Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience

Abstract

Background We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals. Methods In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study. Results Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions. Conclusions This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received. Trial registration Current Controlled Trials ISRCTN12674243 (10 April 2017),

Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial

“…Immediate reduc tions in total DDDs per admission were greater among sites with processes for ongoing audit and feedback in place by implementation (by -16•6%, 95% CI -28•5 to -2•8, relative to sites that did not have processes in place by implementation) and greater among sites that submitted postim plementation audit data within 4 weeks following imple mentation (by -8•3%, -15•1 to -1•0, relative to sites that did not submit audit data within 4 weeks). However, the relative reduction in immediate implementation effect among sites that submitted postimplementation audit data within 4 weeks was not observed after we adjusted for whether the site had a process in place for ongoing audit and feedback by the implementation date in a multivariate model (appendix pp [16][17][18][19][20]. We found nonsignificantly greater sustained reductions in total DDDs per admission among sites that introduced ARK categories into the prescribing process by implementation than among sites that had not introduced ARK categories by implementation (by -11•5%, 95% CI -22•9 to 1•7, relative to the reference group; appendix p 16) and among sites with higher uptake of the online learning by implementation (ie, with ≥20 people per 100 acute beds completing the training) than among sites with lower uptake (by -9•9%, 95% CI -19•7 to 1•1, versus sited training <20 people per 100 acute beds).…”

“…We found nonsignificantly greater sustained reductions in total DDDs per admission among sites that introduced ARK categories into the prescribing process by implementation than among sites that had not introduced ARK categories by implementation (by -11•5%, 95% CI -22•9 to 1•7, relative to the reference group; appendix p 16) and among sites with higher uptake of the online learning by implementation (ie, with ≥20 people per 100 acute beds completing the training) than among sites with lower uptake (by -9•9%, 95% CI -19•7 to 1•1, versus sited training <20 people per 100 acute beds). Mediumsized sites also had non-significantly greater reductions in DDDs at implemen tation (by -7•4%, 95% CI -14•6 to 0•5, relative to small sites), with evidence for sustained year-on-year increases (by 14•6%, 0•1 to 31•3, relative to small sites; appendix pp [16][17][18][19][20].…”

“…The intervention comprised a decision aid that was intended to be embedded in the hospital prescription process, prompting prescribers to clarify the level of diagnostic uncertainty at antibiotic initiation by classifying infection risk as possible or probable, and then either stopping the prescription if a clear indication for ongoing antibiotic treatment could not be established at 48-72 h review or finalising the prescription if a clear indication could be established; online training to motivate and support use of the decision aid; implementation guidance, includ ing audit and feedback tools; and a patient leaflet. 18,19 The ARK tools are freely available through the British Society for Antimicrobial Chemotherapy. By supporting decisions to stop antibiotics at clinical review, the intervention aimed to safely reduce antibiotic use through reducing treatment duration, rather than by targeting the appropriateness of initial prescriptions.…”

“…The ARK programme created a four-component interven tion to help prescribers to take appropriate decisions to stop or continue antibiotics at prescription review, comprising a novel prescribing decision aid, an online training tool supporting use of the decision aid, guidance for implementing audit and feedback, and a patient leaflet. 18,19 In this study we report the immediate and sustained effect of the ARK intervention on antibiotic consumption at the hospital level and clinical outcomes at the patient level.…”

Antibiotic Review Kit for Hospitals (ARK-Hospital): a stepped wedge cluster randomised controlled trial

“…20 It comprised: 1) a decision aid intended to be embedded in the prescription process which classified antibiotic prescriptions initially as either “possible risk from infection” or “probable risk of infection” and then “finalised” when a clear indication for ongoing antibiotic treatment was established at a 48-72h review; 2) online training to motivate and support use of the decision aid; 3) implementation guidance, including audit and feedback tools; and 4) a patient leaflet. 22 All the tools developed within the ARK programme are freely available through the British Society for Antimicrobial Chemotherapy (BSAC) at: antibioticreviewkit.org.uk . Fidelity of intervention implementation was assessed using eight pre-defined criteria measuring staff engagement, uptake of the different intervention components, and timely submission of study data ( Table S1 ).…”