N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study.

BACKGROUND: Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. OBJECTIVE: We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. METHODS: Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. RESULTS: We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. CONCLUSIONS: Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. TRIAL REGISTRATION: ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50417.

P-Hacking in Orthopaedic Literature: A Twist to the Tail.

BACKGROUND: "P-hacking" occurs when researchers preferentially select data or statistical analyses until nonsignificant results become significant. We wanted to evaluate if the phenomenon of p-hacking was evident in orthopaedic literature. METHODS: We text-mined through all articles published in three top orthopaedic journals in 2015. For anonymity, we cipher-coded the three journals. We included all studies that reported a single p value to answer their main hypothesis. These p values were then charted and frequency graphs were generated to illustrate any evidence of p-hacking. Binomial tests were employed to look for evidence of evidential value and significance of p-hacking. RESULTS: Frequency plots for all three journals revealed evidence of p-hacking. Binomial tests for all three journals were significant for evidence of evidential value (p < 0.0001 for all). However, the binomial test for p-hacking was significant only for one journal (p = 0.0092). CONCLUSIONS: P-hacking is an evolving phenomenon that threatens to jeopardize the evidence-based practice of medicine. Although our results show that there is good evidential value for orthopaedic literature published in our top journals, there is some evidence of p-hacking of which authors and readers should be wary.