Prescribing Behavior Research Articles

Opioid Medication Use and Education Following Sports Medicine Procedures: An Evidence-to-Practice Review

According to the Centers for Disease Control (CDC), illicit and prescription drug overdoses are responsible for 128 deaths every day in the United States. In 2018, 70% of all overdose related deaths involved opioids. Efforts to minimize the opioid epidemic focus on community education, research, partnership, and healthcare support. Under the CDC guidelines, current practices include monitoring trends of drug use and drug related deaths, conducting research to recognize areas in need of improvement and to analyze effectiveness of current treatments, partner with community organizations and healthcare systems that deal firsthand with opioid users, and educate the public on drug use, misuse, and overdoses. People are commonly uneducated on the proper use and disposal of their prescription opioids. Consistent and appropriate communication among surgeons and their patients can decrease this risk associated with prescription drugs. The purpose of this evidence-to-practice review was to summarize a systematic review on the current data and findings related to postoperative opioid prescribing and consumption behaviors after a common sports medicine operation. The guiding systematic review explored several ways to reduce the risk of patients developing opioid dependence and abuse due to physicians overprescribing opioids. First, educating each patient about pain management during pre- and postoperative phases, how to store opioids safely, and how to dispose of opioids properly need to be created to help reduce the risk of the patient abusing opioids. Secondly, having the prescribing provider create an extensive history that reveals any red flags for opioid abuse for each patient. Thirdly, the prescribing provider should prescribe the lowest dose and shortest regimen to limit the number of opioids left over. These protocols may help slow the current opioid epidemic.

Drugs Becoming Generics-The Impact of Genericization on the Market Performance of Antihypertensive Active Pharmaceutical Ingredients.

To explore long-term changes in intra and inter-class choices between generic compounds, this paper investigates the market trends of two antihypertensive drug classes that have closely related pharmacological mechanisms—angiotensin convertase enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). We analysed the development of ACEI and ARB markets between 2001 and 2016 in nine European countries, covering the genericization transition periods of both therapeutic groups. The analysis was undertaken on the level of the active pharmaceutical ingredients (API) and focused on international and country-specific diffusion patterns. Comparison of ARB and ACEI therapies shows that although ARBs became off-patent during the observed period, and have a clinical advantage in terms of the adverse event profile over ACEIs, the increasing dominance of ARBs cannot be identified. One explanation is that ACEI therapies became generics earlier, relocating competition to the level of brands, while competition among ARBs remained at the level of the APIs. As for intra-class drug preferences, it was observed that the long-term trends show that ramipril outperformed its ACEI competitors, even though the kinetics and the rank order of preferred active compounds were inconsistent among markets. The diffusion of clinically preferable therapies seems to be ultimately supported by generic entries. In Eastern European countries, the emergence of generic markets has not only improved access to ACE inhibitors and ARBs, but has been a prerequisite for changing preferences. In contrast, genericization resulted in the relative anchoring of prior, branded era-based preferences in some Western European countries, which may be attributed to the role of the cessation of promotion and the fixity of prescription behaviour.

Institutional Opioid Prescription Guidelines are Effective in Reducing Post-Operative Prescriptions Following Urologic Surgery: Results From the American Urologic Association 2018 Census

ObjectiveTo assess provider and practice characteristics that drive opioid prescription behavior using the American Urological Association census data. MethodsStratified weighted analysis using 1,157 census samples was performed to represent 12,660 urologists who practiced in the United States in 2018. We compared urologists according to their opioid prescription patterns to evaluate factors and motivations behind opioid use in the post-operative setting. ResultsOverall, 11,205 (88.5%) urologists prescribe opioids in the post-operative setting. The presence of procedure-specific institutional prescribing guidelines was associated with a greater tendency to prescribe ≤10 pills, and lesser tendency to prescribe 11 to 49 and ≥50 tablets following open abdominal (P = .003), laparoscopic (P < .001), scrotal (P < .001), and endoscopic surgeries (P < .001). The presence of institutional prescribing guidelines was associated with decreasing opioid prescriptions over a three-year period whereas not having guidelines was associated with an unchanged prescription practice over time. Basing current prescriptions on what was given to prior patients was reported by 85% and was more likely to result in an unchanged amount of prescriptions over time (29.2% vs 13.3%, P = .007). Motivations to avoid patient phone calls were reported by 23.8% and were more likely to increase the opioids provided within the next 3 years (3.2% vs 0.1%, P < .001). ConclusionPractitioners who endorsed using institutional guidelines prescribed fewer opioids following all types of surgery and were more likely to decrease their prescription behavior over time. This data supports continued efforts to provide urologists with more evidence-based guidance on best practice opioid prescribing in the future.

Utilization of a National Registry to influence opioid prescribing behavior after hernia repair.

Despite progress toward curtailing opioid prescribing, physicians are often slow to adopt new prescribing practices. Using the Abdominal Core Health Quality Collaborative (ACHQC), we aimed to demonstrate the ability of a national, disease-specific, personalized registry to impact opioid prescribing. Using a collaborative and iterative process, a module was developed to capture surgeon opioid prescribing, patient-reported consumption, and risk factors for opioid use. Study reported according to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Six months after implementation of the ACHQC opioid module, we assessed participation, prescribing and patient consumption patterns. For ventral hernia repair (VHR; n = 398), 23 surgeons reported prescribing > 20 pills (43%), 11-20 (40%), and < 10 (18%). In contrast, patients (n = 217) reported taking < 10 pills in 65% and only 20% reported taking > 15. For inguinal hernia repair (IHR; n = 443) 37 surgeons reported prescribing > 20 tablets (22%), 11-20 (32%), and < 10 (44%). Patients (n = 277) reported taking < 10 pills in 81% of cases, including 50% reporting zero, and only 13% taking > 15. We identified barriers to practice change and developed a strategy for education, provision of individualized data, and encouraging participation. Surgeon participation has since increased significantly (n = 65 for VHR; n = 53 for IHR), and analysis of the impact of this process is ongoing. Quality improvement requires physician engagement, which can be facilitated by meaningful and actionable data. The specificity of the ACHQC and the ability to provide surgeons with individualized data is a model method to incite change in physician behavior and improve patient outcomes.

The use of analgesics in Dutch oral care from 2016 through 2020

Oral care providers frequently prescribe analgesics for the management of dental pain. To get an overview of the analgesics prescribed in the Netherlands from 2016 through 2020, we collected data from the Stichting Farmaceutische Kengetallen (foundation [for] pharmaceutical indicators). Annually, more than 300,000 analgesics are prescribed by dentists in general practice and dental specialists. The largest group concerns NSAIDs (88%), followed by weak opioids (9%), acetaminophen (2%) and strong opioids (1%). Of the NSAIDs, ibuprofen is the most prescribed by all groups of oral care providers (84-91%). Of the weak opioids, dentists and oral and maxillofacial surgeons mainly prescribe codeine and codeine/ acetaminophen (64% and 78%, respectively), while orthodontists mainly prescribe tramadol (53%). Of the strong opioids, oxycodone is the most frequently prescribed by all groups of oral care providers (77-87%). Analgesics are a large part of the prescription medications in Dutch oral care and mainly concern NSAIDs (ibuprofen) and weak opioids (codeine/ acetaminophen). There are no major differences in prescription behaviour among different oral care providers.

Determinants associated with doctors' prescribing behaviors in public hospitals in China.

Doctors' prescribing behaviors impact both medical expenses and health resources. This study aims to identify the significant determinants of prescribing behaviors of doctors, which could potentially provide theoretical evidence on how to improve prescribing decisions. A multistage, stratified, cluster, random sampling method was employed in this survey. Data were collected from Jiangsu and Shanxi provinces in China in 2018. A total of 444 doctors in public hospitals completed the self-administered questionnaires. A structural equation model based on the theory of planned behavior (TPB) was adopted for analysis. On the basis of the TPB, we constructed a model of doctors' prescribing behaviors, which explained the subjective and objective reasons for irrational prescribing behavior. Behavioral attitude, subjective norms, and perceived behavioral control could positively influence the actual behaviors, of which subjective norms impact prescribing behaviors the most. Employing the TPB helped in identifying determinants of prescribing behaviors from a new perspective. More significant policy changes and government support are required to help improve appropriate prescribing behaviors and ultimately make better prescribing decisions. This study provided a deeper understanding of this complex issue and will inform the development of a theory and evidence-based intervention for future research.

PD05-06 PROMOTIONAL PAYMENTS TO MEDICAL ONCOLOGISTS AND UROLOGISTS AND PRESCRIPTIONS FOR ABIRATERONE AND ENZALUTAMIDE

You have accessJournal of UrologyProstate Cancer: Advanced (including Drug Therapy) I (PD05)1 Sep 2021PD05-06 PROMOTIONAL PAYMENTS TO MEDICAL ONCOLOGISTS AND UROLOGISTS AND PRESCRIPTIONS FOR ABIRATERONE AND ENZALUTAMIDE Lillian Lai, Mary Oerline, Samuel Kaufman, Chad Ellimoottil, Vahakn Shahinian, Brent Hollenbeck, and Megan Caram Lillian LaiLillian Lai More articles by this author , Mary OerlineMary Oerline More articles by this author , Samuel KaufmanSamuel Kaufman More articles by this author , Chad EllimoottilChad Ellimoottil More articles by this author , Vahakn ShahinianVahakn Shahinian More articles by this author , Brent HollenbeckBrent Hollenbeck More articles by this author , and Megan CaramMegan Caram More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001969.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The introduction of abiraterone and enzalutamide has allowed medical oncologists and urologists to manage patients with advanced prostate cancer with oral therapeutics. To understand the influence of drug manufacturers on prescribing behavior, we examined the relationship between promotional payments from the manufacturers of abiraterone and enzalutamide and prescriptions of the two drugs. METHODS: Prescriptions filled between 2013 and 2017 were identified in the Medicare Part D File. Promotional payments made to medical oncologists and urologists between 2014 and 2017 were characterized using Open Payments Program data, and categorized as $0, $1-$999, and $1000 or more. The association between payments and prescribing behavior was assessed using generalized linear models. To isolate the effect of payment on subsequent prescribing behavior, a secondary analysis was performed excluding physicians who were already prescribing either drug before receiving their first payment. RESULTS: From 2013 to 2017, the number of medical oncologists and urologists prescribing abiraterone or enzalutamide increased by 38% and 298%, respectively. The percentage of physicians prescribing abiraterone or enzalutamide increased with higher levels of payment for both specialties. (Figure 1) Compared to medical oncologists who received $0, the odds of prescribing abiraterone or enzalutamide were 1.69 (95%CI 1.59-1.79) times higher among those receiving $1-$999 and 2.61 (95% CI 2.14-3.18) times higher among those receiving $1000 or more (p<0.01 overall). Compared to urologists who received $0, the odds of prescribing were 4.04 (95%CI 3.59-4.54) times higher among those receiving $1-$999 and 13.57 (95% CI 9.69-19.0) times higher among those receiving $1000 or more (p<0.01 overall). Associations were similar in magnitude after excluding physicians prescribing prior to receiving their first payment. CONCLUSIONS: Increasing promotional payments were associated with increasing odds of prescribing by physicians of both specialties, with a stronger relationship observed for urologists. Prescribing behavior and entry into this space, particularly for urologists, may be influenced by compensations from drug manufacturers. Source of Funding: NCI Advanced Training in Urologic Oncology T32 CA180984 (LYL) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e57-e57 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lillian Lai More articles by this author Mary Oerline More articles by this author Samuel Kaufman More articles by this author Chad Ellimoottil More articles by this author Vahakn Shahinian More articles by this author Brent Hollenbeck More articles by this author Megan Caram More articles by this author Expand All Advertisement Loading ...

512Challenges and opportunities to appropriate antibiotic prescribing: a survey of clinicians’ perceptions in Australia

Abstract Background Emerging antibiotic resistance is significant threat to global public health. There is evidence on sub-optimal prescribing as a contributing factor to antibiotic resistance. This study aimed to identify behavioral determinants of antibiotic prescribing that may help design effective interventions. Methods A cross-sectional survey was undertaken with clinicians (hospital and primary care) in Australia from June–October 2019. Multivariate logistic regression was used to determine if clinicians’ characteristics, and guidelines’ use, are associated with barriers of appropriate antibiotic prescribing. Results Inappropriate prescribing behavior is not limited to clinicians’ practices, but also relate to patients’ expectation and clinical culture. Lack of data for evidence-based decision-making and diagnostic uncertainty contribute to sub-optimal antibiotic prescribing. Different care settings and clinicians’ experience influence perceptions of whether unavailability of information, delay in diagnostic results and patient expectations regarding treatment led to inappropriate prescribing behavior. Respondents in primary care and with less experience were more likely to consider that patient demands (primary care: OR 1.76, 95%CI 1.34–2.68 &amp; experience (1-10 years): OR 1.34, 95%CI 1.07–1.59) and lack of data required for decision-making (primary care: OR 1.59, 95%CI 1.09–2.10 &amp; experience (1-10 years): OR 1.63, 95%CI 1.13–1.87) are barriers to appropriate prescribing. Conclusions A complex network of social, contextual and clinical factors influence prescribing practices. A holistic approach addressing clinicians’ practices, setting requirements and patient expectations must be considered. Key messages For optimal antibiotic prescribing, there is a need to focus on contextual requirements, shared decision-making and availability of relevant information at point-of-care.

Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). Secondary analyses of a statewide population-based cross-sectional survey. Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Pediatric Opioid Prescribing: A Call for Calm.

Pediatric Opioid Prescribing: A Call for Calm.

Effect of Peer Comparison Feedback, Individual Audit Feedback or Both to Clinicians on Opioid Prescribing in Acute Care Settings: A Cluster Randomized Clinical Trial

Research ObjectivePrescribing opioids, particularly the number of pills, is associated with greater likelihood of patients developing longer‐term opioid dependence. Nudges targeted to clinicians are a low‐cost strategy that could reduce unnecessary opioid prescribing. In particular, clinician‐focused peer comparison feedback has been effective in influencing prescribing for other medications. However, peer comparison feedback has not been well‐tested for opioid prescribing, alone or compared against other feedback approaches such as individual audit feedback.Study DesignWe conducted a pragmatic, four‐arm factorial cluster randomized clinical trial among 48 emergency department (ED) and urgent care (UC) practice sites within Sutter Health System including a 6‐month pre‐intervention period and a 6‐month intervention. 438 clinicians were cluster randomized by practice site. Interventions were delivered to clinicians monthly by email. Peer comparison feedback included the number of pills per opioid prescription and proportion of encounters with an opioid prescription in the prior 3 months, relative to that of their practice site peers. Individual audit feedback included the number of prescriptions with &gt;30 pills in the prior 3 months, indicating potential outlier prescriptions. The primary outcome measure was the change in the number of pills per prescription. Secondary outcomes included changes in the proportion of pills and milligrams of morphine equivalents (MME) per prescription.Population StudiedThe sample included 263 ED and 175 UC clinicians comprised of 294,962 patient encounters, with a mean (SD) age of 49 years (19), 56% female, 9% Black, and 21% Hispanic.Principal FindingsDuring the pre‐intervention period, there was a mean (SD) of 15.1 pills (3.9) and 76.3 MME (23.0) per prescription, and 9.3% of encounters with an opioid prescription. In adjusted analyses compared to usual care during the intervention, there was a significant decrease in pills per prescription among clinicians receiving peer comparison feedback alone (−0.9 pills per prescription; 95% CI ‐1.5 to −0.3, P = 0.002) and receiving both peer comparison and individual audit feedback (−1.4 pills per prescription; 95% CI ‐2 to −0.8, P &lt; 0.001), but not among clinicians receiving individual audit feedback alone (−0.4 pills per prescription; 95% CI ‐1.0 to 0.2, P = 0.24). There was also a significant decrease in MME per prescription for peer comparison feedback alone (−3.4 MME per prescription; 95% CI ‐6.6 to −0.3; P = 0.03) and combined with individual audit feedback (−4.3 MME per prescription; 95% CI ‐7.5 to −1.1; P = 0.009), but not for individual audit feedback alone (−3.1 MME per prescription; 95% CI ‐6.2 to 0.1; P = 0.06). There were no significant changes in the proportion of encounters with an opioid prescription.ConclusionsPeer comparison feedback was effective, alone and together with individual audit feedback, for significantly reducing the number of pills and MME per opioid prescription.Implications for Policy or PracticeThis is one of the largest trials ever conducted testing the impact of nudges on opioid prescribing and provides promise for low‐cost strategies to change clinician prescribing behavior more broadly.Primary Funding SourceThe Donaghue Foundation.

571Effect of a computer network-based feedback program on antibiotic prescription rates of primary care physicians

Abstract Background Antibiotic overuse is one of the major prescription problems in rural China and a major risk factor for antibiotic resistance. Low antibiotic prescription rates can effectively reduce the risk of antibiotic resistance. Methods A cluster randomized crossover open controlled trial was conducted in 31 hospitals. These hospitals were randomly allocated to two groups to receive the intervention for three months followed by no intervention for three months in a random sequence. The feedback intervention information, which displayed the physicians’ antibiotic prescription rates and ranking, was updated every 10 days. The primary outcome was the 10-day antibiotic prescription rate of the physicians. Results There were 82 physicians in group 1 (intervention first followed by control) and 81 in group 2 (control first followed by intervention). Baseline comparison showed no significant difference in antibiotic prescription rate between the two groups (30.8% vs 35.2%, P-value = 0.07). At the crossover point, the relative reduction in antibiotic prescription rate was significantly higher among physicians in the intervention group than in the control group (33.1% vs 20.3%, P-value &amp;lt; 0.001). After a further 3 months, the rate of decline in antibiotic prescriptions was also significantly greater in the intervention group compared to the control group (14.2% vs 4.6%, P-value &amp;lt; 0.001). Conclusions A computer network-based feedback intervention can significantly reduce the antibiotic prescription rates of primary care outpatient physicians. Key messages The feedback intervention continuously affected their prescription behavior for up to six months.

Attitudes and behaviour regarding dose reduction of biologics for psoriasis: a survey among dermatologists worldwide

Dose reduction (DR) of biologics, where possible, seems promising for more efficient use of expensive biologics. For implementation of DR strategies, it is essential to get insight in factors that influence implementation. The objective of this study was to evaluate the attitudes and behaviour regarding dose reduction of biologic therapies for psoriasis among psoriasis expert dermatologists worldwide. A 27-question e-survey was sent through the International Psoriasis Council (IPC) to its 114 dermatologist councilors worldwide. The survey assessed demographics, general and DR prescription behaviour, and motivations for and barriers against application of DR. Of 57 respondents, 53 respondents who prescribed biologics were included for analysis. Thirty-seven (69.8%) applied DR (i.e., ‘DR dermatologists’), and 16 (30.2%) did not (i.e., ‘Non-DR dermatologists’). DR strategies varied among respondents. Regarding criteria for starting DR, differences were reported in required treatment duration, and interpretation and duration of stable low disease activity. In addition, the prolongation of intervals between injections varied between respondents. For most ‘DR dermatologists’ (n = 32/37, 86.5%), cost savings were one of the main reasons to apply DR. Fifteen out of 16 ‘Non-DR dermatologists’ (94%) did not apply DR due to lack of scientific evidence. In conclusion, DR of biologics for psoriasis is part of clinical practice in psoriasis experts globally. Barriers for applying DR included lack of evidence or guidelines, and uncertainty on DR effects and risks. Although growing evidence shows DR feasibility, future studies are needed to accumulate and broaden evidence, along with development of (inter)national guidelines on DR strategies.

Korean physician prescription patterns for home oxygen therapy in chronic obstructive pulmonary disease patients.

Background/AimsHypoxemia in chronic obstructive pulmonary disease (COPD) leads to reduced ability to exercise, decreased quality of life, and, eventually, increased mortality. Home oxygen therapy in patients with severe COPD reduces distress symptoms and mortality rates. However, there have been few studies on physicians’ prescription behavior toward home oxygen therapy. Therefore, we investigated the respiratory specialists’ perspective on home oxygen therapy.MethodsIn this cross-sectional, study, a questionnaire was completed by 30 pulmonary specialists who worked in tertiary hospitals and prescribed home oxygen therapy. The questionnaire consisted of 28 items, including 15 items on oxygen prescription for outpatients, four for inpatients, and nine on service improvement.ResultsAll physicians were prescribing less than 2 L/min of oxygen for either 24 (n = 10, 33.3%) or 15 hours (n = 9, 30.3%). All (n = 30) used pulse oximetry, 26 (86.7%) analyzed arterial blood gas. Thirteen physicians had imposed restrictions and recommended oxygen use only during exercise or sleep. Sixteen (53.3%) physicians were educating their patients about home oxygen therapy. Furthermore, physicians prescribed home oxygen to patients that did not fit the typical criteria for long-term oxygen therapy, with 30 prescribing it for acute relief and 17 for patients with borderline hypoxemia.ConclusionsThis study identified the prescription pattern of home oxygen therapy in Korea. Respiratory physicians prescribe home oxygen therapy to hypoxemic COPD patients for at least 15 hours/day, and at a rate of less than 2 L/min. More research is needed to provide evidence for establishing policies on oxygen therapy in COPD patients.

A Review on The Impact of Pharmaceutical Promotions on Prescribing Behaviour

Doctors may not be aware of how much promotion they are exposed to. This is both the most difficult area to research and the most important. Therefore, as much as possible, research on the effect of promotion on behaviour should avoid relying on self‐report data to show causal relationships. Self‐report data are appropriate for finding out what people think is happening, or how they want to present themselves to others, but in this area, that may be far from the reality. This review looks at the evidence for several different possible effects of promotion on behaviour. These are the impact of promotion on individual prescribing behaviour, on overall drug sales, and on requests for formulary additions; the effect of DTCA on consumers’ decisions, the effect of promotion on the content of continuing medical education courses, and the impact of industry funding on research outcomes.

The Pandemic beyond the Pandemic: A Scoping Review on the Social Relationships between COVID-19 and Antimicrobial Resistance.

The social sciences are essential to include in the fight against both public health challenges of antimicrobial resistance (AMR) and COVID-19. In this scoping review, we document what social science knowledge has been published about the social relationship between COVID-19 and AMR and which social science interventions are suggested to address this social relationship. We analysed 23 peer-reviewed articles published between 2019 and 2021. Results emphasize that changes in antibiotic prescription behaviour, misinformation, over-burdened health systems, financial hardship, environmental impact and gaps in governance might increase the improper access and use of antibiotics during the COVID-19 pandemic, increasing AMR. The identified social sciences transformation strategies include social engagement and sensitisation, misinformation control, health systems strengthening, improved infection prevention and control measures, environmental protection, and better antimicrobial stewardship and infectious diseases governance. The review emphasizes the importance of interdisciplinary research in addressing both AMR and COVID-19.

Factors, Perceptions and Beliefs Associated with Inappropriate Antibiotic Prescribing in German Primary Dental Care: A Qualitative Study.

Dentists account for up to 10% of all prescribed antibiotics in primary care, with up to 80% being inappropriate. Targeted approaches to change prescription behavior are scarce. This study aimed at identifying specific barriers and facilitators for prudent antibiotic use in German dentistry by using qualitative methods. Nine in-depth interviews and two focus group discussions with another nine dentists were conducted and analyzed thematically. Dentists described being conflicted by the discordance of available treatment time and the necessity of thorough therapy. Lacking the opportunity of follow-up led to uncertainty. Dentists felt a lack of medical competency concerning prophylaxis for infectious endocarditis. A lack of empowerment to make therapeutic decisions interfered with guideline-conformity. The communication with fellow physicians is conflictual and improvement was wished for. In consequence, dentists felt pressure by potential medico-legal liability. Patients demanding quick and easy pain relief put extra strain on the interviewed dentists. Our hypotheses concord with preliminary data, mainly from the UK, but highlighted specifically medico-legal concerns and interprofessional communication as even greater barriers as described before. Tailored interventional concepts based on our findings may have the potential to lower antibiotic prescriptions in German primary dental care.

The modern hospital executive, micro improvements, and the rise of antimicrobial resistance

Antimicrobial resistance (AMR) is now recognised as a social, cultural, economic and political phenomenon, positioning the social sciences as central in responding to this global health threat. Yet efforts to address AMR within hospital settings, for example through antimicrobial stewardship (AMS) programs, continue to focus primarily on the prescribing practices of individual clinicians, often with little effect. There has been less attention to the role of healthcare administration, and managerialism therein, in explaining the limited progress to date in reining in antimicrobial misuse. To explore this, drawing on interviews with senior executives and managers from two Australian hospitals, we examine how these stakeholders navigate between management practice and AMR solutions, revealing that antimicrobial optimisation is frequently obscured by accountability structures attuned to other agendas. This has led, we argue, to the institutionalisation of micro-improvements that frequently ‘tick the box’ of having an AMS program, yet do little to effectively counteract rising AMR. Our analysis illustrates how sociological attention to the structural and ideological settings within which prescribing behaviour is carried out will be crucial to any attempts to successfully rein in AMR.

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography

BackgroundAntimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics has contributed to this problem and evidence-based interventions are urgently needed to change inappropriate prescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibiotic prescribing in hospitals through design of an effective behaviour-change intervention.MethodsQualitative synthesis using meta-ethnography of primary studies reporting doctors’ views and experiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twenty electronic databases were systematically searched over a 10-year period and potential studies screened against eligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretations were extracted and coded thematically into NVivo. All study processes were conducted by two reviewers working independently with findings discussed with the wider team and key stakeholders. Studies were related by findings into clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis and conceptual model. Findings are reported using eMERGe guidance.ResultsFifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors of varying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in four ways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals: loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting new line-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level, highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms, normalising input from other specialties and reducing variation in responsibility for antibiotic decisions.ConclusionsThis first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. That is, hospital antibiotic prescribing is a complex, context-dependent and dynamic process, entailing the balancing of many tensions. To change practice, comprehensive efforts are needed to manage failures in communication and information provision, promote distribution of responsibility for antibiotic decisions, and reduce fear of consequences from not prescribing.Trial registrationPROSPERO registration: CRD42017073740.

Modeling Antimicrobial Prescriptions in Scotland: A Spatiotemporal Clustering Approach.

In 2016, the British government acknowledged the importance of reducing antimicrobial prescriptions to avoid the long-term harmful effects of overprescription. Prescription needs are highly dependent on the factors that have a spatiotemporal component, such as bacterial outbreaks and urban densities. In this context, density-based clustering algorithms are flexible tools to analyze data by searching for group structures and therefore identifying peer groups of GPs with similar behavior. The case of Scotland presents an additional challenge due to the diversity of population densities under the area of study. We propose here a spatiotemporal clustering approach for modeling the behavior of antimicrobial prescriptions in Scotland. Particularly, we consider the density-based spatial clustering of applications with noise algorithm (DBSCAN) due to its ability to include both spatial and temporal data. We extend this approach into two directions. For the temporal analysis, we use dynamic time warping to measure the dissimilarity between time series while taking into account effects such as seasonality. For the spatial component, we propose a new way of weighting spatial distances with continuous weights derived from a Kernel density estimation-based process. This makes our approach suitable for cases with different local densities, which presents a well-known challenge for the original DBSCAN. We apply our approach to antibiotic prescription data in Scotland, demonstrating how the findings can be used to compare antimicrobial prescription behavior within a group of similar peers and detect regions of extremebehaviors.