Do family medicine residents optimally prescribe antibiotics for common infectious conditions seen in a primary care setting?

Background: Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting. Methods: This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics. Results: Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]). Conclusions: The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.

Historique: La résistance antimicrobienne est un phénomène mondial responsable d'un grand nombre de décès inutiles et d'hospitalisations coûteuses. Plus de 90 % des antibiotiques sont utilisés en milieu communautaire, et les deux tiers de ces prescriptions proviennent de médecins de famille. Par la présente étude, les auteurs visent à déterminer si les résidents en médecine de famille reçoivent la formation optimale pour prescrire des antibiotiques en vue du traitement des affections infectieuses courantes en soins primaires. Méthodologie: La présente étude est l'analyse secondaire d'une étude antérieure de la gouvernance antimicrobienne dans deux cliniques de soins primaires urbaines du centre de Toronto, en Ontario. Au total, 1 099 consultations de patients adultes effectuées en 2015 et 2016, auxquelles ont participé des résidents en médecine de famille, ont été incluses. Les principales mesures de résultats étaient le taux de prescription d'antibiotiques pour chaque affection et les pratiques de prescription recommandées par les experts, le rythme d'émission d'ordonnances tardives et l'utilisation d'antibiotiques à spectre étroit recommandés en première ligne. Résultats: Par rapport aux taux de prescription recommandés par les experts, les résidents en médecine de famille surprescrivaient en cas d'infections des voies respiratoires supérieures (IVRS) (5,0 % [intervalle de confiance (IC) à 95 % = 2,2 % à 9,7 %] par rapport à 0 % recommandé par les experts) et de sinusite (44,2 % [IC à 95 % = 32,8 % à 55,9 %] par rapport à une plage de 11 % à 18 % chez les experts), et sous-prescrivaient en cas de pneumonie (53,5 % [IC à 95 % = 37,7 % à 68,8 %] par rapport à 100 % chez les experts]). Les taux de prescription se situaient dans les plages recommandées par les experts dans les cas de pharyngite (28,6 % [IC à 95 % = 16,6 % à 43,3 %]), de bronchite (3,6 % [IC à 95 % = 0 % à 18,4 %]) et de cystite (79,4 % [IC à 95 % = 70,6 % à 86,6 %]). Conclusions: Les pratiques de prescription d'antibiotiques des résidents en médecine de famille pendant leur programme de formation démontrent une surprescription d'antibiotiques lors de présentations infectieuses courantes. Il est recommandé de poursuivre l'étude des prescriptions d'antibiotiques en soins primaires au Canada pour déterminer si les futurs médecins de famille assimilent les pratiques appropriées de prescription d'antibiotiques.

Assessing the Validity of Electronic Medical Records for Identifying High Antibiotic Prescribers in Primary Care.

OBJECTIVES: Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. METHODS: The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. RESULTS: Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P = .40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P < .01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P < .001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P = .001). CONCLUSIONS: Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix.

Documenting the indication for antimicrobial prescribing: a scoping review.

BACKGROUND: Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice. OBJECTIVES: We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations. ELIGIBILITY CRITERIA: Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing. SOURCES OF EVIDENCE: A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature. CHARTING AND ANALYSIS: Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively. RESULTS: We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice. CONCLUSION: There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

Specialist wait time reporting using family physicians' electronic medical record data: a mixed method study of feasibility and clinical utility.

BACKGROUND: More than 50% of Canadian adult patients wait longer than four weeks to see a specialist after referral from primary care. Access to accurate wait time information may help primary care physicians choose the timeliest specialist to address a patient's specific needs. We conducted a mixed-methods study to assess if primary to specialist care wait times can be extracted from electronic medical records (EMR), analyzed the wait time information, and used focus groups and interviews to assess the potential clinical utility of the wait time information. METHODS: Two family practices were recruited to examine primary care physician to specialist wait times between January 2016 and December 2017, using EMR data. The primary outcome was the median wait time from physician referral to specialist appointment for each specialty service. Secondary outcomes included the physician and patient characteristics associated with wait times as well as qualitative analyses of physician interviews about the resulting wait time reports. RESULTS: Wait time data can be extracted from the primary care EMR and converted to a report format for family physicians and specialists to review. After data cleaning, there were 7141 referrals included from 4967 unique patients. The 5 most common specialties referred to were Dermatology, Gastroenterology, Ear Nose and Throat, Obstetrics and Gynecology and Urology. Half of the patients were seen by a specialist within 42 days, 75% seen within 80 days and all patients within 760 days. There were significant differences in wait times by specialty, for younger patients, and those with urgently labelled medical situations. Overall, wait time reports were perceived by clinicians to be important since they could help family physicians decide how to triage referrals and might lead to system improvements. CONCLUSIONS: Wait time information from primary to specialist care can aid in decision-making around specialist referrals, identify bottlenecks, and help with system planning. This mixed method study is a starting point to review the importance of providing wait time data for both family physicians, specialists and local health systems. Future work can be directed towards developing wait time reporting functionality and evaluating if wait time information will help increase system efficiency and/or improve provider and patient satisfaction.

Predicting hospital readmission risk: A prospective observational study to compare primary care providers' assessments with the LACE readmission risk index.

PURPOSE: This study aims to determine if the primary care provider (PCP) assessment of readmission risk is comparable to the validated LACE tool at predicting readmission to hospital. METHODS: A prospective observational study of recently discharged adult patients clustered by PCPs in the primary care setting. Physician readmission risk assessment was determined via a questionnaire after the PCP reviewed the hospital discharge summary. LACE scores were calculated using administrative data and the discharge summary. The sensitivity and specificity of the physician assessment and the LACE tool in predicting readmission risk, agreement between the 2 assessments and the area under receiver operating characteristic (AUROC) curves were calculated. RESULTS: 217 patient readmission encounters were included in this study from September 2017 till June 2018. The rate of readmission within 30 days was 14.7%, and 217 discharge summaries were used for analysis. The weighted kappa coefficient was 0.41 (95% CI: 0.30-0.51) demonstrating a moderate level of agreement. Sensitivity of physician assessment was 0.31 (95% CI: 0.22-0.40) and specificity was 0.80 (95% CI: 0.77-0.83). The sensitivity of the LACE assessment was 0.42 (95% CI: 0.25-0.59) and specificity was 0.79 (95% CI: 0.73-0.85). The AUROC for the LACE readmission risk was 0.65 (95% C.I. 0.55-0.76) demonstrating modest predictive power and was 0.57 (95% C.I. 0.46-0.68) for physician assessment, demonstrating low predictive power. CONCLUSION: The LACE index shows moderate discriminatory power in identifying high-risk patients for readmission when compared to the PCP's assessment. If this score can be provided to the PCP, it may help identify patients who requires more intensive follow-up after discharge.

A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada.

BACKGROUND: More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. METHODS: Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. RESULTS: There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). CONCLUSIONS: A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. TRIAL REGISTRATION: clinicaltrials.gov ( NCT03517215 ).

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada.

Background: Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. Methods: A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. Results: Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. Conclusions: PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

Historique: Des programmes de gestion antimicrobienne (PGA) communautaires efficaces doivent exister, parce que 90 % des antimicrobiens sont prescrits dans la communauté. Des chercheurs ont évalué un PGA en première ligne (PGA-PL) afin d'en déterminer l'efficacité à réduire les prescriptions d'antibiotiques pour six infections courantes. Méthodologie: Les chercheurs ont évalué un programme de formation polyvalent au moyen d'une méthodologie avant-après dans quatre cliniques de soins de première ligne entre 2015 et 2017. Le résultat clinique primaire était la différence entre les cliniques de contrôle et d'intervention pour ce qui est du total de prescriptions antibiotiques contre six infections courantes avant et après l'intervention. Les résultats cliniques secondaires incluaient des modifications à l'utilisation des antibiotiques propres au trouble de santé, le report des prescriptions d'antibiotiques, des prescriptions de plus de sept jours, l'utilisation des antibiotiques recommandés et les visites à l'urgence ou les hospitalisations dans les 30 jours. Les chercheurs ont utilisé des méthodes multimodèles tenant compte de la démographie, du mélange de cas et du regroupement par médecin pour évaluer l'effet des traitements. Résultats: Les prescriptions totales d'antibiotiques dans les cliniques de contrôle et d'intervention ne différaient pas (différences des différences = 1,7 %; IC à 95 %, ­12,5 % à 15,9 %), ni l'utilisation de prescriptions reportées (­5,2 %; IC à 95 %, ­24,2 % à 13,8 %). Les prescriptions de plus de sept jours étaient très peu courantes (­21,3 %; IC à 95 %, ­42,5 % à ­0,1 %). Cependant, seulement 781 des 1 777 rencontres (44,0 %) avaient eu lieu avec des dispensateurs qui avaient suivi la formation sur le PGA. Lorsque les dispensateurs avaient suivi la formation, les reports de prescriptions augmentaient de 17,7 % (p = 0,06) et les prescriptions de plus de sept jours diminuaient (­27 %; IC à 95 %, ­48,3 % à ­5,6 %). Les visites subséquentes à l'urgence et les hospitalisations n'ont pas augmenté. Conclusions: L'efficacité du PGA-PL pour l'utilisation d'antibiotiques était variable. Les dispensateurs de soins de première ligne qui y avaient participé préparaient des prescriptions de moins longue durée et reportaient davantage leurs prescriptions.

Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data.

BACKGROUND: Unnecessary antibiotic use in the community in Canada is not well defined. Our objective was to quantify unnecessary antibiotic prescribing in a Canadian primary care setting. METHODS: We performed a descriptive analysis in Ontario from April 2011 to March 2016 using the Electronic Medical Records Primary Care database linked to other health administrative data sets at ICES. We determined antibiotic prescribing rates (per 100 patient-physician encounters) for 23 common conditions and estimated rates of unnecessary prescribing using predefined expected prescribing rates, both stratified by condition and patient age group. RESULTS: The study included 341 physicians, 204 313 patients and 499 570 encounters. The rate of unnecessary antibiotic prescribing for included conditions was 15.4% overall and was 17.6% for those less than 2 years of age, 18.6% for those aged 2-18, 14.5% for those aged 19-64 and 13.0% for those aged 65 or more. The highest unnecessary prescribing rates were observed for acute bronchitis (52.6%), acute sinusitis (48.4%) and acute otitis media (39.3%). The common cold, acute bronchitis, acute sinusitis and miscellaneous nonbacterial infections were responsible for 80% of the unnecessary antibiotic prescriptions. Of all antibiotics prescribed, 12.0% were for conditions for which they are never indicated, and 12.3% for conditions for which they are rarely indicated. In children, 25% of antibiotics were for conditions for which they are never indicated (e.g., common cold). INTERPRETATION: Antibiotics were prescribed unnecessarily for 15.4% of included encounters in a Canadian primary care setting. Almost one-quarter of antibiotics were prescribed for conditions for which they are rarely or never indicated. These findings should guide safe reductions in the use of antibiotics for the common cold, bronchitis and sinusitis.

Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study.

The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.

Defining appropriate antibiotic prescribing in primary care: A modified Delphi panel approach.

Background: Antimicrobial overuse contributes to antimicrobial resistance. In the ambulatory setting, where more than 90% of antibiotics are dispensed, there are no Canadian benchmarks for appropriate use. This study aims to define the expected appropriate outpatient antibiotic prescribing rates for three age groups (<2, 2-18, >18 years) using a modified Delphi method. Methods: We developed an online questionnaire to solicit from a multidisciplinary panel (community-academic family physicians, adult-paediatric infectious disease physicians, and antimicrobial stewardship pharmacists) what percentage of 23 common clinical conditions would appropriately be treated with systemic antibiotics followed with in-person meetings to achieve 100% consensus. Results: The panelists reached consensus for one condition online and 22 conditions face-to-face, which took an average of 2.6 rounds of discussion per condition (range, min-max 1-5). The consensus for appropriate systemic antibiotic prescribing rates were, for pneumonia, pyelonephritis, non-purulent skin and soft tissue infections (SSTI), other bacterial infections, and reproductive tract infections, 100%; urinary tract infections, 95%-100%; prostatitis, 95%; epididymo-orchitis, 85%-88%; chronic obstructive pulmonary disease, 50%; purulent SSTI, 35%-50%; otitis media, 30%-40%; pharyngitis, 18%-40%; acute sinusitis, 18%-20%; chronic sinusitis, 14%; bronchitis, 5%-8%; gastroenteritis, 4%-5%; dental infections, 4%; eye infections, 1%; otitis externa, 0%-1%; and asthma, common cold, influenza, and other non-bacterial infections (0%). (Note that some differed by age group.). Conclusions: This study resulted in expert consensus for defined levels of appropriate antibiotic prescribing across a broad set of outpatient conditions. These results can be applied to community antimicrobial stewardship initiatives to investigate the level of inappropriate use and set targets to optimize antibiotic use.

Historique: La surutilisation d'antimicrobiens contribue à la résistance antimicrobienne. Il n'y a pas de normes canadiennes pour en établir l'utilisation appropriée en milieu ambulatoire, où plus de 90 % des antibiotiques sont prescrits. La présente étude vise à définir le taux de prescription approprié et anticipé d'antibiotiques en milieu ambulatoire dans trois groupes d'âge (moins de 2 ans, de 2 à 18 ans, plus de 18 ans) au moyen de la méthode Delphi modifiée. Méthodologie: Les auteurs ont préparé un questionnaire en ligne pour demander à un groupe multidisciplinaire (médecins de famille en milieu communautaire et universitaire, infectiologues pour adultes et pour enfants et pharmaciens en gestion des antimicrobiens) le pourcentage de 23 affections cliniques courantes qui serait traité correctement par des antibiotiques systémiques et l'ont fait suivre de rencontres en salle pour obtenir un consensus à 100 %. Résultats: Le groupe est parvenu à un consensus en ligne à l'égard d'une affection et à un consensus en salle à l'égard de 22 affections, ce qui a exigé une moyenne de 2,6 séries de discussions par affection (plage minimum-maximum de 1 à 5). Le consensus relatif aux taux de prescription appropriés d'antibiotiques systémiques était de 100 % pour la pneumonie, la pyélonéphrite, les infections non purulentes de la peau et des tissus mous, les autres infections bactériennes et les infections de l'appareil reproducteur; de 95 % à 100 % pour les infections urinaires; de 95 % pour la prostatite; de 85 % à 88 % pour l'épididymo-orchite; de 50 % pour la maladie pulmonaire obstructive chronique; de 35 % à 50 % pour les ITS purulentes; de 30 % à 40 % pour l'otite moyenne; de 18 % à 40 % pour la pharyngite; de 18 % à 20 % pour la sinusite aiguë; de 14 % pour la sinusite chronique; de 5 % à 8 % pour la bronchite; de 4 % à 5 % pour la gastroentérite; de 4 % pour les infections dentaires; de 1 % pour les infections oculaires; de 0 % à 1 % pour l'otite externe et de 0 % pour l'asthme, le rhume banal, la grippe et les autres infections non bactériennes. Il est à souligner que certains pourcentages différaient en fonction des groupes d'âge. Conclusions: La présente étude a suscité un consensus d'experts à l'égard de degrés définis de prescription appropriée d'antibiotiques pour un large éventail d'affections ambulatoires. Ces résultats peuvent être appliqués aux initiatives de gestion des antimicrobiens en milieu communautaire afin d'explorer le degré d'utilisation appropriée et de fixer des objectifs d'optimisation de l'utilisation d'antibiotiques.

Choosing Wisely Canada campaign associated with less overuse of thyroid testing: Retrospective parallel cohort study.

OBJECTIVE: To assess the effectiveness of a Choosing Wisely Canada (CWC) initiative to improve thyroid-stimulating hormone (TSH) test ordering for patients with no identified indication for this test. DESIGN: Retrospective parallel cohort study using routinely collected electronic medical record (EMR) data. The CWC initiative included supporting primary care leads in each participating family health team, providing education on better test ordering, and allowing adaptation appropriate to each local context. SETTING: Toronto, Ont, and surrounding areas. PARTICIPANTS: Family physicians contributing EMR data to the University of Toronto Practice-Based Research Network and their patients aged 18 or older. MAIN OUTCOME MEASURES: Proportion of adult patients with a TSH test done in a 2-year period (2016 to 2017) in the absence of EMR data with an indication for TSH testing; proportion of TSH test results in the normal range for those patients; and change in the rate of TSH screening in sites participating in the CWC initiative compared with sites not participating. RESULTS: A total of 150 944 patients (51.7% of studied adults) had no identified indication for TSH testing; 33.4% of those patients were seen by physicians in the family health teams participating in the CWC initiative. Overall, 35.1% of all patients with no identified indication had at least 1 TSH test between January 1, 2016, and December 31, 2017. The 119 physicians participating in the CWC initiative decreased their monthly rate of testing by 0.23% from 2016 to 2017, a relative reduction of 13.2%. The 233 physicians not participating decreased testing by 0.04%, a relative reduction of 1.8%. The monthly difference between the 2 groups was 0.19% (95% CI -0.02 to -0.35 P = .03), a relative difference of 11.4%. The TSH testing decreased for almost all CWC patient subgroups. More than 95% of patients tested in both groups had TSH results in the normal range. CONCLUSION: This study found high rates of TSH testing without identified indications in the practices studied. A CWC initiative implemented in primary care was effective in reducing TSH testing.

Turning challenges into design principles: Telemonitoring systems for patients with multiple chronic conditions.

People with multiple chronic conditions often struggle with managing their health. The purpose of this research was to identify specific challenges of patients with multiple chronic conditions and to use the findings to form design principles for a telemonitoring system tailored for these patients. Semi-structured interviews with 15 patients with multiple chronic conditions and 10 clinicians were conducted to gain an understanding of their needs and preferences for a smartphone-based telemonitoring system. The interviews were analyzed using a conventional content analysis technique, resulting in six themes. Design principles developed from the themes included that the system must be modular to accommodate various combinations of conditions, reinforce a routine, consolidate record keeping, as well as provide actionable feedback to the patients. Designing an application for multiple chronic conditions is complex due to variability in patient conditions, and therefore, design principles developed in this study can help with future innovations aimed to help manage this population.

External validation study of a clinical decision aid to reduce unnecessary antibiotic prescriptions in women with acute cystitis.

BACKGROUND: Empirical prescribing of antibiotics to women with symptoms of acute cystitis prior to culture results is common, but subsequent culture results are often negative. A clinical decision aid for prescribing decisions in acute cystitis was previously developed that could reduce these unnecessary antibiotic prescriptions but has not been validated. This study sought to validate this decision aid for empirical antibiotic prescribing decisions in a new cohort of women with suspected acute cystitis. METHODS: External validation study of a clinical decision aid in 397 women with symptoms of acute cystitis, involving 230 Canadian family practitioners across Canada between 2009 and 2011. The sensitivity and specificity of the decision aid compared to a gold standard positive urine culture (defined as ≥102 cfu/ml (≥105 CFU/L)) was determined, and compared with physician management, and the earlier development cohort study estimates. Other outcomes assessed were total antibiotic prescriptions, unnecessary antibiotics for negative urine cultures, and recommendations for urine culture testing. Chi-square tests were used for unpaired comparisons, adjusted for physician clustering. McNemar's test was used for paired comparisons. RESULTS: There were 245/397 (61.7%) positive urine cultures. The cystitis aid sensitivity was 202/245 (82.5%, 95% Confidence Interval (CI)) = 77.1%, 86.8%), compared to 167/208 (80.3%) in the previous development cohort (p = 0.54), and 239/245 (97.6%) by family physicians in the current study (p < 0.001). Specificity was low for physicians (10/152, 6.6%) compared to the decision aid (54/152, 35.5%; p < 0.001, resulting in more antibiotic prescriptions by physicians (381/397, 96.0%) than would occur with decision aid recommendations (300/397, 75.6%, p < 0.001). Unnecessary antibiotic prescriptions where urine cultures were negative would be reduced an absolute 11.1% with cystitis aid recommendations (98/397, 24.7%) compared to usual physician care (142/397, 35.8%; p = 0.001). Urine cultures would also be reduced (97/397, 24.4% decision aid vs 351/397, 88.4% physicians; p < 0.001). CONCLUSIONS: A 3-item clinical decision aid demonstrated reproducible accuracy in two cohorts of women with acute cystitis symptoms. Clinically important reductions in total and unnecessary antibiotic use, as well as urine culture testing, could result with routine clinical use compared to current empirical physician management practices.

Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013.

INTRODUCTION: Acute rhinosinusitis (ARS) is a respiratory disease commonly caused by viral infections. Physicians regularly prescribe antibiotics despite bacterial etiologies being uncommon. This is of concern, as this use adds to the selection pressure for resistance. Here we present the descriptive epidemiology of acute rhinosinusitis and corresponding antibiotic prescribing practices by Canadian outpatient physicians from 2007-2013. MATERIALS/METHODS: Diagnosis and antibiotic prescription data for ARS were extracted from the Canadian Disease and Therapeutic Index for 2007 to 2013, and population data were acquired from Statistics Canada. ARS diagnosis and antibiotic prescription rates and frequencies of antibiotic classes were calculated. RESULTS: Eighty-eight percent of patients diagnosed with ARS in 2013 were adults, with a greater rate of antibiotic prescriptions observed among the adults relative to the pediatric patients (1632.9 and 468.6 antibiotic prescriptions per 10,000 inhabitants). Between 2007 and 2013, the ARS diagnosis rate decreased from 596 to 464 diagnoses per 10,000 inhabitants, while the percentage of diagnoses with antibiotic prescriptions at the national level remained stable (87% to 84%). From 2007 to 2013, prescription rates for macrolides decreased from 203.5 to 105.4 prescriptions per 10,000 inhabitants. In 2013, penicillins with extended spectrum were more commonly prescribed compared to macrolides among adult patients (153.5 and 105.4 prescriptions per 10,000 inhabitants, respectively). CONCLUSION: This study is the first to describe physician antibiotic prescribing practices for treatment of ARS in Canada. Results show that antibiotic treatment for ARS represents an area for implementing antimicrobial stewardship, and through it, managing antibiotic resistance. Further work is required to better understand diagnosing practices and treatment criteria for ARS, and use this information to further assist physicians to limit unnecessary antibiotic prescribing practices.

The Effect of Changes in Cervical Cancer Screening Guidelines on Chlamydia Testing.

PURPOSE: Many chlamydia infections are identified through screening, which is frequently offered to females concomitantly with cervical cancer screening. Recent cervical cancer screening guidelines recommend screening less frequently and starting later. We sought to evaluate the impact of the May 2012 Ontario, Canada, cervical cancer screening guideline change on Papanicolaou (Pap) and chlamydia trachomatis (chlamydia) testing and incidence. METHODS: We extracted population-based physician billing claims data to identify Pap and chlamydia tests and public health surveillance data to identify chlamydia cases. We used interrupted time series analysis of quarterly data spanning 2 years before and after the guideline change and fitted segmented linear regression or rational functions to the outcomes using autoregressive integrated moving average models. Outcomes were stratified by sex and age group. RESULTS: Two years after the guideline change, we observed reduced chlamydia testing in females, with the greatest relative reduction (25.5%) among those aged 15 to 19 years. We also observed decreases in reported chlamydia incidence for females aged 15 to 19 years and 20 to 24 years (relative reductions of 16.8% and 14.4%, respectively). Chlamydia incidence remained the same for males, despite increased chlamydia testing. CONCLUSIONS: Recent cervical cancer screening guideline changes in Ontario were associated with reduced chlamydia testing and reported new cases of chlamydia in females. Females aged 15 to 19 years, who are at high risk for chlamydia if sexually active, and who no longer warrant cervical cancer screening, were disproportionately affected. Females should be tested for chlamydia based on risk, regardless of need for Pap testing.

Predicting antibiotic prescription after symptomatic treatment for urinary tract infection: development of a model using data from an RCT in general practice.

BACKGROUND: Uncomplicated urinary tract infection (UTI) is often treated with antibiotics, resulting in increasing resistance levels. A randomised controlled trial showed that two-thirds of females with UTI treated symptomatically recovered without subsequent antibiotic treatment. AIM: To investigate whether there are differences between females with a UTI who were subsequently prescribed antibiotics and those who recovered with symptomatic treatment only, and to develop a model to predict those who can safely and effectively be treated symptomatically. DESIGN AND SETTING: This is a subgroup analysis of females assigned to ibuprofen in a UTI trial in general practices. METHOD: Multiple logistic regression analysis was used to select variables for a prediction model, The discriminative value of the model was estimated by the area under the receiver operator curve (AUC) and the effects of different thresholds were calculated within the model predicting antibiotic prescription and need for follow-up visits. RESULTS: Of the 235 females in the ibuprofen group, 79 were subsequently prescribed antibiotics within 28 days of follow-up. The final model included five predictors: urgency/frequency, impaired daily activities, and positive dipstick test results for erythrocytes, leucocytes, and nitrite. The AUC was 0.73 (95% CI = 0.67 to 0.80). A reasonable threshold for antibiotic initiation would result in 58% of females presenting with UTI being treated with antibiotics. Of the remaining females, only 6% would return to the practice because of symptomatic treatment failure. CONCLUSION: The present model revealed moderately good accuracy and could be the basis for a decision aid for GPs and females to find the treatment option that fits best.

Antibiotic-resistant Escherichia coli in women with acute cystitis in Canada.

BACKGROUND: Trimethoprim-sulfamethoxazole (TMP-SMX) has been a traditional first-line antibiotic treatment for acute cystitis; however, guidelines do not recommend TMP-SMX in regions where Escherichia coli resistance exceeds 20%. While resistance is increasing, there are no recent Canadian estimates from a primary care setting to guide prescribing decisions. METHODS: A total of 330 family physicians assessed 752 women with suspected acute cystitis between 2009 and 2011. Physicians documented clinical features and collected urine for cultures for 430 (57.2%) women. The proportion of resistant isolates of E coli and exact binomial 95% CIs were estimated nationally, and compared regionally and demographically. These estimates were compared with those from a 2002 national study. RESULTS: The proportion of TMP-SMX-resistant E coli was 16.0% nationally (95% CI 11.3% to 21.8%). This was not statistically higher than 2002 (10.9% [P=0.14]). TMP-SMX resistance was increased in women ≤50 years of age (21.4%) compared with older women (10.7% [P=0.037]). In women with no antibiotic exposure in the previous three months, TMP-SMX-resistant E coli remained more prevalent in younger women (21.8%) compared with older women (4.4% [P=0.003]). The proportion of ciprofloxacin-resistant E coli was 5.5% nationally (95% CI 2.7% to 9.9%), and was increased compared with 2002 (1.1% [P=0.036]). Ciprofloxacin resistance was highest in British Columbia (17.7%) compared with other regions (2.7% [P=0.003]), and was increased compared with 2002 levels in this province (0.0% [P=0.025]). Nitrofurantoin-resistant E coli levels were low (0.5% [95% CI 0.01% to 2.7%). DISCUSSION: The proportion of TMP-SMX-resistant E coli causing acute cystitis in women in Canada remains below 20% nationally, but may exceed this level in premenopausal women. Ciprofloxacin resistance has increased, notably in British Columbia. Nitrofurantoin resistance levels are low across the country. These observations indicate that TMP-SMX and nitrofurantoin remain appropriate empirical antibiotic agents for treating cystitis in primary care settings in Canada.

HISTORIQUE: Le triméthoprim-sulfaméthoxazole (TMP-SMX) est un traitement antibiotique de première ligne pour soigner la cystite aiguë, mais les lignes directrices ne le recommandent pas dans les régions ou la résistance à l'Escherichia coli dépasse les 20 %. La résistance augmente, mais il n'y a pas d'évaluation canadienne récente en première ligne pour orienter les décisions relatives aux prescriptions. MÉTHODOLOGIE: Au total, 330 médecins de famille ont évalué 752 femmes ayant eu une cystite aiguë présumée entre 2009 et 2011. Les médecins ont étayé les caractéristiques cliniques et prélevé l'urine de 430 femmes (57,2 %) en vue des cultures. Les chercheurs ont évalué la proportion d'isolats d'E coli résistants et les intervalles de confiance (IC) binomiales exactes à 95 % sur la scène nationale et les ont comparés sur la scène régionale et sur le plan démographique. Ils ont ensuite comparé ces évaluations à celles d'une étude nationale menée en 2002. RÉSULTATS: La proportion d'E coli résistant au TMP-SMX s'élevait à 16,0 % sur la scène nationale (95 % IC 11,3 % à 21,8 %). Ce résultat n'était pas statistiquement plus élevé qu'en 2002 (10,9 % [P=0,14]). La résistance au TMP-SMX était plus importante chez les femmes de 50 ans ou moins (21,4 %) que chez les femmes plus âgées (10,7 % [P=0,037]). Chez les femmes n'ayant pas été exposées aux antibiotiques au cours des trois mois précédents, l'E coli résistant au TMP-SMX demeurait plus prévalent chez les femmes plus jeunes (21,8 %) que chez les femmes plus âgées (4,4 % [P=0,003]). La proportion d'E coli résistant à la ciprofloxacine atteignait 5,5 % sur la scène nationale (95 % IC 2,7 % à 9,9 %), soit un pourcentage plus fort qu'en 2002 (1,1 % [P=0,036]). Dans les régions, la résistance à la ciprofloxacine la plus élevée (17,7 %) s'observait en Colombie-Britannique (2,7 % [P=0,003]), où elle était plus marquée qu'en 2002 (0,0 % [P=0,025]). Le taux d'E coli résistant à la nitrofurantoïne était faible (0,5 % [95 % IC 0,01 % à 2,7 %). EXPOSÉ: La proportion d'E coli résistant au TMP-SMX responsable d'une cystite aiguë chez les femmes du Canada demeure sous les 20 % au pays, mais peut dépasser ce pourcentage chez les femmes préménopausées. La résistance à la ciprofloxacine a augmenté, notamment en Colombie-Britannique. Les taux de résistance à la nitrofurantoïne sont faibles au pays. D'après ces observations, le TMP-SMX et la nitrofurantoïne demeurent des agents antibiotiques empiriques pertinents pour traiter la cystite en première ligne au Canada.