The influence of context on antimicrobial prescribing for febrile respiratory illness: a cohort study.
ABSTRACT Little is known about the influence of contextual factors on a physician's likelihood to prescribe antimicrobials for febrile respiratory illness (FRI). Context includes epidemiologic context (for example, a pandemic period) and personal context (for example, recent exposure to other patients with FRI).
To examine the association between contextual factors and antimicrobial prescribing for FRI.
5.5-year retrospective cohort study.
A network of Midwestern primary care providers.
All patients presenting with FRI during influenza seasons between 2006 and 2011.
Antimicrobial prescribing for FRI during pandemic and seasonal influenza periods.
28 301 unique patient encounters for FRI with 69 physicians in 26 practices were included. An antibiotic was prescribed in 12 795 (45.2%) cases. The range of prescribing among physicians was 17.9% to 83.7%. Antibiotics were prescribed in 47.5% of encounters during the seasonal period and 39.2% during the pandemic period (P < 0.001). After multivariable adjustment for patient and physician characteristics, antibiotic prescribing was lower in the pandemic period (odds ratio [OR], 0.72 [95% CI, 0.68 to 0.77]) than in the seasonal period. The likelihood of prescribing an antibiotic decreased as the number of FRI cases that a physician had seen in the previous week increased (OR, 0.93 [CI, 0.86 to 1.01] for 2 to 3 patients with FRI seen in the previous week; OR, 0.84 [CI, 0.77 to 0.91] for 4 to 6 patients; OR, 0.71 [CI, 0.64 to 0.78] for 7 to 11 patients; and OR, 0.57 [CI, 0.51 to 0.63] for ≥12 patients compared with the reference range of 0 to 1 patients). Pandemic season and recent personal context were also associated with antiviral prescribing.
Retrospective study in a single geographic area.
Epidemiologic context and the number of cases of FRI that a physician had recently seen were associated with his or her likelihood to prescribe antimicrobials for FRI. Interventions that enhance a physician's contextual awareness may improve antimicrobial use.
NorthShore University HealthSystem.
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ABSTRACT: The objective of this study was to educate health care providers and patients to reduce overall antibiotic prescription rates for patients with acute respiratory tract infection (ARTI). An interdisciplinary quality improvement team used the Define, Measure, Analyze, Improve, and Control quality improvement process to change patient expectations and provider antibiotic prescribing patterns. Providers received personal and group academic detailing about baseline behaviors, copies of treatment guidelines, and educational materials to use with patients. Get Smart About Antibiotics Week materials educated patients about appropriate antibiotic use. Providers collected demographic and clinical information about a case series of patients with ARTIs and their subsequent provision of antibiotics. In total, 241 patients with ARTIs were accrued. The antibiotic prescribing rate for patients aged 18 years and older was significantly reduced from 69% at baseline to 56% after interventions (95% confidence interval = 49.1%-63.4%; P<.001). Providers' prescribing behaviors significantly improved after multiple quality improvement interventions.American Journal of Medical Quality 02/2013; 28(6). DOI:10.1177/1062860613476133 · 1.78 Impact Factor
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ABSTRACT: Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians. Clinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29). Compared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions---including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components' effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy. Future efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.BMC Health Services Research 11/2013; 13(1):462. DOI:10.1186/1472-6963-13-462 · 1.66 Impact Factor
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ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization among inpatients is a well-established risk factor for MRSA infection during the same hospitalization, but the long-term risk of MRSA infection is uncertain. We performed a retrospective cohort study to determine the one-year risk of MRSA infection among inpatients with MRSA-positive nasal polymerase chain reaction (PCR) tests confirmed by positive nasal culture (Group 1), patients with positive nasal PCR but negative nasal culture (Group 2), and patients with negative nasal PCR (Group 3). Subjects were adults admitted to a four-hospital system between November 1, 2006 and March 31, 2011, comprising 195,255 admissions. Patients underwent nasal swab for MRSA PCR upon admission; if positive, nasal culture for MRSA was performed; if recovered, MRSA was tested for Panton-Valentine Leukocidin (PVL). Outcomes included MRSA-positive clinical culture and skin and soft tissue infection (SSTI). Group 1 patients had a one-year risk of MRSA-positive clinical culture of 8.0% compared with 3.0% for Group 2 patients, and 0.6% for Group 3 patients (p<0.001). In a multivariable model, the hazard ratios for future MRSA-positive clinical culture were 6.52 (95% CI, 5.57 to 7.64) for Group 1 and 3.40 (95% CI, 2.70 to 4.27) for Group 2, compared with Group 3 (p<0.0001). History of MRSA and concurrent MRSA-positive clinical culture were significant risk factors for future MRSA-positive clinical culture. Group 1 patients colonized with PVL-positive MRSA had a one-year risk of MRSA-positive clinical culture of 10.1%, and a one-year risk of MRSA-positive clinical culture or SSTI diagnosis of 21.7%, compared with risks of 7.1% and 12.5%, respectively, for patients colonized with PVL-negative MRSA (p = 0.04, p = 0.005, respectively). MRSA nasal colonization is a significant risk factor for future MRSA infection; more so if detected by culture than PCR. Colonization with PVL-positive MRSA is associated with greater risk than PVL-negative MRSA.PLoS ONE 11/2013; 8(11):e79716. DOI:10.1371/journal.pone.0079716 · 3.53 Impact Factor