What drives antimicrobial prescribing for companion animals? A mixed-methods study of UK veterinary clinics.

Antimicrobial use in companion animals is a largely overlooked contributor to the complex problem of antimicrobial resistance. Humans and companion animals share living spaces and some classes of antimicrobials, including those categorised as Highest Priority Critically Important Antimicrobials (HPCIAs). Veterinary guidelines recommend that these agents are not used as routine first line treatment and their frequent deployment could offer a surrogate measure of 'inappropriate' antimicrobial use. Anthropological methods provide a complementary means to understand how medicines use makes sense 'on-the-ground' and situated in the broader social context. This mixed-methods study sought to investigate antimicrobial use in companion animals whilst considering the organisational context in which increasing numbers of veterinarians work. Its aims were to i) to epidemiologically analyse the variation in the percentage of antimicrobial events comprising of HPCIAs in companion animal dogs attending UK clinics belonging to large veterinary groups and, ii) to analyse how the organisational structure of companion animal practice influences antimicrobial use, based on insight gained from anthropological fieldwork. A VetCompassTM dataset composed of 468,665 antimicrobial dispensing events in 240,998 dogs from June 2012 to June 2014 was analysed. A hierarchical model for HPCIA usage was built using a backwards elimination approach with clinic and dog identity numbers included as random effects, whilst veterinary group, age quartile, breed and clinic region were included as fixed effects. The largest odds ratio of an antimicrobial event comprising of a HPCIA by veterinary group was 7.34 (95% confidence interval 5.14 - 10.49), compared to the lowest group (p < 0.001). Intraclass correlation was more strongly clustered at dog (0.710, 95% confidence interval 0.701 - 0.719) than clinic level (0.089, 95% confidence interval 0.076 -0.104). This suggests that veterinarians working in the same clinic do not automatically share ways of working with antimicrobials. Fieldwork revealed how the structure of the companion animal veterinary sector was more fluid than that depicted in the statistical model, and identified opportunities and challenges regarding altering antimicrobial use. These findings were organised into the following themes: "Highest priority what?"; "He's just not himself"; "Oh no - here comes the antibiotics police"; "We're like ships that pass in the night"; and "There's not enough hours in the day". This rigorous mixed-methods study demonstrates the importance of working across disciplinary silos when tackling the complex problem of antimicrobial resistance. The findings can help inform the design of sustainable stewardship schemes for the companion animal veterinary sector.

A Decision Analysis of Observation vs Immediate Reintervention for Asymptomatic Residual Fragments Less than 4 mm Following Ureteroscopic Lithotripsy.

INTRODUCTION: We performed a decision analysis model of the cost-effectiveness of observation vs intervention for asymptomatic residual fragments less than 4 mm in diameter following ureteroscopic holmium laser lithotripsy. METHODS: Outcomes data from a retrospective analysis evaluating the natural history, complications and reintervention rates of asymptomatic residual stone fragments performed by the EDGE (Endourology Disease Group for Excellence) Research Consortium were used. A decision analysis model was constructed to compare the cost-effectiveness of initial observation of residual fragments to immediate intervention. Cost of observation included emergency room visits, hospitalizations and reinterventions. The cost analysis model extended to 3 years to account for delayed reintervention rates for fragments less than 4 mm. Costs of emergency department visits, readmissions and reinterventions were calculated based on published figures from the literature. RESULTS: Decision analysis modeling demonstrated that when comparing initial observation to immediate reintervention, the cost was $2,183 vs $4,424. The difference in cost was largely driven by the fact that over 3 years, approximately 55% of all patients remained asymptomatic and did not incur additional costs. This represents an approximate annual per patient savings of $747, and $2,241 over 3 years when observation is selected over immediate reintervention. CONCLUSIONS: Our decision analysis model demonstrates superior cost-effectiveness for observation over immediate reintervention for asymptomatic residual stones less than 4 mm following ureteroscopic lithotripsy. Based on these findings careful stratification and selection of patients may enable surgeons to improve cost-effectiveness of managing small, asymptomatic residual fragments following ureteroscopic lithotripsy.

Spirometry is underused in the diagnosis and monitoring of patients with chronic obstructive pulmonary disease (COPD).

Spirometry is important in the diagnosis and management of chronic obstructive pulmonary disease (COPD), yet it is a common clinical observation that it is underused though the extent is unclear. This survey aims to examine the use of spirometry in the diagnosis and management of COPD patients in a district in Hong Kong. It is a cross-sectional survey involving four clinic settings: hospital-based respiratory specialist clinic, hospital-based mixed medical specialist clinic, general outpatient clinic (primary care), and tuberculosis and chest clinic. Thirty physician-diagnosed COPD patients were randomly selected from each of the four clinic groups. All of them had a forced expiratory volume in 1 second (FEV1) to forced vital capacity ratio less than 0.70 and had been followed up at the participating clinic for at least 6 months for COPD treatment. Of 126 patients who underwent spirometry, six (4.8%) did not have COPD. Of the 120 COPD patients, there were 111 males and mean post-bronchodilator FEV1 was 46.2% predicted. Only 22 patients (18.3%) had spirometry done during diagnostic workup, and 64 patients (53.3%) had spirometry done ever. The only independent factor predicting spirometry done ever was absence of old pulmonary tuberculosis and follow-up at respiratory specialist clinic. Age, sex, smoking status, comorbidities, duration of COPD, percentage predicted FEV1, body mass index, 6-minute walking distance, and Medical Research Council dyspnea score were not predictive. We conclude that spirometry is underused in general but especially by nonrespiratory physicians and family physicians in the management of COPD patients. More effort at educating the medical community is urgently needed.

Estudio de la motivación laboral y el conocimiento de la necesidad predominante según la teoría de las necesidades de Mcclelland, en los médicos del Hospital Nacional Arzobispo Loayza / Study of the labor motivation and the knowledge of the predominant need according to the theory of Mcclelland's needs, in the doctors of the Arzobispo Loayza National Hospital

El presente estudio tiene por objeto conocer el grado de motivación laboral y las necesidades predominantes según la Teoría de las Necesidades de David McClelland, en los médicos del Hospital Nacional Arzobispo Loayza (HNAL). Para tal fin, se realizó un estudio cualitativo de tipo prospectivo, descriptivo, observacional y transversal; bajo el método de selección probabilístico de voluntarios. La muestra estuvo integrada por 63 médicos, pertenecientes a los siguientes grupos: Anestesiología, Cirugía general, Medicina Interna, Cirugía especialidades, Medicina Especialidades, Ginecoobstetricia y Pediatría. El instrumento empleado fue una encuesta basada en la Teoría de las Necesidades según McClelland, que consta de 15 preguntas formuladas con la técnica de Likert, y validada por Steers y Braunstein en 1976. La encuesta permitió clasificar el grado de motivación laboral en alto, medio, o bajo; y determinar si la necesidad predominante es de logro, poder o afiliación. Los resultados obtenidos evidenciaron que la motivación laboral fue alta en el 95.2 por ciento, media en el 4.8 por ciento y ninguno de los encuestados mostró un bajo grado de motivación laboral. Las variables que se relacionaron directamente con el grado de motivación laboral fueron: Edad y tiempo de servicio. La condición laboral de "contratado por locación de servicio", demostró intervenir de manera inversa a las variables antes mencionadas. No aportaron significancia estadística a la motivación laboral, el estado civil ni el grupo de especialidad. El tipo de necesidad predominante encontrado entre los participantes estuvo distribuido de la siguiente manera: Logro 75 por ciento, afiliación 14 por ciento y poder 11 por ciento. La necesidad de afiliación mostró puntajes mínimos más altos entre los que llevan más de 30 años en la institución y en los que tienen más de 60 años de edad...

The present study has for object know the degree of labor motivation and the predominant needs according to the Theory of David McClelland's Needs, in the doctors of the National Hospital Archbishop Loayza (HNAL). For such purpose, there was realized a qualitative study of market, descriptive type, observational and transversely; under the method of selection not probabilistic of volunteers. The sample was integrated by 63 doctors, belonging to the following groups: Anesthesiology, General Surgery, General Medicine, Specialities Surgery, Specialities Medicine, Gynecology-Obstetrics and Pediatrics. The used instrument was a survey based on the Theory of the Needs according to McClelland, which consists of 15 questions formulated with Likert's technology, and validated by Steers and Braunstein in 1976. The survey allowed to classify the degree of labor motivation under high place, way, or down; and to determine if the predominant need is of achievement, power or affiliation. The obtained results demonstrated that the labor motivation was high in 95.2 per cent, average in 4.8 per cent and none of the polled ones showed a low degree of labor motivation. The variants that related directly to the degree of labor motivation were: Age and time of service. The labor condition of "contracted by lease of service", demonstrated to intervene in an inverse way to the variants before mentioned. They contributed significance statistics neither to the labor motivation, the marital status nor the group of speciality. The type of predominant need found between the participants was distributed of the following way: I achieve 75 per cent, affiliation 14 per cent and to be able 11 per cent. The need of affiliation showed scored higher minimums between those who go more than 30 years in the institution and in those who have more than 60 years of age...