System Dynamics modelling to formulate policy interventions to optimise antibiotic prescribing in hospitals

© 2020 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Multiple strategies have been used in the National Health System (NHS) in England to reduce inappropriate antibiotic prescribing and consumption in order to tackle antimicrobial resistance. These strategies have included, among others, restricting dispensing, introduction of prescribing guidelines, use of clinical audit, and performance reviews as well as strategies aimed at changing the prescribing behaviour of clinicians. However, behavioural interventions have had limited effect in optimising doctors’ antibiotic prescribing practices. This study examines the determinants of decision-making for antibiotic prescribing in hospitals in the NHS. A system dynamics model was constructed to capture structural and behavioural influences to simulate doctors’ prescribing practices. Data from the literature, patient records, healthcare professional interviews and survey responses were used to parameterise the model. The scenario simulation shows maximum improvements in guideline compliance are achieved when compliance among senior staff is increased, combined with fast laboratory turnaround of blood cultures, and microbiologist review. Improving guideline compliance of junior staff alone has limited impact. This first use of system dynamics modelling to study antibiotic prescribing decision-making demonstrates the applicability of the methodology for design and evaluation of future policies and interventions.Peer reviewe

ESGAP inventory of target indicators assessing antibiotic prescriptions: A cross-sectional survey

Background A variety of indicators is commonly used to monitor antibiotic prescriptions as part of national antimicrobial stewardship (AMS) programmes. Objectives To make an inventory of indicators that assess antibiotic prescriptions and are linked to specific targets and incentives, at a national level. Methods A cross-sectional survey (three-item questionnaire) was conducted in 2017 among all ESGAP (ESCMID Study Group for Antimicrobial stewardshiP) members, coming from 23 European countries and 16 non-European countries. Results Almost all (20/23, 87%) European countries belonging to the ESGAP network participated, as well as one non-European country. Computerized systems routinely linking antibiotic prescriptions to clinical diagnoses were reported for only two countries (Turkey and Croatia). Only 6/21 (29%) countries had national indicators with both clear targets and incentives (Bulgaria, Croatia, France, the Netherlands, Norway and Portugal). We identified a total of 21 different indicators used in these countries, 16 concerning inpatients (9 quality indicators and 7 quantity metrics) and 8 concerning outpatients (all quantity metrics); some indicators were used in both settings. Three types of incentives were used: financing mechanism, hospitals' accreditation and public reporting. Some respondents reported that such indicators with both clear targets and incentives were used at a regional level in their country (e.g. Andalusia in Spain and England in the UK). Conclusions National indicators, with clear targets and incentives, are not commonly used in Europe and we observed wide variations between countries regarding the selected indicators, the units of measure and the chosen targets

Assessing Metrics of Climate Change. Current Methods and Future Possibilities.

With the principle of comprehensiveness embedded in the UN Framework Convention on Climate Change (Art. 3), a multi-gas abatement strategy with emphasis also on non-CO2 greenhouse gases as targets for reduction and control measures has been adopted in the international climate regime. In the Kyoto Protocol, the comprehensive approach is made operative as the “aggregate anthropogenic carbon dioxide equivalent emissions” of six specified greenhouse gases or groups of gases (Art. 3). With this operationalisation, the emissions of a set of greenhouse gases with very different atmospheric lifetimes and radiative properties are transformed into one common unit – “CO2 equivalents”. This transformation is based on the Global Warming Potential (GWP) index, which in turn is based on the concept of radiative forcing. The GWP metric and its application in policy making has been debated, and several other alternative concepts have been suggested. In this paper, we review existing and alternative metrics of climate change, with particular emphasis on radiative forcing and GWPs, in terms of their scientific performance. This assessment focuses on questions such as the climate impact (end point) against which gases are weighted; the extent to which and how temporality is included, both with regard to emission control and with regard to climate impact; how cost issues are dealt with; and the sensitivity of the metrics to various assumptions. It is concluded that the radiative forcing concept is a robust and useful metric of the potential climatic impact of various agents and that there are prospects for improvement by weighing different forcings according to their effectiveness. We also find that although the GWP concept is associated with serious shortcomings, it retains advantages over any of the proposed alternatives in terms of political feasibility. Alternative metrics, however, make a significant contribution to addressing important issues, and this contribution should be taken into account in the further development of refined metrics of climate change

Working across boundaries: Science-policy interfaces and international forest politics

If scientific knowledge is to influence international environmental policy it needs to be recognised as authoritative and impartial by key politicians and policy makers. In the case of climate change this is achieved by a boundary organisation, the Intergovernmental Panel on Climate Change (IPCC), which enables climate scientists to demonstrate the veracity of their research to climate policy makers while, for the most part, maintaining scientific integrity and resisting political interference in scientific conclusions. However, in the absence of such an organisation for forest science the international forest science community has come forward and created its own mechanism - the Global Forest Expert Panels - which responds to demands from the forest policy community for knowledge in particular areas and which in some respects is based on the IPCC model. However, even if a more effective forest-science policy boundary organisation were to exist, progress in international forest policy would be constrained by some long standing political divisions, in particular on the financing of sustainable forest management

CD64 as a potential biomarker in septic arthritis

Background Traditional inflammatory markers are generally unhelpful in discerning septic arthritis from inflammatory joint disease due to their lack of specificity. We wished to explore the discriminatory power of the novel inflammatory marker, Fc-gamma-receptor type 1, CD64, in patients presenting with acute arthritis. Methods Patients were recruited prospectively in the time period June 2009 to December 2011. Thirty-six patients presenting with an acute flare of chronic rheumatic arthritis, 31 with crystal-induced arthritis and 23 with septic arthritis were included. Traditional inflammatory markers, CD64 and procalcitonin (PCT) were measured and their diagnostic abilities were compared. Results CD64 and PCT both demonstrated a specificity of 98%, but poor sensitivities of 59% and 52%, respectively. White blood cell count (WBC), and erythrocyte sedimentation rate (ESR) did not have significant discriminatory power, while C-reactive protein (CRP) proved to have the best diagnostic accuracy as measured by area under the ROC curve (AUC 0.92, 95% confidence-interval 0.87-0.98). Subgroup analysis excluding patients with septic arthritis without concurrent bacteremia, and likewise exclusion of the patients with septic arthritis caused by coagulase negative staphylococci, both improved the diagnostic accuracy of CD64 and PCT, but not of WBC and CRP.</p< Conclusions CD64 and PCT are highly specific for infectious disease, but they predominantly measure bacteremia. Their use in hospital practice has yet to be defined, and especially so in localized infections