scholarly journals Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study

2019 ◽  
Vol 23 (11) ◽  
pp. 1-70 ◽  
Author(s):  
Martin C Gulliford ◽  
Dorota Juszczyk ◽  
A Toby Prevost ◽  
Jamie Soames ◽  
Lisa McDermott ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practice ◽  
Cohort Study ◽  
Respiratory Infections ◽  
Antibiotic Prescribing ◽  
Intervention Trial ◽  
Health Records ◽  
Multicomponent Intervention ◽  
General Practices ◽  
Electronically Delivered

BackgroundUnnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance.ObjectivesTo develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs).InterventionsA multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing.DesignA parallel-group, cluster randomised controlled trial.SettingThe trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD).ParticipantsAll registered patients were included.Main outcome measuresThe primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period.Cohort studyA separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014.ResultsThere were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99;p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15–84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices.LimitationsThe research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended.ConclusionsThis study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15–84 years, but not for children or the senior elderly.Future workStrategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed.Trial registrationCurrent Controlled Trials ISRCTN95232781.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.

scholarly journals Comparison of antibiotic prescribing records in two UK primary care electronic health record systems: cohort study using CPRD GOLD and CPRD Aurum databases

BMJ Open ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. e038767
Author(s):  
Martin C Gulliford ◽  
Xiaohui Sun ◽  
Thamina Anjuman ◽  
Eleanor Yelland ◽  
Tarita Murray-Thomas
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Electronic Health Record ◽  
Clinical Practice Research Datalink ◽  
Antibiotic Prescribing ◽  
Health Record ◽  
Medical Diagnoses ◽  
General Practices ◽  
Electronic Health ◽  
Tract Infections

ObjectivesWe aimed to evaluate recording of antibiotic prescribing from two primary care electronic health record systems.DesignCohort study.SettingUK general practices contributing to the Clinical Practice Research Datalink (CPRD) databases: CPRD GOLD (Vision data) and CPRD Aurum (EMIS data). English CPRD GOLD general practices were analysed as a subgroup, as all CPRD Aurum practices were located in England.Participants158 305 patients were randomly sampled from CPRD Aurum and 160 394 from CPRD GOLD.Outcome measuresAntibiotic prescriptions in 2017 were identified. Age-standardised and sex-standardised antibiotic prescribing rates per 1000 person years were calculated. Prescribing of individual antibiotic products and associated medical diagnoses was evaluated.ResultsThere were 101 360 antibiotic prescriptions at 883 CPRD Aurum practices and 112 931 prescriptions at 290 CPRD GOLD practices, including 112 general practices in England. The age-standardised and sex-standardised antibiotic prescribing rate in 2017 was 512.6 (95% CI 510.4 to 514.9) per 1000 person years in CPRD Aurum and 584.3 (582.1 to 586.5) per 1000 person years in CPRD GOLD (505.2 (501.6 to 508.9) per 1000 person years if restricted to practices in England). The 25 most frequently prescribed antibiotic products were similar in both databases. One or more medical codes were recorded on the same date as an antibiotic prescription for 72 989 (74%) prescriptions in CPRD Aurum, 84 756 (78%) in CPRD GOLD and 28 471 (78%) for CPRD GOLD in England. Skin, respiratory and genitourinary tract infections were recorded for 39 035 (40%) prescriptions in CPRD Aurum, 41 326 (38%) in CPRD GOLD, with 15 481 (42%) in English CPRD GOLD practices only.ConclusionEstimates for antibiotic prescribing and infection recording were broadly similar in both databases suggesting similar recording across EMIS and Vision systems. Future research on antimicrobial stewardship can also be conducted using primary care data in CPRD Aurum.

scholarly journals Impact Of Electronic Health Record Interface Design On Unsafe Prescribing Of Ciclosporin, Tacrolimus and Diltiazem: A Cohort Study In English NHS Primary Care

2019 ◽  
Author(s):  
Brian MacKenna ◽  
Seb Bacon ◽  
Alex J Walker ◽  
Helen J Curtis ◽  
Richard Croker ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Clinical Practice ◽  
Electronic Health Records ◽  
Interface Design ◽  
Quantitative Research ◽  
Health Records ◽  
General Practices ◽  
Electronic Health ◽  
Almost All

AbstractBackgroundIn England, national safety guidance recommends that ciclosporin, tacrolimus and diltiazem are prescribed by brand name due to their narrow therapeutic windows and, in the case of tacrolimus, to reduce the chance of organ transplantation rejection. Various small studies have shown that changes to electronic health records (EHR) interface can affect prescribing choices.ObjectivesOur objectives were to assess variation by EHR system in breaches of safety guidance around prescribing of ciclosporin, tacrolimus and diltiazem; and to conduct user-interface research into the causes of such breaches.MethodsWe carried out a retrospective cohort study using prescribing data in English primary care. Participants were English general practices and their respective electronic health records. The main outcome measures were (1) variation in ratio of breaching / adherent prescribing all practices (2) description of observations of EHR usage.ResultsA total of 2,575,411 prescriptions were issued in 2018 for ciclosporin, tacrolimus and diltiazem (over 60mg); of these, 316,119 prescriptions breached NHS guidance (12.3%). Breaches were most common amongst users of the EMIS EHR (in 23.2% of ciclosporin & tacrolimus prescriptions, and 22.7% of diltiazem prescriptions); but breaches were observed in all EHRs.ConclusionDesign choices in EHR strongly influence safe prescribing of ciclosporin, tacrolimus and diltiazem; and breaches are prevalent in general practices in England. We recommend that all EHR vendors review their systems to increase safe prescribing of these medicines in line with national guidance. Almost all clinical practice is now mediated through an EHR system: further quantitative research into the effect of EHR design on clinical practice is long overdue.

scholarly journals How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals

2020 ◽  
Vol 75 (9) ◽  
pp. 2681-2688 ◽  
Author(s):  
Aleksandra J Borek ◽  
Sibyl Anthierens ◽  
Rosalie Allison ◽  
Cliodna A M McNulty ◽  
Donna M Lecky ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practice ◽  
Financial Incentives ◽  
Financial Incentive ◽  
Antibiotic Prescribing ◽  
Telephone Interviews ◽  
Local Resources ◽  
Additional Funding ◽  
General Practices ◽  
Competing Priorities

Abstract Background The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. Objectives To understand responses to the QP and how it was perceived to influence antibiotic prescribing. Methods Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. Results The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. Conclusions CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.

scholarly journals Infection-related complications after common infection in association with new antibiotic prescribing in primary care: retrospective cohort study using linked electronic health records

BMJ Open ◽  
2021 ◽  
Vol 11 (1) ◽  
pp. e041218
Author(s):  
Birgitta van Bodegraven ◽  
Victoria Palin ◽  
Chirag Mistry ◽  
Matthew Sperrin ◽  
Andrew White ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practice ◽  
Cohort Study ◽  
Tract Infection ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Hospital Admissions ◽  
Antibiotic Prescribing ◽  
Common Infection ◽  
Common Infections

ObjectiveDetermine the association of incident antibiotic prescribing levels for common infections with infection-related complications and hospitalisations by comparing high with low prescribing general practitioner practices.Design retrospective cohort studyRetrospective cohort study.Data sourceUK primary care records from the Clinical Practice Research Datalink (CPRD GOLD) and SAIL Databank (SAIL) linked with Hospital Episode Statistics (HES) data, including 546 CPRD, 346 CPRD-HES and 338 SAIL-HES practices.ExposuresInitial general practice visit for one of six common infections and the proportion of antibiotic prescribing in each practice.Main outcome measuresIncidence of infection-related complications (as recorded in general practice) or infection-related hospital admission within 30 days after consultation for a common infection.ResultsA practice with 10.4% higher antibiotic prescribing (the IQR) was associated with a 5.7% lower rate of infection-related hospital admissions (adjusted analysis, 95% CI 3.3% to 8.0%). The association varied by infection with larger associations in hospital admissions with lower respiratory tract infection (16.1%; 95% CI 12.4% to 19.7%) and urinary tract infection (14.7%; 95% CI 7.6% to 21.1%) and smaller association in hospital admissions for upper respiratory tract infection (6.5%; 95% CI 3.5% to 9.5%) The association of antibiotic prescribing levels and hospital admission was largest in patients aged 18–39 years (8.6%; 95% CI 4.0% to 13.0%) and smallest in the elderly aged 75+ years (0.3%; 95% CI −3.4% to 3.9%).ConclusionsThere is an association between lower levels of practice level antibiotic prescribing and higher infection-related hospital admissions. Indiscriminately reducing antibiotic prescribing may lead to harm. Greater focus is needed to optimise antibiotic use by reducing inappropriate antibiotic prescribing and better targeting antibiotics to patients at high risk of infection-related complications.

scholarly journals Impact Of Electronic Health Record Interface Design On Unsafe Prescribing Of Ciclosporin, Tacrolimus and Diltiazem: A Cohort Study In English NHS Primary Care (Preprint)

2019 ◽  
Author(s):  
Brian MacKenna ◽  
Seb Bacon ◽  
Alex J Walker ◽  
Helen J Curtis ◽  
Richard Croker ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Clinical Practice ◽  
Electronic Health Records ◽  
Interface Design ◽  
Quantitative Research ◽  
Health Records ◽  
General Practices ◽  
Electronic Health ◽  
Almost All

BACKGROUND In England, national safety guidance recommends that ciclosporin, tacrolimus and diltiazem are prescribed by brand name due to their narrow therapeutic windows and, in the case of tacrolimus, to reduce the chance of organ transplantation rejection. Various small studies have shown that changes to electronic health records (EHR) interface can affect prescribing choices. OBJECTIVE Our objectives were to assess variation by EHR system in breaches of safety guidance around prescribing of ciclosporin, tacrolimus and diltiazem; and to conduct user-interface research into the causes of such breaches. METHODS We carried out a retrospective cohort study using prescribing data in English primary care. Participants were English general practices and their respective electronic health records. The main outcome measures were (1) variation in ratio of breaching / adherent prescribing all practices (2) description of observations of EHR usage. RESULTS A total of 2,575,411 prescriptions were issued in 2018 for ciclosporin, tacrolimus and diltiazem (over 60mg); of these, 316,119 prescriptions breached NHS guidance (12.3%). Breaches were most common amongst users of the EMIS EHR (in 23.2% of ciclosporin & tacrolimus prescriptions, and 22.7% of diltiazem prescriptions); but breaches were observed in all EHRs. CONCLUSIONS Design choices in EHR strongly influence safe prescribing of ciclosporin, tacrolimus and diltiazem; and breaches are prevalent in general practices in England. We recommend that all EHR vendors review their systems to increase safe prescribing of these medicines in line with national guidance. Almost all clinical practice is now mediated through an EHR system: further quantitative research into the effect of EHR design on clinical practice is long overdue. CLINICALTRIAL

scholarly journals Antibiotic prescribing frequency amongst patients in primary care: a cohort study using electronic health records

2017 ◽  
Vol 72 (6) ◽  
pp. 1818-1824 ◽  
Author(s):  
Laura Shallcross ◽  
Nick Beckley ◽  
Greta Rait ◽  
Andrew Hayward ◽  
Irene Petersen
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Electronic Health Records ◽  
Antibiotic Prescribing ◽  
Health Records ◽  
Electronic Health
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