14 research outputs found
General practitioners' antibiotic prescribing practices in Malta : understanding drivers to inform the implementation of a social marketing behaviour change intervention
Background: Antibiotic resistance is a leading global public health problem and complex
challenge. Although a multitude of factors affect its development, antibiotic use is a key
driver. In fact, in Europe, a positive correlation between antibiotic use and resistance has
been shown. The largest volumes of antibiotics are prescribed in the community setting and
respiratory tract infections (RTIs) remain the most common diagnoses despite often being
self-limiting. Malta has one of the highest antibiotic consumption rates in Europe with the
top two reasons being sore throat and the flu. Since most antibiotics are obtained through a
medical prescription, this suggests that antibiotics are overprescribed by doctors, and general
practitioners (GPs) in particular are a suitable target group for interventions to improve antibiotic
prescribing. However, prescribing decisions are often complex and influenced by numerous
interrelated factors. Therefore changing prescribing behaviour first necessitates an
in-depth understanding of antibiotic prescribing practices and factors that impact this behaviour.
To date, large knowledge gaps remain in Malta which makes the implementation of
evidence-based interventions targeting prescribers challenging.
Aim: The aim of this thesis, which forms part of a larger intervention project, was to explore
GPsâ views on antibiotic use and resistance in Malta, and to gain a better understanding of
their antibiotic prescribing patterns for RTIs including the factors that influence their prescribing
behaviour.
Methods: Data were derived from two pre-intervention studies; one qualitative [Papers I &
II] and one quantitative [Papers III & IV]. For the qualitative study, individual face-to-face
interviews were held in 2014 with a quota sample of 20 GPs. Interviews were audio recorded
and transcribed verbatim. Data were analysed iteratively using manifest and latent content
analysis [Paper I] and phenomenography [Paper II]. The quantitative study was a repeated
cross-sectional surveillance study for which 30 GPs and 3 GP trainees collected
monthly data for all patients with an acute respiratory tract complaint during predetermined
one week periods between May 2015 and April 2016. Descriptive statistics were used to
examine patient, consultation and clinical characteristics, and to describe GPsâ prescribing
patterns [Paper III]. In Paper IV, the association between GP-, practice- and consultationlevel
factors, patient sociodemographic factors and patient health status factors, and antibiotic
prescription (yes/no) was investigated using generalised estimating equations to estimate
population-averaged effects.
Key findings: GPsâ provided an antibiotic prescription to 45.7% of cases, the majority of
which (99.6%) were broad-spectrum. Almost all (84.3%) were for immediate use, whilst
15.7% were delayed prescriptions. Through qualitative interviews five qualitatively different
ways by which GPs perceived delayed antibiotic prescribing were described: (i) to maintain a
good GP-patient relationship, retain patients and avoid doctor-shopping, (ii) to reach a
compromise and provide treatment just in case, (iii) to provide the patient comfort and reassurance,
(iv) to empower and educate patients, and limit antibiotic use, and (v) to retain GP
responsibility by employing a wait-and-see approach. Surveillance data also revealed that
GPsâ antibiotic prescribing is associated with a number of GP-, patient-, clinical- and consultation-
level factors. This was largely corroborated by qualitative evidence that showed
that antibiotic prescribing is impacted not only by intrinsic GP factors but several other factors,
including but not limited to, diagnostic uncertainty, patient demand, interaction with
drug reps, availability of guidelines and community resistance data, and access to diagnostic
testing.
Conclusions: GPsâ antibiotic prescribing for RTIs in Malta is high. The abundant use of
broad-spectrum antibiotics is of particular concern and indicates that antibiotics are not being
used appropriately. A number of factors were found to impact GPsâ antibiotic prescribing
behaviour. In order to improve this behaviour, targeted and coordinated implementation activities
must address barriers identified at all levels of the system and provide GPs with the
necessary tools to alleviate diagnostic uncertainty
Impact of a social marketing intervention on general practitionersâ antibiotic prescribing practices for acute respiratory tract complaints in Malta
Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract
complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing
in such settings. We evaluate the impact of a social marketing intervention on general practitionersâ
(GPsâ) antibiotic prescribing for aRTCs in Malta.Methods: Changes in GPsâ antibiotic prescribing
were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change
in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for
immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class.
Data were analysed using clustered analysis and interrupted time series analysis (ITSA).Results:
Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed
a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant
change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold
(p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015).Conclusions: The intervention resulted in modest improvements in GPsâ antibiotic prescribing. A more
top-down approach will likely be required for future initiatives to be successful in this setting,
focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines,
and standardised delayed antibiotic prescriptions.peer-reviewe
General practitionersâ, pharmacistsâ and parentsâ views on antibiotic use and resistance in Malta : an exploratory qualitative study
Background: Antibiotic resistance (ABR) remains a global health threat that requires urgent
action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient
setting. General practitioners (GPs), the public, and pharmacists therefore play an important role
in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic
prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents;
Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014
and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness
on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was
thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and
over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is
more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists
were enthusiastic about their roles as patient educators in raising knowledge and awareness
in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were
perceived to have improved in Malta, our study suggests that even though stakeholders indicated
willingness to drive change, there is still much room for improvement.peer-reviewe
Maltese antibiotic stewardship programme in the community (MASPIC) : protocol of a prospective quasiexperimental social marketing intervention
Introduction: Antibiotic misuse is a key driver of antibiotic resistance. In 2015/2016, Maltese respondents reported the highest proportions of antibiotic consumption in Europe. Since antibiotics are prescription-only medicines in Malta, research on effective strategies targeting general practitionersâ (GPs) knowledge and behaviour is needed. Multifaceted behaviour change (BC) interventions are likely to be effective. Social marketing (SM) can provide the tools to promote sustained BC; however, its utilisation in Europe is limited. This paper aims to describe the design and methods of a multifaceted SM intervention aimed at changing Maltese GPsâ antibiotic prescribing behaviour for patients with acute respiratory tract infections (aRTIs).Methods and analysis: This 4-year quasiexperimental intervention study will be carried out in Malta and includes three phases: preintervention, intervention and postintervention. The preintervention phase intends to gain insight into the practices and attitudes of GPs, pharmacists and parents through interviews, focus group discussions and antibiotic prescribing surveillance. A 6-month intervention targeting GPs will be implemented following assessment of their prescribing intention and readiness for BC. The intervention will likely comprise: prescribing guidelines, patient educational materials, delayed antibiotic prescriptions and GP education. Outcomes will be evaluated in the postintervention phase through questionnaires based on the theory of planned behaviour and stages-of-change theory, as well as postintervention surveillance. The primary outcome will be the antibiotic prescribing rate for all patients with aRTIs. Secondary outcomes will include the proportion of diagnosis-specific antibiotic prescription and symptomatic relief medication prescribed, and the change in GPs stage-of-change and their intention to prescribe antibiotics.peer-reviewe
Antibiotic prescribing for respiratory tract complaints in Malta : a 1 year repeated cross-sectional surveillance study
Objectives: To determine the 1âyear antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta. Methods: In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1âweek period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3âmonthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPsâ prescribing patterns. Results: Participating GPs (nâ=â33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a ÎČ-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed. Conclusions: GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing.peer-reviewe
Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta : a 1-year repeated cross-sectional surveillance study
Objective: To identify factors that influence general practitionersâ (GPsâ) oral antibiotic prescribing for acute respiratory tract complaints (aRTCs) in Malta. Design: Repeated, cross-sectional surveillance. Setting: Maltese general practice; both public health centres and private GP clinics. Participants: 30 GPs registered on the Malta Medical Councilâs Specialist Register and 3 GP trainees registered data of 4831 patients of all ages suffering from any aRTC. Data were collected monthly between May 2015 and April 2016 during predetermined 1-week periods. Outcome measures: The outcome of interest was antibiotic prescription (yes/no), defined as an oral antibiotic prescription issued for an aRTC during an in-person consultation, irrespective of the number of antibiotics given. The association between GP, practice and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription was investigated. Results: The antibiotic prescription rate was 45.0%. Independent factors positively associated with antibiotic prescribing included female GP sex (OR 2.3, 95%âCI 1.22 to 4.26), GP age with GPs â„60 being the most likely (OR 34.7, 95%âCI 14.14 to 84.98), patient age with patients â„65 being the most likely (OR 2.3, 95%âCI 1.71 to 3.18), number of signs and/or symptoms with patients having â„4 being the most likely (OR 9.6, 95%âCI 5.78 to 15.99), fever (OR 2.6, 95%âCI 2.08 to 3.26), productive cough (OR 1.3, 95%âCI 1.03 to 1.61), otalgia (OR 1.3, 95%âCI 1.01 to 1.76), tender cervical nodes (OR 2.2, 95%âCI 1.57 to 3.05), regular clients (OR 1.3, 95%âCI 1.05 to 1.66), antibiotic requests (OR 4.8, 95%âCI 2.52 to 8.99) and smoking (OR 1.4, 95%âCI 1.13 to 1.71). Conversely, patients with non-productive cough (OR 0.3, 95%âCI 0.26 to 0.41), sore throat (OR 0.6, 95%âCI 0.53 to 0.78), rhinorrhoea (OR 0.3, 95%âCI 0.23 to 0.36) or dyspnoea (OR 0.6, 95%âCI 0.41 to 0.83) were less likely to receive an antibiotic prescription. Conclusion: Antibiotic prescribing for aRTCs was high and influenced by a number of factors. Potentially inappropriate prescribing in primary care can be addressed through multifaceted interventions addressing modifiable factors associated with prescription.peer-reviewe
Impact of a Social Marketing Intervention on General Practitionersâ Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta
Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitionersâ (GPsâ) antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPsâ antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPsâ antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions
General practitioners' perceptions of delayed antibiotic prescription for respiratory tract infections : A phenomenographic study
BACKGROUND: Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta. METHODS: This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach. FINDINGS: General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"-maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"-reaching a compromise and providing treatment just in case, (C) "The Comforter"-providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"-empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"-retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon. CONCLUSIONS: In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required. TRIAL REGISTRATION NUMBER: NCT03218930
Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: A qualitative study with general practitioners in Malta.
BackgroundAntibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta.MethodsFace-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour.FindingsWe found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed.ConclusionThis study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment.Trial registration numberNCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930
Analysis of FRAME data (AâFRAME): An analytic approach to assess the impact of adaptations on health services interventions and evaluations
Abstract Introduction Tracking adaptations during implementation can help assess and interpret outcomes. The framework for reporting adaptations and modificationsâexpanded (FRAME) provides a structured approach to characterize adaptations. We applied the FRAME across multiple health services projects, and developed an analytic approach to assess the impact of adaptations. Methods Mixed methods analysis of research diaries from seven quality improvement (QI) and research projects during the early stages of the COVIDâ19 pandemic. Using the FRAME as a codebook, discrete adaptations were described and categorized. We then conducted a threeâstep analysis plan: (1) calculated the frequency of adaptations by FRAME categories across projects; (2) qualitatively assessed the impact of adaptations on project goals; and (3) qualitatively assessed relationships between adaptations within projects to thematically consolidate adaptations to generate more explanatory value on how adaptations influenced intervention progress and outcomes. Results Between March and July 2020, 42 adaptations were identified across seven health services projects. The majority of adaptations related to training or evaluation (52.4%) with the goal of maintaining the feasibility (66.7%) of executing projects during the pandemic. Five FRAME constructs offered the most explanatory benefit to assess the impact of adaptations on program and evaluation goals, providing the basis for creating an analytic approach dubbed the âAâFRAME,â analysis of FRAME data. Using the AâFRAME, the 42 adaptations were consolidated into 17 succinct adaptations. Two QI projects discontinued altogether. Intervention adaptations related to staffing, training, or delivery, while evaluation adaptations included design, recruitment, and data collection adjustments. Conclusions By sifting qualitative data about adaptations into the AâFRAME, implementers and researchers can succinctly describe how adaptations affect interventions and their evaluations. The simple and concise presentation of information using the AâFRAME matrix can help implementers and evaluators account for the influence of adaptations on program outcomes