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

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).

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Comanagement and emergency room admissions in oncology practice.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.5_suppl.21 ◽

2017 ◽

Vol 35 (5_suppl) ◽

pp. 21-21

Author(s):

Jennifer Nadine Slim ◽

Michelle Marie Loch

Keyword(s):

Primary Care ◽

Chest Pain ◽

Cancer Survivors ◽

Emergency Room ◽

Care Provider ◽

Primary Care Provider ◽

Management Strategies ◽

Primary Care Providers ◽

Care Providers ◽

Admission Rates

21 Background: Cancer survivors face many challenges and encompass a multitude of specialties. These patients frequently utilize emergency room services with increased admission rates and, often, significant consequences on health care costs. National Hospital Ambulatory Medical Care Survey data from 2011 reports non-ischemic heart disease, chest pain and pneumonia as the most common emergency room discharge diagnoses for adults. We hypothesized that cancer survivors who continue care with primary providers require fewer emergency room based admissions. Our purpose in identifying these demographics was to allow for further consideration of specific interventions that might improve out patient based management. Methods: We considered ongoing primary care as those assigned to a primary care provider. We developed a memorandum of intention to identify patients at risk for over utilization of emergency room services. We gathered anonymous data about oncology patients seen in clinic from July 2014 to August 2015. We were able to determine how many emergency room based admissions were attributed to these patients as well as patients with and without primary care providers assigned in the EMR. We further attempted to identify those at higher risk taking into account co-morbid diagnoses. Results: 2,627 survivors were seen in clinic with 163 emergency room based admissions. 75% of these patients did not have a primary care provider identified in EPIC and account for 51% of the admissions. Only two patients had 3 or fewer co-morbid diagnoses. The most common co-morbid diagnoses among patients with emergency room based admission were abdominal pain, anemia, and chest pain. Conclusions: This data would suggest that co-management with primary care providers alone is not adequate for cancer survivors. While about half of the admissions were those without assigned primary care; the overall percentage of admission was higher from those assigned primary care providers. We suggest risk factors and management strategies are unique to survivors and require a focused multidisciplinary approach. Further study focused on interventions unique to cancer survivors are warranted.

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The effect of a Housing First intervention on primary care retention among homeless individuals with mental illness

PLoS ONE ◽

10.1371/journal.pone.0246859 ◽

2021 ◽

Vol 16 (2) ◽

pp. e0246859

Author(s):

Adam Whisler ◽

Naheed Dosani ◽

Matthew J. To ◽

Kristen O’Brien ◽

Samantha Young ◽

...

Keyword(s):

Primary Care ◽

Mental Illness ◽

Care Provider ◽

Primary Care Provider ◽

Medical Records ◽

Primary Care Providers ◽

Retention Rates ◽

Housing First ◽

Care Providers ◽

Treatment As Usual

Background Primary care retention, defined as ongoing periodic contact with a consistent primary care provider, is beneficial for people with serious chronic illnesses. This study examined the effect of a Housing First intervention on primary care retention among homeless individuals with mental illness. Methods Two hundred individuals enrolled in the Toronto site of the At Home Project and randomized to Housing First or Treatment As Usual were studied. Medical records were reviewed to determine if participants were retained in primary care, defined as having at least one visit with the same primary care provider in each of two consecutive six-month periods during the 12 month period preceding and following randomization. Results Medical records were obtained for 47 individuals randomized to Housing First and 40 individuals randomized to Treatment As Usual. During the one year period following randomization, the proportion of Housing First and Treatment As Usual participants retained in primary care was not significantly different (38.3% vs. 47.5%, p = 0.39). The change in primary care retention rates from the year preceding randomization to the year following randomization was +10.6% in the Housing First group and -5.0% in the Treatment As Usual group. Conclusion Among homeless individuals with mental illness, Housing First did not significantly affect primary care retention over the follow-up period. These findings suggest Housing First interventions may need to place greater emphasis on connecting clients with primary care providers.

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

Antibiotics ◽

10.3390/antibiotics8020084 ◽

2019 ◽

Vol 8 (2) ◽

pp. 84 ◽

Cited By ~ 4

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.

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Differences in unmet healthcare needs between public and private primary care providers: A population-based study

Scandinavian Journal of Public Health ◽

10.1177/1403494818762983 ◽

2018 ◽

Vol 46 (4) ◽

pp. 488-494 ◽

Cited By ~ 2

Author(s):

Christine Lindström ◽

Maria Rosvall ◽

Martin Lindström

Keyword(s):

Primary Care ◽

Care Provider ◽

Primary Care Provider ◽

Primary Care Providers ◽

Time Interval ◽

Care Providers ◽

Public And Private ◽

Private Providers ◽

Healthcare Needs ◽

Unmet Healthcare Needs

Aims: To investigate if any differences in unmet healthcare needs between persons registered at public and private primary care providers exist in Skåne (southernmost Sweden). Methods: The 2012 public health survey in Skåne was conducted with a postal questionnaire and included 28,029 respondents aged between 18 and 80 years. The study was cross-sectional. If the responder in the last three months had perceived oneself to be in need of medical care by a physician but did not seek it, this was used as a measure of unmet healthcare needs. Differences in unmet healthcare needs in relation to the primary care provider were investigated while adjusting for socioeconomic status and self-rated health in a logistic regression. Results: Differences in unmet healthcare needs were small and non-significant when comparing public and private healthcare providers. Non-manual workers were to a somewhat higher extent using private providers while manual workers showed a reverse pattern. Unmet healthcare needs had decreased slightly since 2008, but so had the response rate. Conclusions: With the current primary care system, no significant differences in unmet healthcare needs seem to exist when comparing public and private providers. It is likely that the providers are similar in their organizational setup, accessibility and doctor-patient continuity. Still more studies need to be done, preferably in a way so that uncertainty about what type of primary care provider the respondent is listed at can be avoided and perhaps using a longer time interval for unmet needs so that more subjects could be included.

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P047: Prevalence and severity of hypertension presenting to Calgary area emergency departments

CJEM ◽

10.1017/cem.2018.245 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S73-S73

Author(s):

K. Eppler ◽

D. Wang ◽

T.P. Pollak ◽

E.S. Lang

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Care Provider ◽

Primary Care Provider ◽

Early Recognition ◽

Primary Care Providers ◽

High Risk Population ◽

Care Providers ◽

Hypertensive Urgency

Introduction: Hypertension is common and a major cause of morbidity and mortality. Because it is asymptomatic, its diagnosis is often delayed. For many Canadians the Emergency Department (ED) is the only point of entry to the health care system, and therefore the recognition of undiagnosed and untreated hypertension in the ED is increasingly important. This study sought to evaluate the prevalence and severity of hypertension in patients presenting to Calgary area EDs, as well as to determine whether medical therapy was initiated and if patients had primary care providers for follow-up. Methods: Multi-centre electronic medical record (EMR) review of all adult patients presenting to Calgary area EDs from January 1, 2016 to December 31st, 2016. Hypertension was coded electronically by triage nurses and defined as systolic blood pressure SBP 140 mmHg and/or diastolic blood pressure DBP 90 mmHg. Hypertensive urgency was defined as SBP 180 mmHg and/or DBP 120 mmHg. Descriptive data was used to show patient demographics and hypertension prevalence. Primary care provider status, previous diagnosis of hypertension, chief complaint, and ED diagnoses were extracted and the EMRs were manually searched to determine whether treatment was initiated in the ED. Results: Of 304392 patients presenting to all Calgary sites, 43055 (14%) were found to have hypertension; mean age 52 (range 18 to 104), female 42%. Of these, 32986 (77%) had no known previous hypertension and 31% lacked a primary care provider. 0.2% had documentation of treatment initiated in the ED. 16% met criteria for hypertensive urgency. Conclusion: Many patients presenting to the ED have hypertension, often previously undiagnosed and at times severe. Many lack access to primary care. EDs may play an important role in the early recognition of hypertension. Dedicated management and follow-up pathways are indicated for this high-risk population.

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173. Identification of Inappropriate Antibiotic Orders During a Pharmacy-Supported Antimicrobial Stewardship Program in the Primary Care Setting: A Retrospective Analysis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.217 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S94-S94

Author(s):

Paula Eckardt ◽

Sheerida Hosein Mohammed ◽

Devada Singh-Franco ◽

William R Wolowich

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Care Setting ◽

Primary Care Setting ◽

Primary Care Providers ◽

Care Providers ◽

Duration Of Therapy ◽

Stewardship Program ◽

Prescribing Trends ◽

Tract Infections

Abstract Background In Florida, the number of antibiotic prescriptions has increased from 710–779 prescription/1000 population in 2012 to 748–839 prescription/1000 population in 2017. Antimicrobial stewardship in the outpatient setting is a suggested solution to combat antibiotics misuse in ambulatory practices. Methods This was a retrospective review of oral antimicrobial orders generated by primary care providers. The research protocol received approval from Memorial Healthcare System’s Institutional Review Board prior to any research related analysis being conducted. Orders from January 1-December 31, 2018 were reviewed for appropriateness by pharmacy based on IDSA guidelines. Appropriateness was assessed based on the need to prescribe the antibiotic for indication, selection, dose and duration of therapy. Descriptive statistics were used to analyze data. Results Of 2995 orders, 50.2% were inappropriate. The most common infections associated with inappropriate antibiotic use were upper/lower respiratory tract infections (URTIs (65%) and LRTIs (61%)), oral cavity infections (61%), and skin/soft tissue infections (SSTI (54%)). Inappropriately-prescribed antibiotics were penicillin (62%), cephalosporins (56%), quinolones (50%), macrolides (49%), and sulfamethoxazole/trimethoprim (46%). Penicillin use for URTIs were inappropriate (406 orders) for the following reasons: duration of therapy only 116/137 (85%); dose and duration 36/58 (62%), drug and dose 12/58 (21%) and all three (drug, dose, duration 85/93 (91%)). Conclusion Implementation of a pharmacist-driven antibiotic stewardship program in the primary care setting identified a significant proportion of orders that were inappropriate for type of antibiotic, dose, and duration of therapy in the management of patients with URTIs. These results serve as an avenue to implement the audit feedback process to promote appropriate use of antibiotics. A process improvement plan will include sharing of the findings, educating primary care physicians per IDSA guidelines and continuous review of prescribing trends. A programmatic evaluation will continue on an on-going basis to decrease the number of inappropriately prescribed antibiotics. Disclosures All Authors: No reported disclosures

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Analysis of an electronic consultation program at an academic medical centre: Primary care provider questions, specialist responses, and primary care provider actions

Journal of Telemedicine and Telecare ◽

10.1177/1357633x16633553 ◽

2016 ◽

Vol 23 (2) ◽

pp. 217-224 ◽

Cited By ~ 20

Author(s):

Katherine Wrenn ◽

Sereina Catschegn ◽

Marisa Cruz ◽

Nathaniel Gleason ◽

Ralph Gonzales

Keyword(s):

Primary Care ◽

San Francisco ◽

Care Provider ◽

Primary Care Provider ◽

Primary Care Providers ◽

Specialty Care ◽

Pulmonary Medicine ◽

Care Providers ◽

Academic Medical Centre ◽

Specialist Visit

Introduction Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations. Methods This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into “diagnosis,” “treatment,” and/or “monitoring.” We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months. Results PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult. Discussion eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists’ recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.

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

BMJ Open Quality ◽

10.1136/bmjoq-2018-000351 ◽

2019 ◽

Vol 8 (1) ◽

pp. e000351 ◽

Cited By ~ 10

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.

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PRECONCEPTION COUNSELING IN WOMEN WITH DIABETES BY PRIMARY CARE PROVIDERS AND PERCEIVED BARRIERS TO INITIATING THIS DISCUSSION

Endocrine Practice ◽

10.4158/ep-2019-0256 ◽

2020 ◽

Vol 26 (2) ◽

pp. 226-234

Author(s):

Angela L. Magdaleno ◽

Sandhya Venkataraman ◽

Melissa Dion ◽

Meredith Rochon ◽

Gretchen Perilli ◽

...

Keyword(s):

Internal Medicine ◽

Diabetes Mellitus ◽

Primary Care ◽

Family Medicine ◽

Care Provider ◽

Primary Care Provider ◽

Primary Care Providers ◽

Perceived Barriers ◽

Preconception Counseling ◽

Care Providers

Objective: To evaluate the frequency that women with diabetes mellitus seen by a primary care provider receive preconception counseling; to identify barriers to preconception counseling; and to determine differences between family medicine, internal medicine, and obstetrics and gynecology. Methods: This was a retrospective cohort study in which medical records were reviewed to determine if preconception counseling was done. An electronic survey evaluated how often preconception counseling was provided and identified perceived barriers to preconception counseling. Characteristics of those who received preconception counseling and those who did not, and survey responses between disciplines, were compared. Results: Women that met inclusion criteria: 577 (18.9% of whom received preconception counseling). A total of 88.7% of primary care providers indicated that preconception counseling was important, but only 39.2% reported that they regularly provide preconception counseling. Conclusion: Women with diabetes mellitus do not regularly receive preconception counseling by primary care providers. Lack of time and knowledge were the most commonly identified barriers to providing preconception counseling. Abbreviations: DM = diabetes mellitus; FM = family medicine; HbA1c = hemoglobin A1c; IM = internal medicine; LVHN = Lehigh Valley Health Network; Ob/Gyn = obstetrics/gynecology; PC = preconception counseling; PCP = primary care provider

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Paging the eCardiologist: insights into referral behaviour of primary care physicians from qualitative analysis of a cardiology eConsult service

Digital Health ◽

10.1177/2055207618792140 ◽

2018 ◽

Vol 4 ◽

pp. 205520761879214

Author(s):

Elizabeth Chan ◽

Christopher B Johnson ◽

Clare Liddy ◽

Erin Keely ◽

Nadine Gauthier ◽

...

Keyword(s):

Primary Care ◽

Qualitative Analysis ◽

Care Provider ◽

Primary Care Provider ◽

Primary Care Physicians ◽

Positive Family History ◽

Primary Care Providers ◽

Secondary Outcome ◽

Care Providers ◽

Convenience Sample

Objective The purpose of this study is to investigate determinants of primary care physician cardiology referrals by performing qualitative analysis of questions asked by primary care physicians in cardiology electronic consultation services (eConsults). Setting A health region in eastern Ontario, Canada, where primary care providers have had access to an eConsult service since 2010. Participants We included all consecutive cardiology eConsults initiated by registered primary care provider users of our eConsult service and who initiated one or more eConsult between July 2014 and January 2015. We excluded eConsults in which the primary care provider attached a document without asking a question. A convenience sample of 100 consecutive eConsults initiated by 61 primary care providers was analysed after excluding 14 eConsults. Primary and secondary outcome measures: Primary care provider eConsult questions are categorised into thematic categories based on the constant comparison method of qualitative analysis with external validation by content experts. Secondary outcomes include sample primary care provider eConsult questions to illustrate each theme and any emergent subthemes. Results Thematic saturation occurred after analysis of 30 eConsults. An additional 70 eConsults were coded with no new emergent themes. Themes include exceptions to clinical guidelines ( n=13), non-cardiac treatment in a cardiac patient ( n=13), specific investigation/management ( n=18), interpretation of diagnostic testing ( n=46), clinical concerns despite normal testing ( n=4) and screening for positive family history ( n=6). Subthemes include multiple comorbidities and mild abnormalities on cardiac tests. Conclusions We report categories of clinical questions that drive primary care provider cardiology eConsults. Multimorbidity leads to cardiology eConsults as primary care providers try to apply treatment guidelines in medically complex patients. Mild test abnormalities unrelated to clinical problems commonly lead to cardiology eConsult requests. Further research is needed to determine how guidelines can better account for multimorbidity, and how cardiologists can better communicate with primary care providers to put cardiac test results in clinical context.

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