scholarly journals Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports

2019 ◽  
Vol 8 (1) ◽  
pp. e000351 ◽  
Author(s):  
Richard V Milani ◽  
Jonathan K Wilt ◽  
Jonathan Entwisle ◽  
Jonathan Hand ◽  
Pedro Cazabon ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Education ◽  
Test Group ◽  
Primary Care Providers ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Normative Comparison ◽  
Second Year ◽  
Tract Infections ◽  
The Impact

ImportanceAntibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI).ObjectiveTo evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI.DesignNon-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year.SettingPrimary care providers in a large regional healthcare system.ParticipantsThe test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions.InterventionThe intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year.Main outcomes and measuresRate of inappropriate antibiotic prescription for ARTI.ResultsBaseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention.Conclusions and relevanceProvider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.

scholarly journals A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Warren McIsaac ◽  
Sahana Kukan ◽  
Ella Huszti ◽  
Leah Szadkowski ◽  
Braden O’Neill ◽  
...  
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Care Provider ◽  
Primary Care Provider ◽  
Antibiotic Use ◽  
Primary Care Providers ◽  
Audit And Feedback ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Tract Infections

Abstract Background More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. Methods Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. Results There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). Conclusions A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. Trial registration clinicaltrials.gov (NCT03517215).

scholarly journals Qualitative Analysis of Primary Care Provider Prescribing Decisions for Urinary Tract Infections

Antibiotics ◽  
2019 ◽  
Vol 8 (2) ◽  
pp. 84 ◽  
Author(s):  
Larissa Grigoryan ◽  
Susan Nash ◽  
Roger Zoorob ◽  
George J. Germanos ◽  
Matthew S. Horsfield ◽  
...  
Keyword(s):  
Primary Care ◽  
Urinary Tract ◽  
Urinary Tract Infections ◽  
Primary Care Providers ◽  
Effective Control ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Sources Of Information ◽  
Acute Cystitis ◽  
Tract Infections

Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs’ knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.

The Perspective of Older Men With Depression on Suicide and Its Prevention in Primary Care

Crisis ◽  
2018 ◽  
Vol 39 (5) ◽  
pp. 397-405 ◽  
Author(s):  
Steven Vannoy ◽  
Mijung Park ◽  
Meredith R. Maroney ◽  
Jürgen Unützer ◽  
Ester Carolina Apesoa-Varano ◽  
...  
Keyword(s):  
Primary Care ◽  
Low Socioeconomic Status ◽  
Thematic Analysis ◽  
Older Men ◽  
Primary Care Providers ◽  
Depression Treatment ◽  
Care Providers ◽  
Low Socioeconomic ◽  
Self Image ◽  
The Impact

Abstract. Background: Suicide rates in older men are higher than in the general population, yet their utilization of mental health services is lower. Aims: This study aimed to describe: (a) what primary care providers (PCPs) can do to prevent late-life suicide, and (b) older men's attitudes toward discussing suicide with a PCP. Method: Thematic analysis of interviews focused on depression and suicide with 77 depressed, low-socioeconomic status, older men of Mexican origin, or US-born non-Hispanic whites recruited from primary care. Results: Several themes inhibiting suicide emerged: it is a problematic solution, due to religious prohibition, conflicts with self-image, the impact on others; and, lack of means/capacity. Three approaches to preventing suicide emerged: talking with them about depression, talking about the impact of their suicide on others, and encouraging them to be active. The vast majority, 98%, were open to such conversations. An unexpected theme spontaneously arose: "What prevents men from acting on suicidal thoughts?" Conclusion: Suicide is rarely discussed in primary care encounters in the context of depression treatment. Our study suggests that older men are likely to be open to discussing suicide with their PCP. We have identified several pragmatic approaches to assist clinicians in reducing older men's distress and preventing suicide.

scholarly journals 145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S83-S83
Author(s):  
Shelby J Kolo ◽  
David J Taber ◽  
Ronald G Washburn ◽  
Katherine A Pleasants
Keyword(s):  
Primary Care ◽  
Respiratory Infections ◽  
Primary Care Providers ◽  
The United States ◽  
Delivery Mode ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Care Providers ◽  
Intervention Period ◽  
Provider Education

Abstract Background Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold). Methods This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period. The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes. Results Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. Conclusion Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates. Disclosures All Authors: No reported disclosures

scholarly journals 22. Patient Satisfaction Remains Unchanged Following Implementation of an Antibiotic Stewardship Intervention in Primary Care

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S11-S12
Author(s):  
Zachary Hostetler ◽  
Keith W Hamilton ◽  
Leigh Cressman ◽  
McWelling H Todman ◽  
Ebbing Lautenbach ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Satisfaction ◽  
Odds Ratio ◽  
Logistic Regression Model ◽  
Adjusted Odds Ratio ◽  
Primary Care Providers ◽  
Mixed Effects ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Targeted Intervention

Abstract Background Inappropriate prescription of antibiotics for respiratory tract infections (RTIs) in ambulatory care settings is common, increasing the risk of adverse health outcomes. Behavioral and educational interventions targeting primary care providers (PCPs) have shown promise in reducing inappropriate antibiotic prescribing for RTIs. While one perceived barrier to such interventions is the concern that these adversely impact patient satisfaction, few data exist in this area. Here, we examine whether a recent PCP-targeted intervention that significantly reduced antibiotic prescribing for RTIs was associated with a change in patient satisfaction. Methods The PCP-targeted intervention involved monthly education sessions and peer benchmarking reports delivered to 31 clinics within an academic health system, and was previously shown to reduce antibiotic prescribing. Here, we performed a retrospective, secondary analysis of Press Ganey (PG) surveys associated with the outpatient encounters in the pre- and post-intervention periods. We evaluated the impact on patient perceptions of PCPs based on provider exposure to the intervention using a mixed effects logistic regression model. Results There were 17,416 out of 197,744 encounters (8.8%) with associated PG surveys for the study time period (July 2016 to September 2018). In the multivariate model, patient satisfaction with PCPs was most strongly associated with patient-level characteristics (age, race, health status, education status) and survey-level characteristics (survey response time, patient’s usual provider) (Figure 1). Satisfaction with PCPs did not change following delivery of the provider-based intervention even after adjusting for patient- and survey-level characteristics [adjusted odds ratio (95% CI): 1.005 (0.928, 1.087)]. However, a small increase in satisfaction associated with receiving antibiotics during the entire study period was seen [adjusted odds ratio (95% CI): 1.146 (1.06, 1.244)]. Figure 1: Association of a provider-targeted intervention as well as patient, provider, and practice characteristics with patient satisfaction in a multivariable mixed effects logistic regression model Conclusion Patient perceptions of PCPs remain unchanged following the delivery of a behavioral and educational intervention to primary care providers that resulted in observable decreases in antibiotic prescribing practices for RTIs. Disclosures All Authors: No reported disclosures

The Impact of Primary Care Providers’ Bias on Depression Screening for Lesbian Women

2021 ◽  
pp. 152483992110660
Author(s):  
Shuying Sha ◽  
Mollie Aleshire
Keyword(s):  
Primary Care ◽  
Statistical Tests ◽  
Secondary Analysis ◽  
Primary Care Providers ◽  
Depression Screening ◽  
Lesbian Women ◽  
Care Providers ◽  
Explicit Bias ◽  
Implicit And Explicit ◽  
The Impact

Primary care providers’ (PCPs) implicit and explicit bias can adversely affect health outcomes of lesbian women including their mental health. Practice guidelines recommend universal screening for depression in primary care settings, yet the guidelines often are not followed. The intersection of PCPs’ implicit and explicit bias toward lesbian women may lead to even lower screening and diagnosis of depression in the lesbian population than in the general population. The purpose of this secondary analysis was to examine the relationship between PCPs’ implicit and explicit bias toward lesbian women and their recommendations for depression screening in this population. PCPs ( n = 195) in Kentucky completed a survey that included bias measures and screening recommendations for a simulated lesbian patient. Bivariate inferential statistical tests were conducted to compare the implicit and explicit bias scores of PCPs who recommended depression screening and those who did not. PCPs who recommended depression screening demonstrated more positive explicit attitudes toward lesbian women ( p < .05) and their implicit bias scores were marginally lower than the providers who did not recommend depression screening (p = .068). Implications for practice: Depression screening rates may be even lower for lesbian women due to implicit and explicit bias toward this population. Training to increase providers’ awareness of bias and its harm is the first step to improve primary care for lesbian women. Policies must protect against discrimination based on sexual orientation or gender identity.

scholarly journals A Scoping Review of Trauma-Informed Curricula for Primary Care Providers

2021 ◽  
Vol 53 (10) ◽  
pp. 843-856
Author(s):  
Constance Gundacker ◽  
Tyler W. Barreto ◽  
Julie P. Phillips
Keyword(s):  
Primary Care ◽  
Patient Satisfaction ◽  
Health Outcomes ◽  
Primary Care Providers ◽  
The United States ◽  
Traumatic Experiences ◽  
Search Term ◽  
Care Providers ◽  
Trauma Informed ◽  
The Impact

Background and Objectives: Traumatic experiences such as abuse, neglect, and household dysfunction have a lifetime prevalence of 62%-75% and can negatively impact health outcomes. However, many primary care providers (PCPs) are inadequately prepared to treat patients with trauma due to a lack of training. Our objective was to identify trauma-informed approach curricula for PCPs, review their effectiveness, and identify gaps. Methods: We systematically identified articles from Medline, Scopus, Web of Science, Academic Search Premier, Cochrane, PsycINFO, MedEd Portal, and the STFM Resource Library. Search term headings “trauma-informed care (TIC),” “resilience,” “patient-centered care,” “primary care,” and “education.” Inclusion criteria were PCP, pediatric and adult patients, and training evaluation. Exclusion criteria were outside the United States, non-English articles, non-PCPs, and inpatient settings. We used the TIC pyramid to extract topics. We analyzed evaluation methods using the Kirkpatrick Model. Results: Researchers reviewed 6,825 articles and identified 17 different curricula. Understanding health effects of trauma was the most common topic (94%). Evaluation data revealed overall positive reactions and improved knowledge, attitudes, and confidence. Half (53%) reported Kirkpatrick level 3 behavior change evaluation outcomes with increased trauma screening and communication, but no change in referrals. Only 12% (2/17) evaluated Kirkpatrick level 4 patient satisfaction (significant results) and health outcomes (not significant). Conclusions: Pilot findings from studies in our review show trauma-informed curricula for PCPs reveal positive reactions, an increase in knowledge, screening, communication, and patient satisfaction, but no change in referrals or health outcomes. Further research is needed to examine the impact of trainings on quality of care and health outcomes.

Improving Primary Care Access to Respirologists Using eConsult

2021 ◽  
Author(s):  
Jean-Grégoire Leduc ◽  
Erin Keely ◽  
Clare Liddy ◽  
Amir Afkham ◽  
Misha Marovac ◽  
...  
Keyword(s):  
Primary Care ◽  
Median Time ◽  
Nurse Practitioners ◽  
Clinical Course ◽  
Primary Care Providers ◽  
Clinical Question ◽  
Care Providers ◽  
Provider Perspectives ◽  
Course Of Action ◽  
The Impact

Abstract Background: Patients and primary care providers (PCP) can experience frustration about poor access to specialist care. The Champlain Building Access to Specialists through eConsultation (BASETM) is a secure online platform that allows PCPs to ask a clinical question to 142 different specialty groups. The specialist is expected to respond within 7 days. Methods: This is a retrospective review of the Champlain BASETM respirology eConsults from January 2017 to December 2018. The eConsults were categorized by types of question asked by the referring provider, and by the clinical content of the referral. Specialists’ response time and time spent answering the clinical question was analyzed. Referring providers close out surveys were reviewed to assess the impact of the respirology eConsult service on traditional referral rates and clinical course of action. Results: Of the 26,679 cases submitted to the Champlain BASE TM eConsult service 268 were respirology cases (1%). 91% were sent by family physicians, 9% by nurse practitioners. The median time to respond by specialists was 0.8 days, and the median time billed by specialists was 20 minutes. The most common topics were pulmonary nodules and masses (16.4%), cough (10.4%), infective problems (8.6%), COPD (8.6%) and dyspnea NYD (7.8%). The most common types of question asked by PCP were related to investigations warranted (43.1% of cases), general management (17.5%), monitoring (12.6%), need for a respirology referral (12.3%), and drug of choice (6.3%). In 23% of cases the PCP indicated they were planning to refer the patient and no longer need to (avoided referrals) and in 13% of cases the PCP was not going to refer but did after receiving the eConsult advice (prompted referrals). The eConsult led to a new or additional clinical course of action by the PCP in 49% of cases. In 51% of cases the PCP suggested the clinical topic would be well suited to a CME event. Conclusions: Participation in eConsult services can improve timely access to respirologists while potentially avoiding clinic visit and significantly impacting referring PCPs clinical course of action. Using the most common clinical topics and types of question for CME planning should be considered. Future research may include a cost analysis, and provider perspectives on the role of eConsult in respirology care.

scholarly journals 1475. Understanding Prescribing Practices for Uncomplicated Urinary Tract Infections (UTIs) in the Primary Care Setting: A Pilot Study

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S538-S538
Author(s):  
Mark Pinkerton ◽  
Jahnavi Bongu ◽  
Aimee James ◽  
Michael Durkin
Keyword(s):  
Primary Care ◽  
Urinary Tract ◽  
Urinary Tract Infections ◽  
Clinical Decision ◽  
Primary Care Providers ◽  
Care Providers ◽  
Prescribing Practices ◽  
Support Tools ◽  
Tract Infections ◽  
Clinical Decision Support Tools

Abstract Background Uncomplicated urinary tract infections (UTIs) should be treated empirically with a short course of narrow-spectrum antibiotics. However, many clinicians order unnecessary tests and treat with long courses of antibiotics. The objective of this study was to understand how internists clinically approach UTIs. Methods We conducted semi-structured qualitative interviews of community primary care providers (n = 15) and internal medicine residents (n = 15) in St. Louis, Missouri from 2018 to 2019 to explore why clinical practices deviate from evidence-based guidelines. Interviews were transcribed, de-identified, and coded by two independent researchers using NVivo qualitative software. A Likert scale was used to evaluate preferences for possible interventions. Results Several common themes emerged. Both providers and residents ordered urine tests to “confirm” presence of urinary tract infections. Antibiotic prescriptions were often based on historical practice and anecdotal experience. Providers were more comfortable treating over the phone than residents and tended to prescribe longer courses of antibiotics. Both providers and residents voiced frustrations with guidelines being difficult to easily incorporate due to length and extraneous information. Preferences for receiving and incorporating guidelines into practice varied. Both groups felt benchmarking would improve prescribing practices, but had reservations about implementation. Pragmatic clinical decision support tools were favored by providers, with residents preferring order sets and attendings preferring nurse triage algorithms. Conclusion Misconceptions regarding urinary tract infection management were common among residents and community primary care providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support tools are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level. Disclosures All authors: No reported disclosures.

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