Determinants of antibiotic over-prescribing for upper respiratory tract infections in an emergency department with good primary care access: a quantitative analysis

Huang, Zhilian; Weng, Yanyi; Ang, Hou; Chow, Angela

doi:10.1016/j.jhin.2021.04.016

Cited by 6 publications

(10 citation statements)

References 29 publications

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“…Apart from the types of medication errors, we identified medications involved in medication errors and found that piperacillin + tazobactam, ceftriaxone, and pantoprazole were the most common medications involved. This can be explained by a fact that antibiotics and proton pump inhibitors are known to be overprescribed regularly due to their use as prophylaxis because of uncertainty in the diagnosis [ 27 , 28 ]. We need to make sure that physicians adhere to the latest therapeutic guidelines when prescribing medications to avoid such errors.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Medication Errors in a Tertiary Care Hospital of a Low- to Middle-Income Country

Parthasarathi¹,

Puvvada²,

Patel

et al. 2021

Cureus

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Introduction Medication errors (MEs) are a major public health concern as they are detrimental to patient safety, compromise patients' confidence in the healthcare system, increase healthcare costs, and adversely affect the patient's quality of life. This is especially true in low to middle-income countries where the significance of MEs is largely undervalued. This study aims to investigate the prevalence of MEs and analyze the causes, medicines involved, reporting, and severity of MEs in a tertiary care setting. Methods A prospective observational study was conducted from March 2020 to February 2021 in a tertiary care teaching hospital in South India. The data was collected after reviewing patient medical records, by interviewing patients and healthcare professionals. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to evaluate MEs. Results A total of 557 MEs were identified from 3798 patients with a prevalence of 14.6%. Prescribing errors were the most commonly observed ME followed by errors related to documentation of medical records, administration-related errors, and dispensing errors. Lack of time for documentation of medication records, shift change and work overload were common causes of MEs. The majority of MEs were category A and B of the NCC MERP severity index. Conclusion Antibiotics and proton pump inhibitors were the most common medicines involved in MEs. Prescribing and documentation errors were most prevalent. Implementation of systems like strict adherence to treatment guidelines, computerized provider order entry (CPOE), barcode medication administration, and closed-loop electronic medication management systems may greatly help reduce MEs. All healthcare institutions should undertake routine audits to determine the prevalence and causes of medication errors.

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Section: Discussionmentioning

confidence: 99%

Evaluation of Medication Errors in a Tertiary Care Hospital of a Low- to Middle-Income Country

Parthasarathi¹,

Puvvada²,

Patel

et al. 2021

Cureus

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“…The attitude-related items were scored on a five-point Likert agreement scale (i.e., Strongly agree, Agree, Neutral, Agree, Strongly Disagree) while the behaviour-related items were scored on a five-point Likert frequency scale (i.e., Always, Most of the time, Sometimes, A few times, Never). The questions were revised from a previous survey [ 20 ] and constructed with reference to the literature on the factors influencing physicians’ antibiotic prescribing for URTI [ 14 , 15 , 21 ]. In our case, URTI refers to patients having symptoms of acute nasopharyngitis, sinusitis, pharyngitis, tonsillitis, laryngitis, tracheitis, and epiglottitis.…”

Section: Methodsmentioning

confidence: 99%

A multi-institutional exploration of emergency medicine physicians’ attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study

Huang

Tay

Kuan

et al. 2023

Antimicrob Resist Infect Control

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Background The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians’ attitudes and behaviours in four EDs in Singapore. Methods We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework. Results We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor. Conclusions Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

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“…Barriers and enablers were the focus of 12 qualitative,48–59 8 quantitative60–67 and 4 mixed-methods studies 68–71. Studies of barriers and enablers explored testing/treatment in infant bronchiolitis,54 55 68 antibiotic stewardship,53 56 57 62 70 cranial CT scans in minor head injury,49 52 guideline implementation in chest pain51 and syncope,69 urinalysis,56 67 urinary catheter insertion,50 lumbar radiographs in back pain,48 respiratory viral testing,54 potentially inappropriate medications in older patients58 and perspectives about low-value care 59 60 64–66 71…”

Section: Resultsmentioning

confidence: 99%

“…Of the included studies, 60% (12/20) of quantitative randomised,82 102 108 110 118 124–130 16.3% (20/123) of quantitative non-randomised,84 85 90 121 131–146 62.5% (5/8) of quantitative descriptive,61 62 64–66 100% (12/12) of qualitative48–57 and 25% (1/4) of mixed methods studies68 were assessed as being of higher quality. Among studies evaluating interventions, 21% (30/143) were of higher quality.…”

Section: Resultsmentioning

confidence: 99%

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Gangathimmaiah,

Drever,

Evans

et al. 2023

BMJ Open

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ObjectivesLow-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.DesignA mixed-methods scoping review was conducted using the Arksey and O’Malley framework.Data sourcesMedline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.Eligibility criteriaPrimary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.Data extraction and synthesisStudy selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.ResultsThe search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.ConclusionHigh-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

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Determinants of antibiotic over-prescribing for upper respiratory tract infections in an emergency department with good primary care access: a quantitative analysis

Cited by 6 publications

References 29 publications

Evaluation of Medication Errors in a Tertiary Care Hospital of a Low- to Middle-Income Country

Evaluation of Medication Errors in a Tertiary Care Hospital of a Low- to Middle-Income Country

A multi-institutional exploration of emergency medicine physicians’ attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

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