Appropriateness of Outpatient Antibiotic Use in Seniors across Two Canadian Provinces

Antimicrobials are among the most prescribed medications in Canada, with over 90% of antibiotics prescribed in outpatient settings. Seniors prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. The extent of inappropriate antibiotic prescribing in outpatient Canadian medical practice, and the potential long-term trends in this practice, are unknown. This study is the first in Canada to examine prescribing quality across two large-scale provincial healthcare systems to compare both quantity and quality of outpatient antibiotic use in seniors. Population-based analyses using administrative health databases were conducted in British Columbia (BC) and Ontario (ON), and all outpatient, oral antimicrobials dispensed to seniors (≥65 years) from 1 January 2000 to 31 December 2018 were identified. Antimicrobials were linked to an indication using a 3-tiered hierarchy. Tier 1 indications, which always require antibiotics, were given priority, followed by Tier 2 indications that sometimes require antibiotics, then Tier 3, which never require antibiotics. Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and by patient demographics. Prescribing remained steady in both provinces, with 11,166,401 prescriptions dispensed overall in BC, and 27,656,014 overall in ON. BC prescribed at slightly elevated rates (range: 790 to 930 per 1000 residents), in comparison to ON (range: 745 to 785 per 1000 residents), throughout the study period. For both provinces, a Tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. Although Tier 3 indications remained the most prescribed-for diagnoses throughout the study period, a declining trend over time is encouraging, with much room for improvement remaining. Elevated prescribing to seniors continues across Canadian outpatient settings, and prescribing quality is of high concern, with 50% of all antimicrobials prescribed inappropriately for common infections that do not require antimicrobials.

Quantifying the Gap between Expected and Actual Rates of Antibiotic Prescribing in British Columbia, Canada

Despite decades of stewardship efforts to combat antimicrobial resistance and quantify changes in use, the quality of antibiotic use in British Columbia (BC) remains unknown. As the overuse and misuse of antibiotics drives antibiotic resistance, it is imperative to expand surveillance efforts to examine the quality of antibiotic prescriptions. In late 2019, Canadian expected rates of antibiotic prescribing were developed for common infections. These rates were utilized to quantify the gap between the observed rates of prescribing and Canadian expected rates for antibiotic use for the province of BC. The prescribing data were extracted and matched to physician billing systems using anonymized patient identifiers from January 1, 2000 to December 31, 2018. Outpatient prescribing was further subdivided into community and emergency department settings and stratified by the following age groups: <2 years, 2–18 years, and ≥19 years. The proportions of physician visits that received antibiotic prescription were compared against the Canadian expected rates to quantify the unnecessary use for 18 common indications. Respiratory tract infections (RTI), including acute bronchitis, acute sinusitis, and acute pharyngitis, reported significant levels of overprescribing. Across all ages and health care settings, prescribing for RTI indications occurred at rates 2–8 times higher than the expected rates recommended by a group of expert Canadian physicians. Understanding the magnitude of unnecessary prescribing is a first step in delineating the provincial prescribing quality. The quantification of antibiotic overuse offers concrete targets for provincial stewardship efforts to reduce unnecessary prescribing by an average of 30% across both outpatient and emergency care settings.

How many medications do doctors in primary care use? An observational study of the DU90% indicator in primary care in England

AimTo apply the drug utilisation 90% (DU90%) indicator (the number of unique drugs which makes up 90% of a doctor’s prescribing) to general practitioner (GP) practices prescribing in England to examine time trends, practice-level variation, and relationships with practice characteristics, prescribing costs and low-value prescribing.Study designRetrospective cohort study.SettingPrimary care in England, using publicly available prescribing data available from the National Health Service (NHS) digital platform for 2013–2017.ParticipantsAll general practices in England (n=7620).Primary and secondary outcome measuresThe DU90% was calculated on an annual basis for each practice based on medication British National Formulary codes. Low-value prescribing was defined using NHS 2017 guidance (including lidocaine plasters, liothyronine, omega-3 supplements). Descriptive statistics were generated per year on time trends and practice-level variation in the DU90%. Multilevel linear regression was used to examine the practice characteristics (relating to staff, patients and deprivation of the practice area).ResultsAmong 7620 practices, mean DU90% ranged from 130.0 to 131.0 across study years, and regarding variation between practices, there was a 1.4-fold difference between the lowest and highest 5% of practices. A range of medications were included in the DU90% of virtually all practices, including atorvastatin, levothyroxine, omeprazole, ramipril, amlodipine, simvastatin and aspirin. A higher volume of prescribing was associated with a lower DU90%, while having more patients, higher proportions of patients who are women or aged ≥45 years, higher number of GPs working in the practice and being in a more deprived area were associated with a higher DU90%. Practices in higher quintiles of DU90% had higher levels of low-priority prescribing and prescribing costs.ConclusionGP practices typically use 130 different medications in the bulk of their prescribing. Higher DU90% was associated with higher levels of low-priority prescribing and prescribing costs. Increasing use of personal formularies may enhance prescribing quality and reduce costs.

Effects of coronavirus disease 2019 (COVID-19) pandemic on antimicrobial prevalence and prescribing in a tertiary hospital in Singapore

Background The deployment of antimicrobial stewardship (AMS) teams to deal with the COVID-19 pandemic can lead to a loss of developed frameworks, best practices and leadership resulting in adverse impact on antimicrobial prescribing and resistance. We aim to investigate effects of reduction in AMS resources during the COVID-19 pandemic on antimicrobial prescribing. Methods One of 5 full-time equivalent AMS pharmacists was deployed to support pandemic work and AMS rounds with infectious disease physicians were reduced from 5 to 2 times a week. A survey in acute inpatients was conducted using the Global Point Prevalence Survey methodology in July 2020 and compared with those in 2015 and 2017–2019. Results The prevalence of antimicrobial prescribing (55% in 2015 to 49% in 2019 and 47% in 2020, p = 0.02) and antibacterials (54% in 2015 to 45% in 2019 and 42% in 2020, p < 0.01) have been reducing despite the pandemic. Antimicrobial prescribing in infectious disease wards with suspected or confirmed COVID-19 cases was 29% in 2020. Overall, antimicrobial prescribing quality indicators continued to improve (e.g. reasons in notes, 91% in 2015 to 94% in 2019 and 97% in 2020, p < 0.01) or remained stable (compliance to guideline, 71% in 2015 to 62% in 2019 and 73% in 2020, p = 0.08). Conclusion During the COVID-19 pandemic, there was no increase in antimicrobial prescribing and no significant differences in antimicrobial prescribing quality indicators.

Development of an explicit tool assessing potentially inappropriate medication use in Hong Kong elder patients

Background Potentially inappropriate medication (PIM) use has adverse effects on health, particularly in elder patients. Various country-specific explicit criteria have been developed to measure the appropriateness of prescribing worldwide. However, it is difficult to apply the criteria developed from other regions to measure and guide the local prescribing practice in Hong Kong. This study aims to develop a Hong Kong-specific PIM assessing tool from previously published criteria and validate this tool using the modified Delphi method. Methods A disease-oriented Hong Kong-specific preliminary PIM list was developed based on nine sets of reference criteria selected from a literature review. Any medication or medication class appeared in at least two sets of the reference criteria as well as its related medical conditions were selected as PIM candidates. After examining the availability of PIM candidates by the Hong Kong Hospital Authority drug formulary, the Hong Kong-specific preliminary PIM list was validated by a two-round of modified Delphi process. Eight experts from different specialties were invited to rate the degree of inappropriateness of each PIM candidate using a five-point Likert scale. The experts were also encouraged to propose therapeutic alternatives and new PIM candidates not covered by the preliminary PIM list. The PIM candidates that the expert panel didn’t reach consensus on were excluded from the final Hong Kong-specific PIM list. Results After two rounds of the Delphi process, eight PIM candidates remained questionable and thus were excluded from the PIM list. The final Hong Kong-specific PIM list included a total of 164 statements applicable to older adults aged 65 years or above, among which 77 were under PIMs independent of diagnoses, and 87 were under PIMs considering specific medical conditions. Conclusions The Hong Kong-specific PIM list can be used as a quality measure and an educational tool to improve the local prescribing quality. Further studies should validate its association with adverse health outcomes in clinical and research settings.

Focus and features of prescribing indications spanning multiple chronic conditions in older adults: A narrative review

Background: Inappropriate prescribing is frequent in older adults and associated with adverse outcomes. Prescribing indications aim to optimize prescribing, but little is known about the focus and features of prescribing indications for the most common chronic conditions in older adults. Understanding the conditions, medications, and issues addressed (e.g., patient perspective, drug-disease interaction, adverse drug event) in current prescribing indications may help to identify missing indications and develop standardized measures to improve prescribing quality. Methods: We searched Ovid/MEDLINE and EMBASE for articles published between 2015 and 2020 reporting prescribing indications for older adults. Prescribing indication included 1) prescribing “criteria,” or statements that guide prescribing action, and 2) prescribing “measures,” or prescribing actions observed in a population. We categorized their focus by conditions, medications and issues addressed, as well as level of evidence provided. Results: Among 16 sets of prescribing indications, we identified 748 criteria and 47 measures. The most common addressed medications were antihypertensives, analgesics/antirheumatics, and antiplatelets/anticoagulants. The most frequently addressed issues were drug-disease interaction, adverse drug event, administration, better therapeutic alternative, and (co-)prescription omission (20.8–36.1%). Age/functioning, drug-drug interaction, monitoring, and efficacy/safety ratio were found in only 9.9–16.5% of indications. Indications rarely focused on the patient perspective or issues with multiple providers. Conclusion: Most prescribing indications for chronic conditions in older patients are criteria rather than measures. Indications accounting for patient perspective and multiple providers are limited. The gaps identified in this review may help improve the development of prescribing measures for older adults and ultimately improve quality of care.

Effects of Coronavirus Disease 2019 (COVID-19) Pandemic on Antimicrobial Prevalence and Prescribing in a Tertiary Hospital in Singapore

Background: The deployment of antimicrobial stewardship (AMS) teams to deal with the COVID-19 pandemic can lead to a loss of developed frameworks, best practices and leadership resulting in adverse impact on antimicrobial prescribing and resistance. We aim to investigate effects of reduction in AMS resources during the COVID-19 pandemic on antimicrobial prescribing and resistance.Methods: One of 5 full-time equivalent AMS pharmacists was deployed to support pandemic work and AMS rounds with infectious disease physicians were reduced from 5 to 2 times a week. A survey in acute inpatients was conducted using the Global Point Prevalence Survey methodology in July 2020 and compared with those in 2015 and 2017-2019.Results: The prevalence of antimicrobial prescribing (55% in 2015 to 49% in 2019 and 47% in 2020, p =0.02) and antibacterials (54% in 2015 to 45% in 2019 and 42% in 2020, p < 0.01) have been reducing despite the pandemic. Antimicrobial prescribing in infectious disease wards with suspected or confirmed COVID-19 cases was 29% in 2020. Overall, antimicrobial prescribing quality indicators continued to improve (e.g. reasons in notes, 91% in 2015 to 94% in 2019 and 97% in 2020, p <0.01) or remained stable (compliance to guideline, 71% in 2015 to 62% in 2019 and 73% in 2020, p =0.08). Conclusion: AMS efforts over the years paid dividends during the COVID-19 pandemic to sustain the control of antimicrobial prevalence and quality of AMU in non-COVID-19 wards and plausibly also in COVID-19 wards.

Structural Antibiotic Surveillance and Stewardship via Indication-Linked Quality Indicators: Pilot in Dutch Primary Care

Insight into antibiotic prescribing quality is key to general practitioners (GPs) to improve their prescribing behavior and to national antibiotic surveillance and stewardship programs. Additionally to numbers of prescribed antibiotics, quality indicators (QIs) linked to the clinical indication for prescribing are urgently needed. The aim of this proof of concept study was to define indication-linked QIs which can be easily implemented in Dutch primary care by collaborating with data-extraction/processing companies that routinely process patient data for GP practices. An expert group of academic and practicing GPs defined indication-linked QIs for which outcomes can be derived from routine care data. QI outcomes were calculated and fed back to GPs from 44 practices, associations between QI outcomes were determined, and GPs’ opinions and suggestions with respect to the new set were captured using an online questionnaire. The new set comprises: (1) total number of prescribed antibiotics per 1000 registered patients and percentages of generally non-1st choice antibiotics; (2) prescribing percentages for episodes of upper and lower respiratory tract infection; (3) 1st choice prescribing for episodes of tonsillitis, pneumonia and cystitis in women. Large inter-practice variation in QI outcomes was found. The validity of the QI outcomes was confirmed by associations that were expected. The new set was highly appreciated by GPs and additional QIs were suggested. We conclude that it proved feasible to provide GPs with informative, indication-linked feedback of their antibiotic prescribing quality by collaborating with established data extraction/processing companies. Based on GPs’ suggestions the set will be refined and extended and used in the near future as yearly feedback with benchmarking for GPs and for national surveillance and stewardship purposes.

P15 Using prescribing nudges to reduce medication errors: paracetamol on paediatric intensive care

AimParacetamol is widely available and its safety profile is relatively good. However, the risk associated with a paracetamol overdose is much greater in a neonate than that associated with an adult.In 2018, 8% of paediatric medication errors related to the use of paracetamol, including three 10x overdoses. These irregular but serious risks are difficult to manage over time due to degradation of heightened awareness. The aim of this project was to improve the prescribing quality of IV paracetamol on PICU and prevent recurrence of a 10-fold overdose by the implementation of multi-level changes.MethodElectronic prescribing (EP) has been in use on our unit since 2016. Small changes (prescribing nudges) in the configuration of the EP system can be used to improve prescribing quality. Forced functions, automation and standardisation have been found to be more effective in this than more traditional education and training methods.1 2The changes implemented in January 2019 were as follows:Forced function: All paracetamol prescriptions for patients under 1 year of age were capped at 180 mg (change from 1000 mg). The prescriber could not enter a number greater than 180 mg.Automation: All oral paracetamol prescriptions were changed to automatically prescribe 15 mg/kg 6 hourly regardless of age (previously 2 different options requiring the prescriber to input dose and frequency according to formulary directions).Standardisation/simplification: All oral paracetamol prescriptions were rationalised to a single option with automatic dose and frequency as above (previously 2 different options unnecessarily).Reminder/rule: A rule of ‘Consultant Approval’ was added to all intravenous paracetamol prescriptions. The intention of this was for a review of the prescription before use to ensure appropriate use and dose/frequency. This could not be forced, so an education package was launched across the unit by the quality improvement group.Prescription details were downloaded from the EP system for 3 month periods pre and post changes. he data was audited by pharmacy undergraduate students for prescribing accuracy.ResultsThe forced function, automation and standardisation options were implemented with 100% compliance. The ‘consultant approval’ rule was followed in 23% of cases. Consultant review led to a 58.6% reduction of IV paracetamol prescriptions on the unit and zero prescriptions for the first 2 months post implementation. The usage of oral paracetamol increased accordingly. This change corresponded to an overall reduction rate of 41.7% for intravenous paracetamol prescriptions.ConclusionsThis project demonstrates how changes that increase automation within prescribing can reduce error and that implementation is more successful than education. A limitation of our data analysis was that we did not measure the effect on pain relief or pain scores in the patients who did not receive IV paracetamol compared to those who did.ReferencesCafazzo JA, et al. From discovery to design: the evolution of human factors in healthcare. Healthcare Quarterly 2012; 15: 24–29.Patel Ms, et al. Nudge units to improve the delivery of healthcare NEJM 2018; 378: 214–216.

Non-dispensing pharmacist integrated in the primary care team: effect on the quality of physician’s prescribing, a non-randomised comparative study

Background Especially in elderly with polypharmacy, medication can do harm. Clinical pharmacists integrated in primary care teams might improve quality of pharmaceutical care. Objective To assess the effect of non-dispensing clinical pharmacists integrated in primary care teams on general practitioners’ prescribing quality. Setting This study was conducted in 25 primary care practices in the Netherlands. Methods Non-randomised, controlled, multi-centre, complex intervention study with pre-post comparison. First, we identified potential prescribing quality indicators from the literature and assessed their feasibility, validity, acceptability, reliability and sensitivity to change. Also, an expert panel assessed the indicators’ health impact. Next, using the final set of indicators, we measured the quality of prescribing in practices where non-dispensing pharmacists were integrated in the team (intervention group) compared to usual care (two control groups). Data were extracted anonymously from the healthcare records. Comparisons were made using mixed models correcting for potential confounders. Main outcome measure Quality of prescribing, measured with prescribing quality indicators. Results Of 388 eligible indicators reported in the literature we selected 8. In addition, two more indicators relevant for Dutch general practice were formulated by an expert panel. Scores on all 10 indicators improved in the intervention group after introduction of the non-dispensing pharmacist. However, when compared to control groups, prescribing quality improved solely on the indicator measuring monitoring of the renal function in patients using antihypertensive medication: relative risk of a monitored renal function in the intervention group compared to usual care: 1.03 (95% CI 1.01–1.05, p-value 0.010) and compared to usual care plus: 1.04 (1.01–1.06, p-value 0.004). Conclusion This study did not demonstrate a consistent effect of the introduction of non-dispensing clinical pharmacists in the primary care team on the quality of physician’s prescribing. This study is part of the POINT-study, which was registered at The Netherlands National Trial Register with trial registration number NTR‐4389.