Prescribing Behavior Research Articles

Trends and Frequencies of Antibiotic Prescriptions for Acute Sinusitis Outpatient Visits in Adults.

The objective of this study was to analyze the trends and frequency in which recommended first-line therapy, amoxicillin with or without clavulanate, was prescribed for acute sinusitis based on current otolaryngology and other gold standard guidelines, as well as analyze differences in prescription behaviors of otolaryngologists compared with non-otolaryngologists for outpatient adult acute sinusitis visits. Weighted patient data from the National Ambulatory Medical Care Survey were analyzed to calculate visit rates and trends of antibiotic prescriptions for adults diagnosed with acute sinusitis from 2007 to 2019. Visits with multiple prescribed antibiotics or concomitant diagnoses requiring antibiotics were excluded. Each visit was classified based on the type of antibiotic prescribed. Acute sinusitis was diagnosed in 0.63% of all outpatient visits from 2007 to 2019 (95% confidence interval: 0.56%-0.71%). Amoxicillin had the greatest increase in prescription frequency (13.4%), whereas macrolides had the largest decrease in prescription frequency (13.9%). Among adult acute sinusitis outpatient visits in which antibiotics were prescribed, recommended first-line antibiotic therapy of amoxicillin-clavulanate or amoxicillin alone was prescribed in 40.4% of visits. The most common antibiotic prescribed was amoxicillin-clavulanate at otolaryngologist visits (20.5%) and macrolides at non-otolaryngologist visits (26.0%). A greater proportion of otolaryngologist visits resulted in no antibiotics prescribed for acute sinusitis (36.8% vs. 22.5%, p < 0.001). Otolaryngologists engage in watchful waiting more than non-otolaryngologists. Broader dissemination of existing guidelines for acute sinusitis treatment to non-Otolaryngologist (ENT) primary care specialties that take care of acute sinusitis to improve antibiotic stewardship and appropriate antibiotic selection is needed. 4 Laryngoscope, 134:2622-2625, 2024.

Gamified antimicrobial decision support app (GADSA) changes antibiotics prescription behaviour in surgeons in Nigeria: a hospital-based pilot study

AimsSurgical Antibiotic Prophylaxis (SAP) in Nigeria is often not evidence based. The aim of this study is to test if the GADSA application can change prescription behaviour of surgeons in Nigeria. In addition, the study aims to identify AMS strategies and policies for the future.MethodsThe GADSA gamified decision support app uses WHO and Sanford prescribing guidelines to deliver real-time persuasive technology feedback to surgeons through an interactive mentor. The app can advise on whether clinician’s decisions align with SAP recommendations and provides the opportunity for clinicians to make adjustments. Twenty surgeons actively participated in a 6-month pilot study in three hospitals in Nigeria. The surgeons determined the risk of infection of a surgical procedure, and the need, type and duration of SAP. The study used a longitudinal approach to test whether the GADSA app significantly changed prescribing behaviour of participating surgeons by analysing the reported prescription decisions within the app.Results321 SAP prescriptions were recorded. Concerning the surgical risk decision, 12% of surgeons changed their decision to be in line with guidelines after app feedback (p < 0.001) and 10% of surgeons changed their decision about the need for SAP (p = 0.0035) to align with guidelines. The change in decision making for SAP use in terms of “type” and “duration” to align with guidelines was similar with 6% and 5% respectively (both p-values < 0.001).ConclusionThis study suggests that the GADSA app, with its game based and feedback feature, could significantly change prescribing behaviour at the point of care in an African setting, which could help tackle the global challenge of antibiotic resistance.

Excellence in Antibiotic Stewardship: A Mixed-Methods Study Comparing High-, Medium-, and Low-Performing Hospitals.

Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P = .001), considered valuable team members (P = .001), and comfortable recommending antibiotic changes (P = .02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist-physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles. This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.

Uncovering doctors' perceived barriers and facilitators of antibiotic prescribing behaviours: a qualitative study using the theoretical domains framework.

Uncovering the barriers and facilitators of antibiotic prescribing is crucial in order to develop effective strategies for promoting responsible and evidence-based antibiotic use, thereby combating antibiotic resistance and enhancing patient care. This qualitative study, informed by the Theoretical Domains Framework (TDF) - specifically designed to understand and analyze the factors that influence human behavior, with a focus on identifying barriers and facilitators to behavior change, was aimed to explore the determinants (barriers and facilitators) of antibiotic prescribing behaviors from the perspective of doctors. Semi-structured interviews were conducted with healthcare professionals, and data analysis followed a theory-driven approach guided by the TDF. The analysis identified eight TDF domains influencing antibiotic prescribing, including memory, attention, and decision processes; knowledge; skills; belief about capabilities; goals; belief about consequences; emotions; and environmental context and resources. These domains were clustered into three overarching themes according to a bottom-up logic: the decision-making prescribing process itself, intrinsic factors related to the physician, and extrinsic factors influencing the decision. This research provides a comprehensive understanding of the complex interactions between these determinants in antibiotic prescribing. The evidence gained from the study valuable information for developing targeted interventions to improve antibiotic prescribing practices and combat antimicrobial resistance considering psychosocial and environmental variables impacting on antibiotic prescription decision making.

Physician Characteristics Associated With Opioid Prescribing After Same-Day Breast Surgery in Ontario, Canada: A Population-Based Cohort Study.

Opioid overprescribing in patients undergoing breast surgery is a concern, as evidence suggests that minimal or no opioid is needed to manage pain. We sought to describe characteristics of opioid prescribers and determine associations between prescriber's characteristics and high opioid prescribing within 7 days of same-day breast surgery. Patients ≥18 years of age who underwent same-day breast surgery in Ontario, Canada from 2012 to 2020 were identified and linked to prescriber data. The primary outcome was current high opioid prescribing defined as >75th percentile of the mean oral morphine equivalents (OME; milligrams). Prescriber characteristics including age, sex, specialty, years in practice, practice setting, and history of high (>75th percentile) opioid prescribing in the previous year were captured. Associations between prescriber characteristics and the primary outcome were estimated in modified Poisson regression models. The final cohort contained 56,434 patients, 3469 unique prescribers, and 58,656 prescriptions. Over half (1971/3469; 57%) of prescribers wrote ≥1 prescription that was >75th percentile of mean OME of 180 mg, of which 50% were family practice physicians. Adjusted mean OMEs prescribed varied by specialty with family practice specialties prescribing the highest mean OME (614 ± 38 mg) compared to surgical specialties (general surgery [165 ± 9 mg], plastic surgery [198 ± 10 mg], surgical oncology [154 ± 14 mg]). Whereas 73% of first and 31% of second prescriptions were provided by general surgery physicians, family practice physicians provided 2% of first and 51% of second prescriptions. Prescriber characteristics associated with a higher likelihood of high current opioid prescribing were family practice (risk ratio [RR], 1.56; 95% confidence interval [CI], 1.35-1.79 compared to general surgery), larger community practice setting (RR, 1.34; 95% CI, 1.05-1.71 compared to urban), and a previous high opioid prescribing behavior (RR, 2.28; 95% CI, 2.06-2.52). While most studies examine surgeon opioid prescribing, our data suggest that other specialties contribute to opioid overprescribing in surgical patients and identify characteristics of physicians likely to overprescribe.

Branded response to generic entry: Detailing beyond the patent cliff

The literature on pharmaceutical marketing devotes little attention to the promotion of branded drugs after generic competitors enter the market. This paper addresses this gap in the literature and explores how the sales of branded drugs respond to specific promotional strategies following generic entry. We focus on physician detailing, and specifically, firms’ post-generic-entry decisions regarding overall detailing spending and physician-level allocation (i.e., which physicians to visit). We utilize a novel, custom-built dataset containing information on aggregate-level sales, prescriptions, and promotional budget for 72 brands and their competitors; our dataset further includes detailed physician-level data on detailing visits and prescription behavior for 25 of these brands. We first describe the detailing strategies that brands use in practice, and then analyze the outcomes associated with changes in detailing spending and allocation. Our analyses reveal that, on average, brands’ detailing spending decreases after generic entry, yet the ROI on such spending increases compared to before generic entry. Refocusing of detailing efforts after generic entry such that physicians with higher brand preference are targeted is more likely to lead to an increase in detailing ROI than other allocation strategies post entry. However, in practice, many brands do not undertake such reallocation and do not enhance their ROIs. Our findings are of clear practical relevance to manufacturers of branded drugs, as well as to policy makers who wish to curb detailing efforts for branded drugs when generic alternatives are available, so as to lower healthcare costs.

Digital Twins for Anomaly Detection in the Industrial Internet of Things: Conceptual Architecture and Proof-of-Concept

Modern cyber-physical systems based on the Industrial Internet of Things (IIoT) can be highly distributed and heterogeneous, and that increases the risk of failures due to misbehavior of interconnected components, or other interaction anomalies. In this paper, we introduce a conceptual architecture for IIoT anomaly detection based on the paradigms of Digital Twins (DT) and Autonomic Computing (AC), and we test it through a proof-of-concept of industrial relevance. The architecture is derived from the current state-of-the-art in DT research and leverages on the MAPE-K feedback loop of AC in order to monitor, analyze, plan, and execute appropriate reconfiguration or mitigation strategies based on the detected deviation from prescriptive behavior stored as shared knowledge. We demonstrate the approach and discuss results by using a reference operational scenario of adequate complexity and criticality within the European Railway Traffic Management System.

1174. Impact of an Electronic Antibiotic Time-out Best Practice Alert on Antibiotic Use and Prescribing Behavior in Hospitalized Patients

Abstract Background Antibiotic time-outs (ATOs) are an evolving stewardship strategy capable of widespread impact with relatively low perceived personnel effort. ATO-based interventions have been shown to improve the rates of antibiotic de-escalation and increase the likelihood of antibiotic optimization. In August 2022, Hartford HealthCare implemented a 72-hour ATO best practice alert (BPA) within the electronic medical record (EMR). Herein, we evaluated the impact of this intervention on antibiotic use and describe behaviors associated with alert prompting. Methods This is a multi-center, quasi-experimental, retrospective chart review of admitted patients receiving empiric antibiotics for &amp;gt; 72 hours. An ATO alert was designed and embedded within the EMR and set to fire between the hours of 0700 and 1630. On BPA firing, prescribers were prompted to assess for antibiotic modification – a composite including discontinuation, de-escalation, inclusion of stop-date, and transition to oral therapies. Differences in the rate of antibiotic modification and overall antibiotic prescribing patterns for the 10 most frequently utilized antibiotics were compared between a pre-implementation control period (10/1/21 – 10/31/21) and a post-implementation period (10/1/22 – 10/31/22). Results A total of 800 patients were included for analysis. There was no significant difference in the rate of antibiotic modification when comparing the pre- and post-implementation cohort (54.5% vs 57.5%, p = 0.433); however, there was a numerically lower rate of antibiotic escalation in the post-cohort (9.5% vs 5.8%, p = 0.062). The duration of antibiotic therapy was longer in the post-implementation cohort (4.7 vs 5.0 days, p &amp;lt; 0.001). Conclusion Despite ATO implementation, rates of antibiotic modification were similar between the pre- and post-cohort. Further work to understand the optimal approach to implementing an ATO will be required to improve the impact on antimicrobial therapy. Disclosures Joseph L. Kuti, PharmD, bioMeriuex Inc.: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Merck &amp; Co, Inc: Grant/Research Support|Shionogi Inc: Advisor/Consultant|Shionogi Inc: Grant/Research Support|Shionogi Inc: Honoraria

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial.

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Сюжетная символика иносказаний (на материале средневековых армянских басен)

The paper deals with edifications expressed in Armenian fables of the XII–XIII centuries. These narratives describe common situations of overcoming serious difficulties, interrelations between authorities and people, and paradoxical unpredictability of existence. Three main topics presented in the narratives have been analyzed – the attitudes to the world, to authorities and to human character. The general principles of the world-view comprise loyalty to one’s own people, understanding the connection of cause and consequence, and emphasizing responsibility of one’s actions. The attitude to authorities is mainly critical. The fables show that power makes people cruel, but sober-minded shrewd people may win or at least remain alive. In times of war people should put aside their criticism and defend their country. The narratives about human nature describe envy and stupidity, and victims of fraud are not given sympathy to. The main inferences of the mediaeval Armenian fables may be summarized as fundamental ethical and utilitarian prescriptions of behavior – a realistic evaluation of complicated situations, impermissibility of credulousness, rejection of futile attempts to change the world, and loyalty to the principles of estimable life. The content of the fables reflects universal observations as expressed in similar narratives of other cultures, but has a vivid originality which manifests itself in the appeal to survive in almost unbearable circumstances.

Subthreshold opioid use disorder prevention (STOP) trial: a cluster randomized clinical trial: study design and methods

BackgroundPreventing progression to moderate or severe opioid use disorder (OUD) among people who exhibit risky opioid use behavior that does not meet criteria for treatment with opioid agonists or antagonists (subthreshold OUD) is poorly understood. The Subthreshold Opioid Use Disorder Prevention (STOP) Trial is designed to study the efficacy of a collaborative care intervention to reduce risky opioid use and to prevent progression to moderate or severe OUD in adult primary care patients with subthreshold OUD.MethodsThe STOP trial is a cluster randomized controlled trial, randomized at the PCP level, conducted in 5 distinct geographic sites. STOP tests the efficacy of the STOP intervention in comparison to enhanced usual care (EUC) in adult primary care patients with risky opioid use that does not meet criteria for moderate-severe OUD. The STOP intervention consists of (1) a practice-embedded nurse care manager (NCM) who provides patient participant education and supports primary care providers (PCPs) in engaging and monitoring patient-participants; (2) brief advice, delivered to patient participants by their PCP and/or prerecorded video message, about health risks of opioid misuse; and (3) up to 6 sessions of telephone health coaching to motivate and support behavior change. EUC consists of primary care treatment as usual, plus printed overdose prevention educational materials and an educational video on cancer screening. The primary outcome measure is self-reported number of days of risky (illicit or nonmedical) opioid use over 180 days, assessed monthly via text message using items from the Addiction Severity Index and the Current Opioid Misuse Measure. Secondary outcomes assess other substance use, mental health, quality of life, and healthcare utilization as well as PCP prescribing and monitoring behaviors. A mixed effects negative binomial model with a log link will be fit to estimate the difference in means between treatment and control groups using an intent-to-treat population.DiscussionGiven a growing interest in interventions for the management of patients with risky opioid use, and the need for primary care-based interventions, this study potentially offers a blueprint for a feasible and effective approach to improving outcomes in this population.Trial Registration: Clinicaltrials.gov, identifier NCT04218201, January 6, 2020.

Evidence-Based Opioid Education That Reduces Prescribing: The 10 Principles of Opioid Prescribing in Foot and Ankle Surgery

Over half of opioid misusers last obtained access to opioids via a friend or relative, a problematic reflection of the opioid reservoir phenomenon, which results from an unused backlog of excess prescription opioids that are typically stored in the American home. We aim to determine if a voluntary educational intervention containing standard opioid and nonopioid analgesic prescribing ranges for common surgeries is effective in altering postoperative prescribing practice. We utilized a mixed methods approach and sent out a questionnaire to American podiatric physicians, including residents (baseline group A), via email in early 2020 for baseline data; then, we interviewed foot and ankle surgeons and the primary themes of these semistructured interviews informed us to target residents for an educational intervention. We repeated the survey 3 years later in summer 2022 (preintervention group B). We created an opioid guide and emailed it to residents in fall 2022. Another repeat survey was done in spring 2023 (postintervention group C). We used the Mann-Whitney U test to examine differences between the groups among their reported postoperative opioid quantities for a first metatarsal osteotomy surgical scenario. Groups A, B, and C had 60, 100, and 99 residents, respectively. There was no significant difference (p = .9873) between baseline group A and preintervention group B. There was a difference (p < .0001; -5 median) between preintervention group B and postintervention group C (same residency year). In postintervention group C, a majority (91/99) reported viewing the guide at least once, and the number of residents that reported supplementing with NSAIDs also doubled compared to preintervention group B. This novel opioid educational intervention resulted in meaningful change in self-reported postoperative prescribing behavior among residents.

Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study

Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A). We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines. We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing. A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours. The Wellcome Trust, grant agreement number 215490/Z/19/Z.

Abstract 15848: Hardly a Windfall: Prescribing Practices in Pediatric Heart Failure Before and After Food and Drug Administration Approval

Background: Prior to the 2019 Food and Drug Administration (FDA) approval of ivabradine and sacubitril/valsartan, there were no medications approved for the treatment of pediatric heart failure (PHF). There are minimal data regarding the use of on- or off-label medications in PHF. Aims: We aim to describe medication use in PHF, factors associated with PHF medication use, and test the hypothesis that FDA approval is associated with changes in prescriber practice. Methods: Utilizing the Truven Health Marketscan Claims Encounter Database (2013-2021), we determined the prevalence of medication [diuretics, angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs), beta-blockers, pulmonary vasodilators, ivabradine, and sacubitril/valsartan] use in children ≤19yo with PHF and cardiomyopathy (CM), with a focus on use before and after FDA approval. Results: Of 2,218 children with PHF and CM, 76% were prescribed ≥ 1 HF medication. Diuretics (57%) and ACEi/ARBs (57%) were used most frequently ( Fig 1A) . Only 0.4% of patients were prescribed ivabradine and 3% sacubitril/valsartan. Patients enrolled in Medicaid were more likely to be prescribed HF medications than those with commercial insurance (OR 1.83, 95% CI 1.50-2.22). After FDA approval in 2019, sacubitril/valsartan prescription rose significantly from 0.4% in 2013-2018, to 3.9% in 2020-2021 (p &lt;0.001), and ivabradine use increased from 0.1% in 2018 to 0.5% (p = 0.043) in 2020-2021, but both remained rare (Fig 1B) . Conclusion: Diuretics and ACEi/ARBs are the most commonly used PHF medications, despite not being approved for this indication. The two FDA approved medications are used in ≤5% of patients. While FDA approval is important, it did not substantially influence physician prescribing behavior for PHF. Further study is needed to understand the value of FDA approval and the potential socioeconomic implications of the association between insurance type and medication use.

Physician beneficence and profit-taking among private for-profit clinics in China: A field study using a mystery shopper audit

This study employs a mystery shopper audit on a random sample of 96 for-profit private clinics in Jinan, China. We investigate two instruments which reflect beneficence among for-profit clinicians in private practice. The first is whether physicians returned a lost wallet “accidentally” left next to the physician’s table; and the second, whether physicians prescribed antibiotics to pseudo-patients who displayed no symptoms of any illness but had complained of fever the night before. These measures quantify beneficence under two different valence framing: returning a wallet represents clinicians who “do good” at personal cost to themselves, while not prescribing antibiotics represents a choice “not to do harm” to patients. We look at the correlation between these beneficence measures and the physicians’ prescription behaviors, and their revenues from the consultation. We find that whether doctors return a lost wallet or not, and prescribe antibiotics or not, such physicians are still as likely to prescribe medications which increase their incomes.

Factors influencing antibiotic prescribing by nurse practitioners: A quantitative pilot study using the theory of planned behavior.

The overuse of antibiotics contributes to the development of antibiotic resistance (AR) and exposes patients to potential antibiotic-related harm. Nurse practitioners (NPs) are well positioned to optimize antibiotic use; however, little is known about the factors influencing NP prescribing behaviors. Describe the knowledge, attitude, subjective norms, and perceived behavioral control in prescribing antibiotics among NPs practicing at a large university-affiliated health care system in the northeast United States. This was a cross-sectional online anonymous survey using the Theory of Planned Behavior. Descriptive statistics were used to describe the sample. Nonparametric tests were used to examine differences in the dependent variables by demographic characteristics. One hundred seventy-four of 618 NPs (28%) completed the survey. Almost all considered AR a problem in the United States, but only half considered it a problem in their health care setting. More than half indicated they prescribed antibiotics less than 25% of the time in daily practice. Most were confident in making antibiotic prescribing decisions. There was a positive relationship between years of experience as NPs and their confidence in making antibiotic prescribing decisions (p < .003) and an inverse relationship between years of experience as NPs and asking for advice from physicians or pharmacists when prescribing antibiotics (p < .002). With increasing numbers of NPs managing infectious diseases and prescribing antibiotics, these findings will inform interventions to support appropriate prescribing behaviors.

From guidelines to current practices: Suboptimal hypertension management in France

In France, the prevalence of hypertension is higher than 30%. Although treatment guidelines have been well established over the last twenty years, the national blood pressure control rate is below the average of high-income countries. This observational study aimed to describe the antihypertensive prescription behaviours of primary care physicians (PCPs) in France and to assess their compliance with current French guidelines, focusing on three specific prescription issues and their potential repercussions on blood pressure control: treatment initiation, treatment renewal or change and type of triple therapy. Prescription data were retrieved using the IQVIA longitudinal patient database (LPD), which delivers real-world data insights from French primary care electronic medical records (EMR). The average number of prescribed therapeutic agents was 1.9 per patient, with 39.3% monotherapy prescriptions. Treatment initiation represented 7.2% of all antihypertensive prescriptions. At treatment initiation, 22.5% of patients were prescribed dual therapy. The proportion of treatment renewal in the same therapeutic class was 74.3% while the proportion of treatment change was 18.5%. Of these, only 6.3% of patients received an additional therapy. Lastly, 35.7% of triple therapies were consistent with the recommended combinations. In conclusion, this study provides evidence of therapeutic gaps in hypertension management in France. The low blood control rate may be attributed to PCPs' therapeutic inertia and lack of knowledge of treatment guidelines. All stakeholders should commit to rapid corrective action in order to provide patients with the best care.

Using intervention mapping to design and implement a multicomponent intervention to improve antibiotic and NSAID prescribing.

Successfully changing prescribing behavior to reduce inappropriate antibiotic and nonsteroidal anti-inflammatory drug (NSAID) prescriptions often requires combining components into a multicomponent intervention. However, multicomponent interventions often fail because of development and implementation complexity. To increase the likelihood of successfully changing prescribing behavior, we applied a systematic process to design and implement a multicomponent intervention. We used Intervention Mapping to create a roadmap for a multicomponent intervention in unscheduled outpatient care settings in the Veterans Health Administration. Intervention Mapping is a systematic process consisting of six steps that we grouped into three phases: (i) understand behavioral determinants and barriers to implementation, (ii) develop the intervention, and (iii) define evaluation plan and implementation strategies. A targeted literature review, combined with 25 prescriber and 25 stakeholder interviews, helped identify key behavioral determinants to inappropriate prescribing (e.g. perceived social pressure from patients to prescribe). We targeted three desired prescriber behaviors: (i) review guideline-concordant prescribing and patient outcomes, (ii) manage diagnostic and treatment uncertainty, and (iii) educate patients and caregivers. The intervention consisted of components for academic detailing, prescribing feedback, and alternative prescription order sets. Implementation strategies consisted of preparing clinical champions, conducting readiness assessments, and incentivizing use of the intervention. We chose a mixed-method study design with a commonly used evaluation framework to assess effectiveness and implementation outcomes in a subsequent trial. This study furthers knowledge about causes of inappropriate antibiotic and NSAID prescribing and demonstrates how theoretical, empirical, and practical information can be systematically applied to develop a multicomponent intervention to help address these causes.

Association of arbitrary prescribing behavior to costly drug expenditures: a pharmacoeconomic study in primary care.

We aimed to examine the cost-related prescribing performance of primary care physicians who had a higher versus lower tendency of arbitrary prescribing. In this cross-sectional study, we evaluated the prescriptions of primary care physicians in Istanbul, collected with 3:1 systematic sampling. We determined higher versus lower arbitrary prescribing by the physician's degree of writing the solo diagnosis of "Z00- General examination without diagnosis/complaint": those for whom such prescriptions constituted >5% were classified as Group A and those with them at <0.5% as Group B. We compared these two groups by the total and disease-specific drug costs per prescription they produced for 10 frequently encountered indications. The median cost of disease-specific medication for all diagnoses in Group A and Group B, except anemia, was equal. In upper respiratory tract infections (URTIs), hypertension, anemia, diabetes, and conjunctivitis, the mean prescription costs of Group A were significantly higher than those of Group B (P < .001, P < .001, P = .009, P = .007, and P < .001, respectively), whereas disease-specific drug costs per prescription were similar (P > .05 in all diagnoses). In myalgia, Group A had lower cost per prescription (P < .001) and higher analgesic costs per prescription (P < .001) compared to those in Group B. We found significantly higher disease-specific drug cost share in Group B for URTIs (antibiotic), gastroesophageal reflux disease (gastric acid-suppressant), hypertension (antihypertensive), anemia (iron preparations), diabetes (antidiabetic), depression (antidepressant), and conjunctivitis (corticosteroid) than those in Group A (P < .001 for each). Our study showed that physicians who had a higher tendency of prescribing for no clear indication are also more likely to produce costly prescriptions.

The opinions of farm animal veterinarians in Ireland on antibiotic use and their role in antimicrobial stewardship

BackgroundAntibiotic use and resistance in animal production are a concern to public health, and there is an urgent need to reduce antibiotic use in farm animals. To prevent blame shifting, professionals from human medicine, animal medicine and environmental backgrounds must collaborate to tackle this issue. Veterinarians are typically responsible for overseeing and prescribing antibiotic use in animals. There are currently no available studies on the opinions of Irish farm animal veterinarians on antibiotic use, reduction opportunities and their relationships with farmers. A digital survey was developed and sent out to Irish farm animal veterinarians. This paper presents the results of a cross-sectional study of Irish farm animal veterinarians’ attitudes towards antimicrobial stewardship, their prescribing behaviours, antibiotic reduction opportunities and their attitudes for the future of antibiotic use. The veterinarian-farmer relationship is examined and potential interventions to reduce antibiotic use on farms are identified.ResultsIn total, 114 complete questionnaires were received, representing approximately 11 per cent of all farm animal veterinarians in Ireland. Respondents were aware of the problem of antibiotic resistance and recognise their role in the fight against it. They realise what actions they must take to reduce antibiotic use and identify barriers that prevent their farmer clients from implementing their advice. Many of them say that they can reduce antibiotic use on farms in the future, but some remain doubtful. There was no statistical difference between veterinarians that had less experience working than those that had more experience in their attitudes towards future reduction in antibiotic use.ConclusionMost of the respondents seek to use antibiotics as judiciously as they can. The majority agree that antibiotic overuse is the main contributor to antibiotic resistance. Possible solutions to reduce antibiotic use include the development of antibiotic treatment guidelines, assigning one unique practice to each farm and compulsory CPD (Continuous Professional Development) courses.