Does public reporting influence antibiotic and injection prescribing to all patients? A cluster-randomized matched-pair trial in china

Liu, Chenxi; Wang, Xuan; Zhang, Xiaopeng; Wan, Jie; Zhong, Fangying

doi:10.1097/md.0000000000003965

Cited by 19 publications

(41 citation statements)

References 40 publications

(62 reference statements)

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“…Inappropriate use of antibiotics is influenced by nonbiomedical factors within and beyond clinical settings that are unique to mainland China, yet common among lowincome and middle-income countries, including public misconceptions, 16-18 22 28 31 35 36 43 57 59 habitual use without professional guidance, 58 insufficient FDA monitoring, 56 incentivising the healthcare system towards prescribing and selling, 23 24 56 lack of diagnostic capacity, 25 27 and the delicate relationships between patients and prescribers, 27 but some critical factors such as antibiotic literacy remained as research gaps. To date, there have been only few interventions implemented in primary care settings to reduce inappropriate prescribing, [64][65][66][67][68][69][70] largely targeting clinicians and ignoring demand-side factors. Further, more research is needed to investigate the associations between human and animal use of antibiotics in rural China, where 564 million people reside 71 in order to inform effective One Health interventions.…”

Section: Discussionmentioning

confidence: 99%

Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review

et al. 2020

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BackgroundFor decades, antibiotics have been excessively consumed around the world, contributing to increased antimicrobial resistance (AMR) and negatively impacting health outcomes and expenditures. Antibiotic use in China accounts for half of worldwide antibiotic consumption, which mainly takes place in outpatient and community settings, and often unnecessarily for self-limiting community-acquired infections. This study aimed to identify and assess factors of inappropriate use of antibiotics in the Chinese context to inform the development of interventions to mitigate inappropriate consumption in the absence of clinical indications.MethodsWe conducted a mixed-methods systematic review and included empirical studies with original data conducted in mainland China, Hong Kong and Taiwan that investigated factors of antibiotic use in the community including outpatient care among patients, caregivers and prescribers. We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, Google Scholar and one Chinese database CNKI (China Knowledge Resource Integrated Database), using a combination of the key terms ‘antibiotic’, ‘antimicrobial’, ‘use’, ‘consumption’, ‘behaviour’, ‘prescribe’ and related syntax for all peer-reviewed publications published before June 2020. Health Belief Model was employed for data synthesis.FindingsFifty-four studies were included in the full-text review: 44 quantitative, 5 qualitative and 5 mixed-methods studies. Despite a high AMR awareness, public perception/misconception of antibiotic efficacy and easy access to antibiotics for self-limiting conditions drive inappropriate demand and use in the community including primary care setting. Providers’ prescribing behaviours are influenced by financial incentives, lack of diagnostic capacity and concerns over complications.ConclusionsInappropriate outpatient and community antibiotic use is influenced by non-biomedical factors at the individual, community, health system and societal levels in mainland China, contributing to a high antibiotic use rate. This study calls for context-tailored One Health interventions, restrictive antibiotic drug policy and multifaceted antibiotic stewardship programmes that simultaneously address drivers of inappropriate use from both the supply-side and demand-side within and beyond clinical settings.PROSPERO registration numberCRD42019139591.

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Section: Discussionmentioning

confidence: 99%

Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review

et al. 2020

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“…In 2017, Hubei had 347 UCHCs and 1137 RTHCs, receiving 23.03 million and 56.00 million outpatient visits, respectively [26]. Over-prescription of antibiotics was prevalent in these facilities: 65% of prescriptions contained antibiotics and 20% involved two or more antibiotics [27].…”

Section: Methodsmentioning

confidence: 99%

Intrinsic and external determinants of antibiotic prescribing: a multi-level path analysis of primary care prescriptions in Hubei, China

Liu

Wang

et al. 2019

Antimicrob Resist Infect Control

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Background Irrational use of antibiotics is a major driver of development of antibiotic resistance, which heavily threatens population health worldwide. Understanding the mechanism of physician’s antibiotic prescribing decisions is increasingly highlighted to promote prudent use of antibiotics. Therefore, the current study aimed to fill the gap, modelling physician’s antibiotic prescribing and identifying the potential intrinsic and external determinants of antibiotic prescribing in primary care. Methods A total of 428,475 prescriptions from 499 prescribers in 65 primary care facilities in Hubei of China were audited. Teixeira Antibiotic Prescribing Behavioral Model (TAPBM) was referred as theoretical basis to identify intrinsic and external predictors of antibiotic prescriptions. A questionnaire survey was conducted, covering potential physician’s intrinsic determinants (knowledge, attitudes and individual characteristics) and external factors both in individual level (patient pressure, time pressure and financial incentives) and institutional level (setting and local socio-economic development). A two-level path analysis was performed linking potential determinants of antibiotic use with physician’s actual practices. Results About 44.28% of the prescriptions contained antibiotics, with 9.28% containing two or more antibiotics. The multi-level path analysis revealed that knowledge was a significant predictor of attitudes (β = 0.154, p < 0.05), but higher knowledge and attitudes failed to translate into antibiotic prescribing practices ((β = − 0.076 – 0.039, p > 0.05). Instead, external factors played a more important role and physician’s antibiotic use was significantly associated with patient pressure (β = 0.102, p = 0.022), time pressure (β = − 0.164, p = 0.002), financial incentives (β = − 0.133– − 0.155, p = 0.027) and institutional environments (rural area, β = 0.408, p = 0.002; and high socioeconomic setting, β = − 0.641 - -0.578, p < 0.001 ). The prescribers who were male (β = − 0.168, p = 0.007) or had lower qualification (β = − 0.114, p = 0.028) were also more likely to prescribe antibiotics than others. Conclusion Antibiotic prescribing practices are complex process and associated with both intrinsic (prescriber) and external (patients and institutional environment) factors. A systematic approach is required to curb over-prescription of antibiotics. Apart from educating prescribers, it is equally important, if not more, to educate patients, break incentives and nurture professional culture within organization to reduce the overuse of antibiotics. Electronic supplementary material The online version of this article (10.1186/s13756-019...

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“…Public opinion/expectations and peer comparison appear to influence prescribing behaviours but in contrasting ways depending on the disease, patient cohort and doctor’s ranking. Liu et al [58], Tang et al [59], Tang et al [60], and Yang et al [61] reported effects of public reporting in primary care settings in China. Data on antibiotic prescribing (percentage of prescriptions including antibiotics or injections, and cost) were collected and individual doctors and facilities were compared and rankings were published publicly, e.g., on posters outside facilities.…”

Section: Table A1mentioning

confidence: 99%

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

2018

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This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

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Does public reporting influence antibiotic and injection prescribing to all patients? A cluster-randomized matched-pair trial in china

Abstract: Supplemental Digital Content is available in the text

Cited by 19 publications

References 40 publications

Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review

Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review

Intrinsic and external determinants of antibiotic prescribing: a multi-level path analysis of primary care prescriptions in Hubei, China

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

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