Patients without records and records without patients: review of patient records in primary care and implications for surveillance of antibiotic prescribing in rural China

Abstract

Background: We need to monitor patterns of antibiotic prescribing in order to develop and evaluate antibiotic stewardship interventions in rural China. As part of a multidisciplinary study of antibiotic use in Anhui Province we assessed the validity of electronic records (e-records) as a source of surveillance data. Methods: One township healthcare centre and one village clinic were selected in each of three different counties. Patients with symptoms of Upper Respiratory Tract Infection (URTI), exacerbation of Chronic Obstructive Pulmonary Disease (COPD) or Urinary Tract Infection (UTI) were recruited consecutively. Researchers observed and documented clinic consultations and interviewed each of the study participants. E-records were compared to clinic observations and patient interviews. Results: A total of 1030 patients were observed in clinic. Antibiotics were prescribed in 917 (89%) of consultations. Erecords were created only for individuals with health insurance, with considerable between-site variation in completeness (0 to 98.7% of clinic consultations) and in the timing of documentation (within-consultation up to weeks afterwards). Erecord accuracy was better in relation to antibiotics (82.8% of e-records accurately recorded what was prescribed in clinic) than for diagnosis and symptoms (45.0 and 1.1% accuracy). Only 31 participants (3.0%) presented with UTI symptoms. Conclusions: We have confirmed very high rates of outpatient antibiotic prescribing in rural Anhui province. E-records could provide useful information to inform stewardship interventions, however they may be inaccurate and/or biased. Public Health authorities should focus on improving technical infrastructure and record-keeping culture in outpatient settings. Further research is needed into community treatment of UTIs.

Antimicrobial stewardship in rural and remote primary health care: a narrative review

“…Use of antimicrobials bought from medicine shops without prescriptions ranged from 8.8 to 17.2% whereas use of antimicrobials leftover from previous illnesses or given by a relative ranged from 7.6 to 13.4% [ 34 ] Giles 2019 Single-centre, retrospective study Prevalence Study (5/9) United States Rural outpatient family medicine clinic 75% of 28 patients received a first-line antimicrobial based on treatment guidelines, of which 18 obtained a recommended dose. However, an appropriate treatment duration was prescribed for only 17% of patients [ 42 ] Kwiatkowska 2020 Cross-sectional quantitative study Cross Sectional Study (7/8) China Township health care centre and village clinic The rural Anhui province in China had considerably high rates of outpatient antibiotic prescribing. While e-records could be useful to inform antimicrobial stewardship, they may have inaccuracies and/or biases [ 36 ] Sarwar 2018 Cross-sectional quantitative study Cross Sectional Study (7/8) Pakistan 16 rural health care centres and 16 basic health units Antimicrobial agents were frequently prescribed in primary health care centres in Pakistan, a large proportion of which were inappropriate [ 38 ] Xue 2019 Quasi-experimental Quasi-experimental Study (9/9) China Rural village clinics and township health centres Primary care providers in rural China frequently prescribed antibiotics inappropriately, predominantly due to deficits in diagnostic knowledge but also to financial incentives linked to drug sales and perceived patient demand Mixed urban and rural [ 44 ] Davey 2020 Cross-sectional quantitative analysis Cross Sectional Study (7/8) ...…”

“…Clinicians in rural and remote PHC services tended to be high-volume prescribers of antimicrobial agents [40][41][42][43]. Antibiotics were prescribed more frequently in rural regions compared to urban areas, 85% versus 68-80% respectively [40][41][42].…”

“…Clinicians in rural and remote PHC services tended to be high-volume prescribers of antimicrobial agents [40][41][42][43]. Antibiotics were prescribed more frequently in rural regions compared to urban areas, 85% versus 68-80% respectively [40][41][42]. Primary health care services in rural and remote areas face additional challenges in the provision of health care, including limited resource allocations and a different patient population compared to urban clinics, which may contribute to differences in prescribing.…”

Low Prevalence of Antibiotic Resistance and High Level of Antibiotic Consumption in Rural China: Interdisciplinary Study

“…Full details of the analysis of the record review data are provided elsewhere. (8) Table 1 summarizes study sites and main research activities by site. A total of 1123 eligible patients in the clinical settings were recruited into the microbiological study and completed a structured exit interview following their consultation.…”

“…Full methodological details of this study component are provided elsewhere. (8) Patient and public involvement It was not feasible to involve patients or public in the design or conduct of this study as these approaches are not yet customary when undertaking health research in China; setting up a new PPI mechanism for the study was beyond our capacity. However, ndings will be disseminated to participating patients and healthcare staff and patient and public consultations will be undertaken prior to the development of interventions based on the study ndings.…”