherapy

Special Report: Measurement-Based Care—Using Data to Augment Psychotherapy

Risk Factors and Incidence Rates of Covid-19 Breakthrough Infections in Vaccinated People in General Medicine Practice in Toledo (Spain)

The coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, has had a great impact on public health worldwide, due to its rapid spread with pandemic behavior, its difficult control and few therapeutic alternatives [1]. Vaccines for COVID-19 have been developed at unprecedented speed, and phase III clinical efficacy trials reported results for some vaccines less than a year after the World Health Organization (WHO) declared the pandemic.

Correlation between arterial and venous sodium and potassium values in critically ill patients by arterial blood gas and electrolyte analyzer attending tertiary hospital of Nepal

Introduction: Electrolytes are elements and compounds that occur naturally in the body and control important physiological function. Electrolyte disorder occurs when the levels of electrolytes in the body are either too high or too low. The causes, severity, treatment, and outcomes can vastly differ depending on the implicated electrolyte imbalances. The objective of this study is to comprehend the correlation between sodium and potassium levels measured in critically ill patients attending a tertiary care hospital of Nepal.
 
 Method: This study was a hospital based prospective observational comparative study conducted in the Department of General Practice and Emergency Medicine, Bir hospital, Kathmandu, from June 2019 to December 2019. After fulfilling inclusion and exclusion criteria a total of 95 patients were included in the study. Data were entered and analyzed in SPSS 20. The findings were presented in figures and tables. Statistical analysis was done using appropriate formula. Mean, standard deviation and correlation coefficient were calculated.
 
 Result: The mean value of arterial sodium was 134.67mmol/L and venous sodium was 135.93mmol/L. The mean value of arterial potassium was 4.0mmol/L and venous potassium was 4.19mmol/L. The correlation coefficient obtained for sodium was 0.703 and for potassium was 0.436. There was positive correlation of arterial sodium and arterial potassium with venous sodium and venous potassium indicating agreement between the parameters.
 
 Conclusion: Arterial sodium and arterial potassium can be used instead of venous sodium and venous potassium levels in management of critically ill patients.

Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery

ObjectivesHaving previously shown similar clinical outcomes, this study compared the healthcare resource utilization and direct costs in stable patients with RA followed in the nurse-led care (NLC) and rheumatologist-led care (RLC) models. MethodsPreviously collected clinical data were linked to data on practitioner claims, ambulatory care, and hospital discharges. Assessed resources included physician visits; emergency department (ED) visits; hospital admissions, and disease-modifying anti-rheumatic drugs (DMARDs). The mean per-patient resource utilization and cost (2020 Canadian dollars) over 1 year were compared between the groups using Wilcoxon rank-sum test. The mean per-patient cost of health services and total cost were also estimated using Generalized Linear Models (GLMs) accounting for the baseline differences between the groups. ResultsOverall, 244 patients were included. No differences in the number of visits to the ED or to general practice and internal medicine physicians and orthopedic surgeons were found. The NLC group had fewer hospitalizations than the RLC group (p-value=0.03). The mean cost of health services was not statistically different in NLC and RLC groups ($2275 vs. $3772, p-value=0.30). The RLC group included more patients on biologic DMARDs, contributing to a higher mean total cost than the NLC group ($9191 vs. $3056, p-value<0.01). The mean cost estimates with GLMs were consistent with the observed costs. ConclusionsA nurse-led model of care delivery for stable patients with RA was not associated with increases in healthcare resource utilization or cost as compared to RLC. NLC is one approach to meeting patient needs and better managing scarce healthcare resources.

Seven cardinal questions for the patient with ear, nose or throat complaints: Review.

The incidence of otolaryngological problems in general medicine practice is highly seasonal and approaches 25% in some months of the year. Accurate diagnosis in the otolaryngology office often requires the use of binocular microscopy, nasal endoscopy, and flexible laryngoscopy, none of which are available in a general medicine office. Therefore, history taking and physical examination techniques available in the non-otolaryngology office are of utmost importance. Using evidence-based history taking for ear, nose, and throat (ENT) problems facilitates dealing with patients who present with otolaryngologic complaints. In this paper, I present 7 cardinal questions to be asked when taking the history of a patient with ENT complaints.

A Study on The Quality Evaluation of General Medical Education in China: An Empirical Analysis Based on 36 Medical Schools

Context: In the context of a healthy China, promoting general medical education and improving its quality have become key measures to strengthen primary health services and meet health needs in China, and it is of great significance to evaluate the current situation and quality of general medical education in China. The existing literature mostly studies and evaluates general medical education from a single perspective, lacking a comprehensive, systematic and integrated evaluation of general medical education. Objective: This paper analyzes the current situation, quality and key factors affecting the quality of general medical education in China, and provides a reference for medical schools to improve the quality of general medical education. Methods: The questionnaire was administered to 5271 students from 36 medical schools in August 2021 using a whole sample method. SPSS 26.0 software was used to analyze the differences in variables among the groups using independent samples t-test and multiple regression analysis of the key factors affecting the quality of general medical education. Results: The mean value of students' evaluation of each question item of the course is 3.69-3.81. The teachers' teaching methods are diversified, but they neglect the cultivation of students' personality, and there are problems such as inaccurate positioning of training objectives and weak practical links. In addition, students rated the mean value of each question item of the general medicine faculty as 3.76-3.79. 95.9% of students with internship experience rated the internship process as generally satisfactory or above, but considered the number of general medicine practice sites insufficient. Curriculum (β=0.567, p=0.000) was a key factor influencing the quality of general medicine education from the student perspective. There were differences in the evaluation of the quality of general medical education in China by students from different types of universities (p&lt;0.05). Conclusion: Students rate the current status and quality of general medicine education in China highly, and curriculum is a key factor affecting the quality of general medicine education from students' perspective. There are differences in the evaluation of the quality of general medical education in China by students from different types of universities. Quality improvement programs for general medical education should be designed in a hierarchical and categorical manner, and different measures should be taken for different types of medical schools to improve the quality of education.

Contributions from Türkiye to the international emergency medicine literature during the COVID-19 pandemic: A bibliometric analysis

Aim: The present study aimed to evaluate the bibliometric contributions made from Türkiye to the international scientific literature in the field of Emergency Medicine during the 2020-2021 period, which covered the COVID-19 pandemic period. Materials and Methods: The present study included a total of 872 studies in Emergency Medicine WoS Indexes between 2020-2021. The study data were retrieved from the Web of Science (WoS) database of Thomson Reuters – Clarivate Analytics, and the review included publications in the "Emergency Medicine" category from Turkey that spanned the pandemic period between the years 2019-2020. Results: 78.1% of the aforementioned studies were included in the Science Citation Index Expanded and 88.2% were original research papers. A total of 2930 researchers were involved in the 872 publications in the scope of the study. The average number of co-authors per publication was 5.2, where the average number of publications per author was 0.3. As regards the scope of the publications, the main topic was "SARS-Cov-2 and pandemic". The aforementioned main theme was associated with general emergency medicine practices, COVID-19 pneumonia, and high-mortality emergency cases. Conclusion: To the best of our knowledge, the present study is the first that investigated the studies from Türkiye that contributed to the international literature in the field of emergency medicine during the pandemic period and provided valuable data reflecting the scientific productivity of the researchers, who continued their research in the field of emergency medicine, during the pandemic period.

Risk Factors of Coronary Artery Disease: A Hospital-Based Study.

Coronary artery disease is among the leading cause of morbidity and mortality worldwide. There are limited scientific evidence on the risk factors for coronary artery disease specific to the Nepalese context. This study aimed to determine the association of various modifiable cardiovascular risk factors with coronary artery disease in Nepal. It is a hospital-based case-control study conducted among 300 participants. Case group comprised of 150 newly diagnosed coronary artery disease patients attending Manmohan Cardiothoracic Vascular and Transplant Centre while the Age and sex matched non-cardiac patients (n=150) from the outpatient department of the Department of General Practice and Emergency Medicine of Tribhuvan University Teaching Hospital were recruited as controls. Adjusted odds ratios (AOR) were calculated using multivariable logistic regression. Of the 300 participants, 208 (69.3%) were males and 92 (30.7%) were females. The mean age was 59.8 years ± 11 years (standard deviation). In multivariable analysis, current smoking (AOR=3.05, 95% CI: 1.61-5.78), hypertension (AOR=1.82, 95% CI: 1.08-3.09), diabetes (AOR=3.78, 95% CI: 1.91-7.47), family history of coronary artery disease (AOR=2.92, 95% CI: 1.27-6.71), and low high density lipoprotein (AOR= 2.0, 95% CI: 1.17-3.42) were significantly associated with coronary artery disease. Current alcohol use (AOR=0.51, 95% CI: 0.29-0.89) was identified as a protective factor for coronary artery disease. Among the modifiable cardiovascular risk factors, smoking, hypertension, diabetes, and low level of high density lipoprotein were significantly associated with coronary artery disease, which should be considered while developing public health interventions for cardiovascular disease prevention in Nepal in future.

Administering medications in general practice: what do non-prescribers need to know?

Administering medicines in general practice is often complicated for non-prescribers. Allison Brindley looks at the legal and professional boundaries around this complex topic Misunderstandings and uncertainty around the professional responsibilities and legal requirements for non-prescribing general practice nurses (GPNs) when administering medications in general practice is an ongoing issue. This article reflects on practices of the past and the influences and drivers for GPN practice, helping to explain why this remains such a difficult concept. The legal and professional boundaries are explored and summarised into understandable and relatable terms, encouraging non-prescribing GPNs to make safe and considered decisions regarding the supply and administration of medicines. The dynamics of being employed by GPs can create tension for nurses in terms of meeting the expectations of the employer while working within professional boundaries. After reading this article, GPNs should feel empowered to question prescribing practices in their place of work.

How colleges should lead on climate.

How colleges should lead on climate.

Remote Consultations in General Practice - A Systematic Review.

Remote consultations in general practice can be very useful form of telemedicine, which is basically a way to exchange medical information to improve the clinical health of patients when the patient and their general practitioner (GP) are not on the same place at the same time. This concept was developed in the 1980s to provide health care to patients who lived in remote areas. We were interested in researching what kind of remote consultations are available in general practice and what is the usage of these methods. We used four keywords - remote consultation and general practice or family medicine or primary care - and we searched in four different scientific databases: Medline-PubMed, Scopus, Web of Science and IEEX Xplore. We used a PRISMA diagram to identify studies and search the four main databases, we investigated 48 full text articles and when we applied our inclusion and exclusion criteria, 12 studies were included in this systematic review. This systematic review covers the topics of remote consultation versus a traditional or classic physical consultation. Studies have shown its importance prior to the COVID-19 pandemic, and its value while in the mist of the pandemic then caring for infected patients. We have found that remote consultation is necessary, but it must be an improvement on the previous system. Teleconsultations can reduce the number of visits, especially during lockdown situations, with both patients and GPs satisfied with the method, but we should not forget that a physical consultation cannot be fully replaced by a remote consultation due to the limitations of the latter.

Lúpulo y valeriana en el manejo del insomnio. Opinión de expertos; recomendaciones para su uso en el primer nivel de atención médica

Introduction. Insomnia is a complaint of dissatisfaction with the quantity and/or quality of sleep. It may consist of difficulty initiating and/or maintaining sleep and waking up early in the morning, which leads to a significant deterioration in daily functioning. The breaking point between acute and chronic insomnia is three months duration. Occasionally there is an identifiable trigger. Insomnia is a frequent and commonly overlooked disorder in the primary care setting. It produces frequent complications such as anxiety, depression, decreased quality of life, diminished cognitive abilities and memory, accidents, lower productivity at work, increased risk of alcoholism, as well as cardiovascular disease, hypertension, dyslipidemia and type II diabetes mellitus. Valeriana officinalis (valerian extract) has been used as a treatment for anxiety and insomnia since the Middle Ages. It is currently approved by the FDA (Food and Drug Administration) and the EMA (European Medicines Agency) as a treatment for mild anxiety and insomnia. Likewise, Humulus lupulus (hops extract) has been traditionally used since ancient times for treating insomnia as part of the European herbal pharmacopoeia. Material and Methods. An interdisciplinary group of experts held several meetings to generate search terms, develop a literature search protocol to examine and weigh the evidence and create consensus recommendations for the use of a fixed and standardized dose of 250 mg of valerian extract and 60 mg of hops extract in the management of insomnia in primary care. Results. The evidence supports the effectiveness and safety of a fixed and standardized dose of 250 mg of valerian extract and 60 mg of hops extract in the management of mild to moderate insomnia. In order to support the diagnosis and treatment of insomnia, recommendations were generated for using these phytopharmaceuticals in the first level of medical care. Conclusions. The fixed combination of valerian and hops extracts helps manage insomnia in the practice of family and general medicine, as well as in obstetrics and gynecology at the recommended doses and duration. It is crucial to make a timely and correct diagnosis and refer patients with severe insomnia or associated pathology to a specialist.

Metabolic syndrome in primary care: A latent variable analysis of electronic medical records

BackgroundThe best definition of the metabolic syndrome (MetSyn) remains controversial. The aim was to develop a latent variable measurement model for the MetSyn using primary care data. MethodsThis retrospective case-control study was based on the data from the IQVIA Disease Analyzer (DA) database including a representative panel of general and internal medicine practices in Germany. 23,020 adult patients, who were newly diagnosed with ≥1 component of the MetSyn (cases; median age [IQR]: 60 [50–72] years; 54 % males) between January 2016 to December 2019, and 2,144 patients without any MetSyn component (controls; 48 [38–61] years; 45 % males) were included. MetSyn was modeled by ICD-10 codes (E66: obesity, I10: hypertension, E11: type 2 diabetes, E78: lipid disorders) and physiological measures (BMI, HbA1c, blood pressure, HDL-cholesterol, LDL-cholesterol, triglycerides). ResultsThe covariance structure of the ICD codes and physiological measures could not be accounted for by a single MetSyn factor (root mean square error of approximation, RMSEA=0.085). Enrichment by another factor “Likelihood to Diagnose” significantly increased model fit with the observed data (RMSEA=0.054). “Likelihood to Diagnose” hardly correlated with MetSyn (r = 0.06), and was differentially associated with male sex, older age, and corresponding cardio- and cerebrovascular diseases. MetSyn showed the highest loading on four subordinate factors “hyperlipidemia” (0.70), “obesity” (0.66), “type 2 diabetes” (0.60), followed by “hypertension” (0.42). The ICD codes E66 and E78 were less indicative of these factors relative to BMI and triglycerides/HDL-cholesterol, respectively, whereas E11 and I10 were similarly indicative as their corresponding physiological measures. ConclusionsMetSyn was best indicated by BMI, triglycerides (an indirect marker of insulin sensitivity), HbA1c, and ICD-10 diagnosis E11 (type 2 diabetes). The factor “Likelihood to diagnose” probably constitutes a method factor of differential diagnosis systematically contributing to the common consistency of the MetSyn diagnosis in primary care.

Association of glucose-lowering drugs with incident stroke and transient ischaemic attacks in primary care patients with type 2 diabetes: disease analyzer database

AimsPrevious observational studies on glucose-lowering drugs and risk of stroke in type 2 diabetes yielded conflicting results. The aim was to examine the association of glucose-lowering drugs with incident stroke and transient ischaemic attacks (TIA) in newly diagnosed type 2 diabetes.MethodsWe conducted a retrospective cohort analysis of the disease analyzer, which comprises a representative panel of 1248 general and internal medicine practices throughout Germany (01/2000–12/2019: 9.8 million patients). Incident non-fatal stroke/TIA was defined based on ICD-10 codes (I63, I64; G45) in newly diagnosed type 2 diabetes. Cox regression models were fitted to obtain hazard ratios (HR; 95%CI) for stroke/TIA adjusting for potential confounders (age, sex, health insurance, coronary heart disease, myocardial infarction, heart failure, polyneuropathy, blood pressure, eGFR) and anthropometric and metabolic intermediators (BMI, HbA1c, HDL- and LDL-cholesterol, triglycerides, lipid-lowering drugs).Result312,368 persons with newly diagnosed type 2 diabetes without previous stroke/TIA (mean age: 64 years; 52% males) were included. There were 16,701 events of non-fatal stroke/TIA corresponding to an incidence rate of 9.3 (95%CI 9.1–9.4) per 1000 person-years. Using Cox regression, adjusted HR for stroke/TIA (per 1 year of treatment) of 0.59 (0.54–0.64) for SGLT2 inhibitors and of 0.79 (0.74–0.85) for GLP-1 receptor agonists were estimated. DPP-4 inhibitors (0.84; 0.82–0.86), metformin (0.90; 0.89–0.91), insulin (0.92; 0.91–0.93) and sulfonylureas (0.98; 0.96–0.99) also showed moderately reduced HR for stroke/TIA. Sex-specific regression analyses yielded similar results (HR).ConclusionsTreatment with SGLT2 inhibitors or GLP-1 receptor agonists might reduce non-fatal stroke/TIA in persons with newly diagnosed type 2 diabetes.

The Preventive and Therapeutic Effects of Ajwa Date Fruit Extract Against Acute Diclofenac Toxicity-Induced Colopathy: An Experimental Study.

BackgroundStudies regarding treatment of acute toxicity with diclofenac (ATD) are quite few. Diclofenac is commonly prescribed in neurology, psychiatry, and general medicine practice. This study investigated possible colon-protective effects exerted by Ajwa date fruit extract (ADFE), a prophetic medicine remedy native to Al-Madinah, Saudi Arabia against ATD. Phytochemicals in ADFE as gallic acid and quercetin have reported protective effects against ATD.MethodsTotal phenols and flavonoids in ADFE were estimated as equivalents to gallic acid and quercetin. Four experimental groups were allocated each of six rats: control group, ATD group received a single dose of 150 mg diclofenac intraperitoneally, toxicity prevention group received a single dose of ADFE orally followed 4 hours later by diclofenac injection, and toxicity treatment group received a similar diclofenac dose followed 4 hours later by a single dose of ADFE. Four days later, animals were sacrificed. Histological and biochemical examinations were done.ResultsADFE has a total phenolic content of 331.7 gallic acid equivalent/gram extract and a total flavonoid content of 70.23 quercetin equivalent/gram. ATD significantly increased oxidative stress markers as serum malondialdehyde (MDA) and hydrogen peroxide (H2O2). Serum MDA and H2O2 were significantly scavenged by ADFE. ATD significantly (p<0.001) decreased antioxidant power as serum total antioxidant capacity and catalase activity. That was reversed by ADFE in both prevention and treatment groups. Histologically, ATD caused complete destruction of colonic crypts architecture, patchy loss of the crypts, loss of the surface epithelium, absent goblet cells and submucosal exudate, heavy infiltration of the lamina propria and submucosa with inflammatory cells, mainly lymphocytes and eosinophils. There were mucosal haemorrhages and submucosal dilated congested blood vessels. All that was prevented and treated using ADFE.ConclusionADFE is rich in quercetin and gallic acid equivalents that exert potent antitoxic effects. ADFE is strongly recommended for preventive and therapeutic colon effects against ATD.

Assessment of antibiotic prescribing patterns at dental and primary health care clinics according to WHO Access, Watch, Reserve (AWaRe) classification

BackgroundThe 2019 WHO Access, Watch, Reserve (AWaRe) antibiotic classification framework aims to prevent irrational prescribing of antibiotics used to treat widespread infections. This study explored antibiotic prescribing pattern for appropriate indications by family physicians and general dentists in primary health care practices. MethodsA retrospective review of patients’ electronic medical records was conducted over 6 months, from May 1, 2020, to November 30, 2020. The data were collected from 24 general family medicine and dental practices within the North West Armed Forces in Tabuk city. Antibiotic prescribing for systemic use (J01) was assessed by the number of prescriptions and the number defined daily doses (DDDs) and then analyzed according to the AWaRe classification. The prescribing of antibiotics for appropriate indications was assessed through comparing the prescription pattern with the recently published and relevant clinical guidelines. Multivariate logistic regression analysis was used to predict the association between the prescribing of AWaRe category and some demographic and disease-related factors. ResultsIn total, 752 prescriptions of antibiotics were collected. Watch-group antibiotics such as second-generation cephalosporin and macrolides were more likely prescribed (51.1%) based on the number of prescriptions and (52.2%) based on DDDs compared with Access-group antibiotics (48.9%) and (47.8%), respectively. The percentages of Watch group antibiotics for children and adults were 66.7% and 42.9%, respectively. Adherence to prescribing guidelines was poor for children (27.2%) and adults (64%). Being a child (adjusted odds ratio [OR]: 2.89; 95% confidence interval [CI] = 1.46-5.78), diagnosis with acute respiratory tract infection (adjusted OR, 2.62; 95% CI = 1.03-6.69), and urinary tract infection (adjusted OR, 4.69; 95% CI = 2.09-10.56) were associated with higher prescriptions of Watch-group antibiotics. Conclusionsa higher prescribing of Watch-group antibiotics and poor adherence to antibiotic guidelines were observed, especially for children. The findings of this study identified targets for further improvement and interventions needed to develop better antibiotic-prescribing practices.