Dataset Information

Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation.

ABSTRACT:

Objectives

To explore healthcare professionals' views of antibiotic prescribing in long-term care facilities (LTCFs). To use the findings to recommend intervention strategies for antimicrobial stewardship in LTCFs.

Design

Qualitative semistructured interviews were conducted. The data were analysed by thematic content analysis. After the interviews, the emerging findings were mapped to the theoretical domains framework (TDF), and the behaviour change wheel and behaviour change technique (BCT) taxonomy were used to recommend future intervention strategies.

Participants

Interviews were conducted with 37 healthcare professionals who work in LTCFs (10 general practitioners, 4 consultants, 14 nurses, 9 pharmacists) between December 2012 and March 2013.

Setting

Interviews were conducted in the greater Cork region.

Results

The main domains from the TDF which emerged were: 'Knowledge', 'Environmental context and resources', 'Social influences', 'Beliefs about consequences', 'Memory, attention and decision making', with the findings identifying a need for 'Behavioural regulation'. Many participants believed that antibiotic prescribing was satisfactory at their LTCF, despite the lack of surveillance activities.

Conclusions

This study, using the TDF and BCT taxonomy, has found that antibiotic prescribing in LTCFs is influenced by many social and contextual factors. The challenges of the setting and patient population, the belief about consequences to the patient, and the lack of implementation of guidelines and knowledge regarding antibiotic prescribing patterns are significant challenges to address. On the basis of the study findings and the application of the TDF and BCT taxonomy, we suggest some practical intervention functions for antimicrobial stewardship in LTCFs.

SUBMITTER: Fleming A

PROVIDER: S-EPMC4225237 | biostudies-literature | 2014 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation.

Fleming Aoife A Bradley Colin C Cullinan Shane S Byrne Stephen S

BMJ open 20141105 11

<h4>Objectives</h4>To explore healthcare professionals' views of antibiotic prescribing in long-term care facilities (LTCFs). To use the findings to recommend intervention strategies for antimicrobial stewardship in LTCFs.<h4>Design</h4>Qualitative semistructured interviews were conducted. The data were analysed by thematic content analysis. After the interviews, the emerging findings were mapped to the theoretical domains framework (TDF), and the behaviour change wheel and behaviour change tech ...[more]

PMID: 25377014

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Project description:BackgroundInsight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors.MethodsSemi-structured qualitative interviews were conducted with physicians (n?=?13) and nursing staff (n?=?13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff.ResultsThe analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians' perceived risks, influence of others, and influence of the environment. Each category comprises several factors that may influence the decision to prescribe or not prescribe antibiotics directly (e.g. pressure of patients' family leading to antibiotic prescribing) or indirectly via influence on other factors (e.g. unfamiliarity with patients resulting in a higher physician perceived risk of non-treatment, in turn resulting in a higher tendency to prescribe antibiotics).ConclusionsOur interview study shows that several non-rational factors may affect antibiotic prescribing decision making in long-term care facilities, suggesting opportunities to reduce inappropriate antibiotic use. We developed a conceptual model that integrates the identified categories of influencing factors and shows the relationships between those categories. This model may be used as a practical tool in long-term care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriate antibiotic prescribing.

Project description:BackgroundOveruse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities' antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes.MethodA systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as 'very promising' (all outcomes statistically significant), 'quite promising' (some outcomes statistically significant), or 'not promising' (no outcomes statistically significant). 'Promise ratios' (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2.ResultsTwenty studies (of19 interventions) were included. Seven interventions (37%) were 'very promising', eight 'quite promising' (42%) and four 'not promising' (21%). Most promising intervention types were 'persuasion' (n = 12; promise ratio (PR) = 5.0), 'enablement' (n = 16; PR = 4.33) and 'education' (n = 19; PR = 3.75). Most promising behaviour change techniques were 'feedback on behaviour' (n = 9; PR = 8.0) and 'restructuring the social environment' (e.g. staff role changes; n = 8; PR = 7.0).ConclusionSystematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Project description:ImportanceAntibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown.ObjectivesTo determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings.Design, setting, and participantsThis quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019.InterventionsFifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate.Main outcomes and measuresThe primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10 000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time.ResultsOf a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was -0.41 (95% CI, -0.76 to -0.07; P = .02), with fluoroquinolones showing the greatest decrease at -0.21 starts per 1000 resident-days (95% CI, -0.35 to -0.08; P = .002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (-3.05; 95% CI, -6.34 to 0.23; P = .07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, -1.75 to -0.49; P < .001) and 9.97 per 1000 resident-days (95% CI, -15.4 to -4.6; P < .001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, -0.61 to -0.15; P = .001). There was no significant change in facility-onset C difficile laboratory-identified events.Conclusions and relevanceParticipation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings.

Dataset Information

Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation.

Objectives

Design

Participants

Setting

Results

Conclusions

Publications

Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation.

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