Physician behaviour for antimicrobial prescribing for paediatric upper respiratory tract infections: a survey in general practice in Trinidad, West Indies

BACKGROUND: Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference. METHODS: A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students. RESULTS: The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50%), the most common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%). CONCLUSIONS: Antibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs

The implementation of a standardized paper-based chronic noncommunicable diseases registry at primary health-care clinics

Background: The use of a standardized national chronic noncommunicable disease (CNCD) registry is of immense benefit in addressing the CNCD burden in Trinidad and Tobago (T&T). This study seeks to assess the outcomes of a paper-based CNCD registry implemented in the primary health-care centers in South Trinidad. Methods: At the South-West Regional Health Authority, a standardized paper-based registry was implemented in 2017, at the 33 public primary health-care clinics. Following this, a CNCD Registry Assessment Survey was administered cross-sectionally to 94 end-users to evaluate the implementation outcomes of the registry. The outcome domains – feasibility, penetration, acceptability, sustainability, fidelity, uptake, and costs were analyzed using summary statistics. Results: Fifty-five percent of end-users responded. Most responses came from the primary care physicians 1 (50.0%) of County Caroni. Most respondents were from County Caroni, 19 (36.5%) and St. Patrick, 19 (36.5%). Ninety-one percent of end-users thought that the CNCD registry was easily adopted. For 85.9% of end-users, the registry had fidelity (85.9%); 84.2% thought it was well accepted; feasible (82.7%); easily penetrated (82.7%), and appropriate (76.0%). Forty-two percent thought that the cost of implementation was high, while 30.8% were neutral. Seventy-one percent thought that the paper-based CNCD registry should be sustained, and 94.2% of end-users thought that an electronic CNCD registry should be implemented. Conclusion: It is possible and feasible to implement a standardized paper-based registry. Through this process, we were able to define the prevalence of five CNCDs and two risk factors of overweight/obesity and smoking for the chronic disease clinic population. Subsequently, we would like to implement a digitized CNCD registry

Assessing the Quality of Patient Referrals from Primary Care Physicians at the South-West Regional Health Authority, Trinidad, 2019

Aim: To assess the adequacy and justification of referrals from primary care physicians (PCPs) to specialized care services. Methods: Descriptive, retrospective, and cross-sectional. In 2019, 1810 patient referrals from over 46 PCPs working at 23 centers, obtained through consecutive convenient sampling were reviewed. Parameters of the referral were assessed using the “South-West Regional Health Authority Tool for Assessing the Adequacy of Outgoing Referrals from Primary Health Care (PHC),” by senior PCPs. Descriptive statistics were used to calculate the proportions of the degree of adequacy and completeness of referral parameters and the distribution of referral scores; referral rates; proportion of referrals to specialized care services and proportion of justified and unjustified referrals. Results: The referral rate was 5.28%. In terms of adequacy and completeness: Demographics - 77.96% - partially adequately completed; diagnoses - 91.65% adequately completed; History - 83.82% partially adequately completed; Examination findings - 43.70% - adequately completed. In 57.54% of referrals, the treatment given was not completed. In most referrals, sections that were adequately completed include recent labs - 57.54%; current medications - 48.83%; footer - 55.20%. The scores ranged from 5 to 21; median - 15 and mode - 16. Based on the senior PCPs’ perception, 94.36% of the outgoing referrals were justified. Most patients, 63.84%, were referred to the outpatient clinics and 33.89% to the emergency department. Conclusions: Most referrals were justified. The adequacy can further be assessed by an expert panel of end-users. Addressing gaps identified in the referral system should enable cost-effective use of specialized and PHC services

Identifying the necessary capacities for the adaptation of a diabetes phenotyping algorithm in countries of differing economic development status

Background In 2019, the World Health Organization recognised diabetes as a clinically and pathophysiologically heterogeneous set of related diseases. Little is currently known about the diabetes phenotypes in the population of low- and middle-income countries (LMICs), yet identifying their different risks and aetiology has great potential to guide the development of more effective, tailored prevention and treatment. Objectives This study reviewed the scope of diabetes datasets, health information ecosystems, and human resource capacity in four countries to assess whether a diabetes phenotyping algorithm (developed under a companion study) could be successfully applied. Methods The capacity assessment was undertaken with four countries: Trinidad, Malaysia, Kenya, and Rwanda. Diabetes programme staff completed a checklist of available diabetes data variables and then participated in semi-structured interviews about Health Information System (HIS) ecosystem conditions, diabetes programme context, and human resource needs. Descriptive analysis was undertaken. Results Only Malaysia collected the full set of the required diabetes data for the diabetes algorithm, although all countries did collect the required diabetes complication data. An HIS ecosystem existed in all settings, with variations in data hosting and sharing. All countries had access to HIS or ICT support, and epidemiologists or biostatisticians to support dataset preparation and algorithm application. Conclusions Malaysia was found to be most ready to apply the phenotyping algorithm. A fundamental impediment in the other settings was the absence of several core diabetes data variables. Additionally, if countries digitise diabetes data collection and centralise diabetes data hosting, this will simplify dataset preparation for algorithm application. These issues reflect common LMIC health systems’ weaknesses in relation to diabetes care, and specifically highlight the importance of investment in improving diabetes data, which can guide population-tailored prevention and management approaches

Diabetes prevention in the Caribbean using Lifestyle Intervention and Metformin Escalation (LIME): Protocol for a hybrid Type-1 effectiveness-implementation trial using a quasi-experimental study design

Background: Globally, several diabetes prevention interventions have been shown to be cost-effective, yet they have had limited adaptation, implementation, and evaluation in the Caribbean and among Caribbean-descent individuals, where the burden of type 2 diabetes is high. We report on the protocol for the Lifestyle Intervention with Metformin Escalation (LIME) study – an evidence-based diabetes prevention intervention to reduce the incidence of diabetes among Caribbean-descent individuals with prediabetes. Methods: LIME is a hybrid type-I effectiveness-implementation quasi-experimental study taking place in 4 clinical sites in Barbados, Trinidad, the U.S. Virgin Islands, and Puerto Rico. LIME targets individuals who self-identify as Caribbean or Caribbean-descent and have high-risk prediabetes with a hemoglobin A1c (HbA1c) between 6 and 6.4%. Eligible participants in the intervention arm are enrolled in a six-week lifestyle modification workshop. Six months later, individuals who have not lost at least 5% of their bodyweight or continue to have an HbA1c of 6% or higher are prescribed metformin medication. In total, participants are followed for one year. The primary effectiveness outcome is proportion of individuals who lower their HbA1c below 6%. Discussion: LIME is a unique diabetes prevention intervention for Caribbean and Caribbean-descent individuals. LIME utilizes a tailored lifestyle change curriculum, incorporates appropriate metformin prescribing when lifestyle change alone is insufficient, targets the highest-risk individuals with prediabetes, and is based in a clinical setting to ensure sustainability