Prescribing In Primary Care Research Articles

Analysis of CYP2C19 genetic variants with ischaemic events in UK patients prescribed clopidogrel in primary care: a retrospective cohort study

ObjectiveTo determine whether CYP2C19 loss-of-function (LoF) alleles increase risk of ischaemic stroke and myocardial infarction (MI) in UK primary care patients prescribed clopidogrel.DesignRetrospective cohort analysis.SettingPrimary care practices in the UK...

OP321 The Scale And Variation Of The Impact Of COVID-19 On Prescribing Of Medicines In Primary Care In Wales

IntroductionPrescribing of medicines in primary care in Wales has been exceptional in 2020 due to COVID-19 and the associated changes to the delivery of health services. The changes are likely to have harmful, albeit unintended, consequences, including disruption of pharmacy stock management; unpredictable changes in prescribing; and interruption to patients’ supply of medicines and reduced medication adherence. Changes in prescribing are unlikely to be distributed evenly across the country or population. Therefore, this study aimed to identify changes in GP prescribing compared with previous years, the variation of these changes, and factors related to the variation in changes, to identify patient subgroups for whom the impact is disproportionate.MethodsWe identified medicines of interest where concerns around prescribing have been raised and, for each of these medicines, retrieved monthly prescribing data for each GP practice in Wales (N = 492). We then linked these data with other publicly available data (for example, practice size, indices of multiple deprivation, disease prevalence).We developed a novel approach to measure the impact of COVID-19 on GP prescribing. We compared observed with expected prescribing volume projected via time series modelling and differences were related to patient and practice characteristics using general estimating equations.ResultsThere was evidence of stockpiling of medicines during March 2020 (for example, oral-contraceptives and oral-anticoagulants with 11.6 and 18.5 percent increases from March 2019), followed by a short-term reduction in prescribing for oral-contraceptives (a reduction of 12.9 percent), but not oral-anticoagulants (an increase of 6.5 percent). However, GP level data show considerable deviation from the national trend for several GPs, which may be due to health and socio-demographic factors.ConclusionsCOVID-19 has had a major impact on primary care prescribing in Wales. The distribution of changes in prescribing will not be even across the country or the population. Identification of systematic variation in impacts on prescribing could identify geographical areas or patients in need of additional support to ensure uninterrupted and appropriate access to medicines.

Evidence-Based Management of Infective Conjunctivitis: A Review of Antibiotic Prescribing in Primary Care

Infective conjunctivitis is a common ophthalmic condition encountered in general practice. Topical antibiotics are often routinely prescribed in primary care for this generally self-limiting condition, despite evidence-based guidance consistently recommending otherwise. Injudicious antimicrobial prescribing has important social, economic, and public health consequences. This review discusses the evidence-based management of infective conjunctivitis and the implications of overprescribing antibiotics for this condition in primary care.

Analgesic prescribing in patients with inflammatory arthritis in England: an observational study using electronic healthcare record data.

ObjectivesInternational data suggest inflammatory arthritis (IA) pain management frequently involves opioid prescribing, despite little evidence of efficacy, and potential harms. We evaluated analgesic prescribing in English National Health Service-managed patients with IA.MethodsRepeated cross-sectional analyses in the Consultations in Primary Care Archive (primary care consultation and prescription data in nine general practices from 2000 to 2015) evaluated the annual prevalence of analgesic prescriptions in: (i) IA cases (RA, PsA or axial spondyloarthritis [SpA]), and (ii) up to five age-, sex- and practice-matched controls. Analgesic prescriptions were classified into basic, opioids, gabapentinoids and oral NSAIDs, and sub-classified into chronic and intermittent (≥3 and 1–2 prescriptions per calendar year, respectively).ResultsIn 2000, there were 594 cases and 2652 controls, rising to 1080 cases and 4703 controls in 2015. In all years, most (65.3–78.5%) cases received analgesics, compared with fewer (37.5–41.1%) controls. Opioid prescribing in cases fell between 2000 and 2015 but remained common with 45.4% (95% CI: 42.4%, 48.4%) and 32.9% (95% CI: 29.8%, 36.0%) receiving at least 1 and ≥3 opioid prescriptions, respectively, in 2015. Gabapentinoid prescription prevalence in cases increased from 0% in 2000 to 9.5% (95% CI: 7.9%, 11.4%) in 2015, and oral NSAID prescription prevalence fell from 53.7% (95% CI: 49.6%, 57.8%) in 2000 to 25.0% (95% CI: 22.4%, 27.7%) in 2015. Across years, analgesic prescribing was commoner in RA than PsA/axial SpA, and 1.7–2.0 times higher in cases than controls.ConclusionsAnalgesic prescribing in IA is common. This is at variance with existing evidence of analgesic efficacy and risks, and guidelines. Interventions are needed to improve analgesic prescribing in this population.

Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model.

ObjectiveTo investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar.DesignRetrospective analysis of statin prescribing in primary care and cost simulation model.SettingRoyal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database.ParticipantsNew patients prescribed statins for the first time between July 2003 and September 2018.Main outcome measuresShares of new patients prescribed one of the five statins available in the British National Formulary, and cost of prescribing statins to new and existing patients in primary care in England.ResultsGeneral trends of statin’ prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin acrossGPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment.ConclusionsThere is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

BackgroundHow contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.MethodThe authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.ResultsThree hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades.Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.ConclusionContext is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection.

Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally.

Reducing antibiotic prescribing using nudges: A systematic review of interventions in primary care

Introduction: Inappropriate antibiotic use in primary care is high. Nudge interventions, from the field of behavioural economics, are an approach to behaviour change that has been making significant inroads in healthcare. We conducted a systematic review to assess the effect of nudge interventions to reduce inappropriate antibiotic prescribing in primary care.

The Implementation of a Clinic-Based Opioid Review Board to Address High-Risk Opioid Prescribing in Primary Care.

The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain emphasized safety risks of opioids while promoting a risk-benefit approach to opioid prescribing.1 Although the CDC focused on prescriber decision making around opioid therapy, primary care

Impact of the COVID-19 pandemic on health-care usage and mental health of clinically extremely vulnerable individuals in Wales: a population-scale data linkage study

BackgroundThe public health response to the COVID-19 pandemic in the UK included advising those identified as clinically extremely vulnerable (CEV) to self-isolate within their homes. We compared the health-care usage and mental health of the CEV population with that of the general population during the pandemic. MethodsIn this retrospective population-scale data linkage study in Wales, we used person-level linked, routinely collected, data sources available within the Secure Anonymous Information Linkage Databank. Age-standardised rates of monthly planned and emergency care attendances between Jan 1, 2020, and Dec 31, 2020, were examined. We used a Cox model to explore risk factors for depression or anxiety (identified from primary care diagnosis, symptoms, and prescription Read codes). FindingsThe CEV cohort included 127 787 patients and was older than the general population (52·4% (66 963) CEV were aged ≥65 years, vs 21·0% (662 376) of the general population, p<0·0001). Average monthly trends showed that the decline in planned care was greater among the CEV than the general population from March–August, 2020 (elective admissions: –7·2% for CEV vs –0·6 for general population; outpatient attendances: –3·8% vs –1·3%), with a slower recovery into December, 2020 for CEV (elective: CEV –1.4% vs general population 3·9%; outpatient: 1·7% vs 4·1%). There were increases in both ED attendances and emergency admissions from March–August, 2020, which were greater among the general population (7·0% vs 3·1%, respectively) compared with the CEV (4·3% vs 0·5%). Being CEV (hazard ratio 1·2 [95% CI 1·2–1·3]) and historical poor mental health (3·7 [3·5–3·9]) were associated with an increased risk of anxiety or depression. InterpretationDeclines in planned care were not unexpected given the impact of COVID-19 on the National Health Service, and suggest considerable unmet need. Declines in secondary care activity amongst the CEV could reflect reluctance to attend hospital, not reduced clinical need. Reliance on an algorithm to identify CEV might have led to overestimation of the heterogeneous CEV population. FundingThe Health Foundation as part of the Networked Data Labs.

Effects of the COVID-19 pandemic on the mental health of shielded children and children living in shielded households in Wales: a data linkage study

BackgroundThe COVID-19 pandemic has had a detrimental effect on children's mental health. Shielded children or those living with a shielded person might be particularly susceptible to mental health difficulties arising as a result of strict public health restrictions. However, studies examining mental health outcomes in these children are scarce. We aimed to address this evidence gap. MethodsWe linked the COVID-19 Shielded Patient List to demographic and health-care datasets within the Secure Anonymised Information Linkage (SAIL) databank. We constructed three cohorts of children aged 2–17 years who were living in Wales and registered with a general practitioner that provides data to SAIL when shielding was introduced on March 23, 2020: shielded children, children living with a shielded person, a general population group of registered children who were neither shielding or living with a shielded person. We used published Read codes to identify children with primary care diagnoses or prescriptions relating to anxiety or depression, before and during the pandemic. We compared the difference in proportions of new diagnoses or prescriptions during COVID-19 between groups. FindingsBefore the COVID-19 pandemic (March 23, 2019, to March 23, 2020), 155 (4·2%) of 3721 shielded children received diagnoses or prescriptions for anxiety or depression, compared with 128 (3·4%) of 3721 children during the pandemic (March 23, 2020, to Jan 31, 2021); 71 (2·0%) of 3566 had new diagnoses or prescriptions during the pandemic. For children in shielded households, these values were 489 (2·5%) of 19 954 children before COVID-19 and 301 (1·5%) of 19 954 children during COVID-19, with 218 (1·1%) of 19 456 having new diagnoses or prescriptions during the pandemic. For the general population, these values were 8001 (2·0%) of 411 680 children before COVID-19 and 5420 (1·3%) of 411 680 children during COVID-19, with 4070 (1·0%) of 403 679 having new diagnoses or prescriptions during the pandemic. The difference in the proportion of new diagnoses or prescriptions between shielded children and the general population was significant (χ2 35·40 [95% CI 0·59–1·51], p<0·0001). InterpretationOur findings show a decrease in diagnoses or prescriptions for anxiety or depression during COVID-19, which could be partly attributed to a reluctance to seek health care during this time. The prevalence of anxiety or depression was highest in shielded children, and the rate of new diagnoses or prescriptions during COVID-19 was significantly higher among shielded children. Future work could involve longitudinal follow-up of these children to assess future trends in health-care use for mental health-related conditions and longer-term health and education outcomes among these groups. FundingHealth and Care Research Wales.

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

How Physicians Renew Electronic Prescriptions in Primary Care: Therapeutic Decision or Technical Task?

In long-term pharmacotherapies, the renewal of prescriptions is part of the medication use process. Although the majority of medicines are used with renewed prescriptions, little research has focused on renewal practices. The aim of this study was to explore current renewal practices from a primary care physician’s perspective to identify system-based challenges and development needs related to the renewal practices. This qualitative study was conducted in two phases in public primary health care centres of Kirkkonummi, Finland. First, five physicians were shadowed on-site while they renewed prescriptions. The findings of the shadowing phase were further discussed in two focus group discussions with seven other physicians than in the shadowing phase. Inductive content analysis was used for data analysis utilizing Reason’s risk management theory as a theoretical framework. Due to problems in the renewal process, including impractical information systems, a lack of reconciled medication lists, and a lack of time allocated for renewing prescriptions, physicians felt that monitoring and reviewing each patients’ medications for renewal was complicated. Therefore, they felt that renewing, at times, became a technical task rather than a therapeutic decision. The physicians suggested information system improvements, enhanced interprofessional cooperation, and patient involvement as strategies to ensure rational pharmacotherapy and patient safety in the renewal of prescription medicines.

Exploring antibiotic prescribing in public and private primary care settings in Singapore: a qualitative analysis informing theory and evidence-based planning for value-driven intervention design

BackgroundSingapore’s healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems.AimTo explore processes underpinning decision-making for antibiotic prescribing, by considering doctors’ experiences in different primary care settings.MethodsThirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing.ResultsGiven Singapore’s lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices.These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change.ConclusionsThese VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly.

The impact of COVID-19 on primary health care and antibiotic prescribing in rural China: qualitative study

BackgroundIn China, the primary health care (PHC) system has been designated responsible for control and prevention of COVID-19, but not treatment. Suspected COVID-19 cases presenting to PHC facilities must be transferred to specialist fever clinics. This study aims to understand the impact of COVID-19 on PHC delivery and on antibiotic prescribing at a community level in rural areas of central China.MethodsQualitative semi-structured interviews were conducted with 18 PHC practitioners and seven patients recruited from two township health centres and nine village clinics in two rural residential areas of Anhui province. Interviews were transcribed verbatim and analysed thematically.ResultsPHC practitioners reported a major shift in their work away from seeing and treating patients (due to government-mandated referral to specialist Covid clinics) to focus on the key public health roles of tracing, screening and educating in rural areas. The additional work, risk, and financial pressure that PHC practitioners faced, placed considerable strain on them, particularly those working in village clinics. Face to face PHC provision was reduced and there was no substitution with consultations by phone or app, which practitioners attributed to the fact that most of their patients were elderly and not willing or able to switch. Practitioners saw COVID-19 as outside of their area of expertise and very different to the non-COVID-19 respiratory tract infections that they frequently treated pre-pandemic. They reported that antibiotic prescribing was reduced overall because far fewer patients were attending rural PHC facilities, but otherwise their antibiotic prescribing practices remained unchanged.ConclusionsThe COVID-19 pandemic had considerable impact on PHC in rural China. Practitioners took on substantial additional workload as part of epidemic control and fewer patients were seen in PHC. The reduction in patients seen and treated in PHC led to a reduction in antibiotic prescribing, although clinical practice remains unchanged. Since COVID-19 epidemic control work has been designated as a long-term task in China, rural PHC clinics now face the challenge of how to balance their principal clinical and increased public health roles and, in the case of the village clinics, remain financially viable.

The effects of an evidence- and theory-informed feedback intervention on opioid prescribing for non-cancer pain in primary care: A controlled interrupted time series analysis.

The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care. A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate. Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.

Analgesia prescribing in primary care

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Secondary effects of an opioid-focused academic detailing program on non-opioid controlled substance prescribing in primary care

Background: Educational outreach programs that focus on safe opioid prescribing and awareness of state prescription monitoring programs may modify clinicians’ prescribing behavior. The objective of this study was to evaluate the secondary effects of an opioid-focused academic detailing (AD) program on non-opioid controlled substance prescribing in primary care. Methods: A quasi-experimental pre-post study of primary care clinicians exposed and unexposed to the AD program was conducted using data from the Illinois Prescription Monitoring Program from December 2017 to February 2019. Outcomes were mean monthly prescriptions for benzodiazepines (BZD), non-BZD sedative-hypnotics, and carisoprodol, per clinician. A difference-in-differences (DID) approach utilizing repeated-measures mixed-effects linear regression models was used to compare changes in outcomes six-months before and after the program. Results: Mean monthly BZD prescriptions declined in both groups of clinicians (AD-exposed n = 151; controls n = 399) after implementation of the AD program. Although the mean monthly number of BZD prescriptions decreased in both groups after the AD program, BZD prescribing in the AD-exposed group declined at a slower rate following the AD program (DID = 0.73; 95% CI: 0.14, 1.31). The AD-exposed group had a 0.06 (95% CI: −0.11, −0.01) lower rate of mean monthly carisoprodol prescriptions compared to the control group following the AD program. There was no change in the rate of mean monthly non-BZD sedative-hypnotic prescriptions between the two groups. Conclusions: The higher relative rate of BZD prescribing in the AD-exposed group compared to the control group following the AD program may be reflective of an unintended consequence of opioid-focused AD programs as clinicians learn to be cautious about opioid prescribing. Our findings may suggest the need for incorporation of targeted education on appropriate BZD prescribing into opioid-focused AD programs as a featured component. These findings warrant further consideration and investigation before large-scale implementation of opioid-focused educational outreach programs.

Program development and implementation outcomes of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS)

Background: As the opioid epidemic continues, there is a mounting sense of urgency to improve access to high-quality early identification and treatment services. However, the need is outpacing capacity in many states and effective solutions to support primary care and specialty prescribers to identify and treat more patients with opioid use disorders are still emerging. This paper describes one state’s approach to increase access to medication for opioid use disorders (MOUD) through development and implementation of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS). Methods: Program components include a warmline, outreach and training, and resource and referral linkages for prescribers based on related consultation service models and documented barriers to prescribing MOUDs. Results: Initial implementation outcomes indicate service components are being adopted as intended and by the target audience; many prescribers who engaged with the service have their buprenorphine waiver (44%) but do not have any additional formal addiction training (57%). Also, statewide penetration is promising with prescriber engagement in 100% of counites, however only 33% of counties in engaged in all four types of MACS services. Most calls (61%) originated from urban counties. Conclusions: The MACS program increases access to specialty addiction medicine consultation and training through use of technology. MACS can serve as a model for other states looking to bridge the gap in access to addiction treatment.

Management of Common Infections in German Primary Care: A Cross-Sectional Survey of Knowledge and Confidence among General Practitioners and Outpatient Pediatricians.

Outpatient antibiotic use is closely related to antimicrobial resistance and in Germany, almost 70% of antibiotic prescriptions in human health are issued by primary care physicians (PCPs). The aim of this study was to explore PCPs, namely General Practitioners’ (GPs) and outpatient pediatricians’ (PDs) knowledge of guideline recommendations on rational antimicrobial treatment, the determinants of confidence in treatment decisions and the perceived need for training in this topic in a large sample of PCPs from southern Germany. Out of 3753 reachable PCPs, 1311 completed the survey (overall response rate = 34.9%). Knowledge of guideline recommendations and perceived confidence in making treatment decisions were high in both GPs and PDs. The two highest rated influencing factors on prescribing decisions were reported to be guideline recommendations and own clinical experiences, hence patients’ demands and expectations were judged as not influencing treatment decisions. The majority of physicians declared to have attended at least one specific training course on antibiotic use, yet almost all the participating PCPs declared to need more training on this topic. More studies are needed to explore how consultation-related and context-specific factors could influence antibiotic prescriptions in general and pediatric primary care in Germany beyond knowledge. Moreover, efforts should be undertaken to explore the training needs of PCPs in Germany, as this would serve the development of evidence-based educational interventions targeted to the improvement of antibiotic prescribing decisions rather than being focused solely on knowledge of guidelines.