Selection of proxy indicators estimating the appropriateness of antibiotic prescriptions in general practice: a national consensus procedure in France.

Background: GPs are responsible for more than 70% of outpatient antibiotic prescriptions in France. Metrics are important antibiotic stewardship tools that can be used to set targets for improvement and to give feedback to professionals and stakeholders. Objectives: The primary objective of the present study was to select a set of proxy indicators (PIs) based on 10 previously developed PIs, to estimate the appropriateness of antibiotic prescriptions by GPs. The secondary objective was to evaluate the clinimetric properties of the selected PIs. Methods: A RAND-modified Delphi consensus procedure was conducted with a multidisciplinary panel of stakeholders. This procedure consisted of two successive online surveys with a consensus meeting in between. Clinimetric properties (measurability, applicability and potential room for improvement) were evaluated for the PIs selected through the consensus procedure, using 2022 Regional Health Insurance data. Results: Seventeen experts participated in the first-round survey and 14 in the second-round. A final set of 12 PIs was selected. Among the 10 initial PIs, 3 were selected without modification and 7 were modified and selected. Moreover, two newly suggested PIs were selected. Ten of the 12 PIs presented good clinimetric properties. Conclusions: The 12 selected PIs cover the main situations responsible for inappropriate and unnecessary use of antibiotics in general practice. These PIs, easily calculable using routinely collected health insurance reimbursement data, might be used to give feedback to prescribers and stakeholders and help improve antibiotic prescriptions in primary care.

Risk of readmission and death after hospitalization for worsening heart failure: Role of post-discharge follow-up visits in a real-world study from the Grand Est Region of France.

AIMS: Patients who experience hospitalizations due to heart failure (HF) face a significant risk of readmission and mortality. Our objective was to evaluate whether the risk of hospitalization and mortality following discharge from HF hospitalization differed based on adherence to the outpatient follow-up (FU) protocol comprising an appointment with a general practitioner (GP) within 15 days, a cardiologist within 2 months or both (termed combined FU). METHODS AND RESULTS: We studied all adults admitted for a first HF hospitalization from 2016 to 2020 in France's Grand Est region. Association between adherence to outpatient FU and outcomes were assessed with time-dependent survival analysis model. Among 67 476 admitted patients (mean age 80.3 ± 11.3 years, 53% women), 62 156 patients (92.2%) were discharged alive and followed for 723 (317-1276) days. Combined FU within 2 months was used in 21.1% of patients, with lower rates among >85 years, women, and those with higher comorbidity levels (p < 0.0001 for all). Combined FU was associated with a lower 1-year death or rehospitalization (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.94, p < 0.0001) mostly related to lower mortality (adjusted HR 0.65, 95% CI 0.62-0.68, p < 0.0001) whereas HF readmission was higher (adjusted HR 1.19, 95% CI 1.15-1.24, p < 0.0001). When analysing components of combined FU separately, 1-year mortality was more related to cardiologist FU (HR 0.65, 95% CI 0.62-0.67, p < 0.0001), than GP FU (HR 0.87, 95% CI 0.85-0.90, p < 0.0001). CONCLUSION: Combined FU is carried out in a minority of patients following HF hospitalization, yet it is linked to a substantial reduction in 1-year mortality, albeit at the expense of an increase in HF hospitalizations.

Impact of a public commitment charter, a non-prescription pad and an antibiotic information leaflet to improve antibiotic prescription among general practitioners: A randomised controlled study.

BACKGROUND: This study evaluated the effect of a multifaceted antibiotic stewardship intervention on the overall prescription of systemic antibiotics in primary care. Secondary objectives evaluated the effect on the prescription of broad-spectrum antibiotics and the seasonal variation of both total antibiotic and quinolone prescriptions, as a proxy for unnecessary prescribing. METHODS: This pragmatic, randomised, controlled, before-after intervention study was conducted among general practitioners (GPs) who over prescribe antibiotics in Lorraine, France (Intervention group, n = 109; Control group, n = 236; Before period, 01/10/2017-30/09/2018; After period, 01/10/2018-30/09/2019). The intervention included a public commitment charter, a patient information leaflet and a non-prescription pad. Health Insurance data was obtained to calculate overall and broad-spectrum prescription rate (defined daily doses/1000 consultations) and the seasonal variation of prescriptions (%), by period. The intervention effect was measured with general linear mixed models including three independent variables (group, period and group x period interaction). RESULTS: Overall, compared to the Before period, GPs in both groups prescribed significantly fewer systemic antibiotics (p < 0.001) and broad-spectrum antibiotics (p < 0.001) after the intervention was implemented. However, the group x period interaction did not show any evidence that the intervention had an effect on these outcomes. Nevertheless, the intervention did result in a trend towards less seasonal variation in total systemic antibiotic prescription (p = 0.052). CONCLUSIONS: A tendency towards an effect of the intervention to reduce unnecessary antibiotic prescribing during winter months was observed. No effect was observed on the overall volume of systemic antibiotic prescription. This study invites discussion about the challenges faced when evaluating non-pharmacological interventions in primary care.

Expert consensus on monitoring antimicrobial stewardship in French nursing homes using assessed reimbursement database indicators.

Objectives: Monitoring the appropriateness of antibiotic prescriptions with indicators based on reimbursement data is required to guide antibiotic stewardship (AMS) interventions in nursing homes (NHs). Quantity metrics (QMs) monitor the volume of prescriptions while proxy indicators (PIs) reflect the appropriateness of antibiotic use. Our objectives were: (i) to provide a relevant consensual set of indicators to be used in French NHs; and (ii) to assess the feasibility of their implementation at the national and local scale. Methods: Nine French professional organizations implicated in AMS in NHs were asked to nominate at least one member to create a national expert panel of 20 physicians. Twenty-one recently published QMs and 11 PIs were assessed by the expert panel. Indicators were evaluated using a RAND-modified Delphi procedure comprising two online surveys and a videoconference meeting. Indicators were kept in the final list if >70% of stakeholders validated their relevance for estimating the volume (QMs) and appropriateness (PIs) of prescriptions. Results: Of the 21 QM indicators submitted to the panel, 14 were selected, describing the consumption of antibiotics overall (n = 3), broad-spectrum (n = 6) and second-line antibiotics (n = 2). The three remaining QMs evaluated the route of administration (n = 1) and urine culture prescriptions (n = 2). Ten PIs (six modified, two rejected, one new) were selected to assess the appropriateness of prescriptions for urinary tract infections (n = 2), seasonal variations in prescriptions (n = 2), repeated prescriptions of fluoroquinolones (n = 1), cephalosporins' route of administration (n = 1), duration of treatment (n = 1), rate of second-line antibiotics (n = 1), co-prescriptions with non-steroidal anti-inflammatory drugs (n = 1), and flu vaccine coverage (n = 1). The panel was in favour of using these indicators for regional and facility level AMS programmes (91%), feedback to NH prescribers (82%), benchmarking by health authorities (55%) and public reporting at the facility level (9%). Conclusions: This consensual list of indicators, covering a wide range of frequent clinical situations, may be used as part of the French national AMS strategy for monitoring antibiotic prescriptions in NHs at the national and local levels. Regional AMS networks might manage this selected list to guide personalized action plans with concrete objectives of reducing the quantity and improving the quality of antibiotic prescriptions.

Characteristics of dentists and patients associated with appropriate antibiotic prescriptions by French dentists: a cross-sectional study using Health Insurance databases.

BACKGROUND: The use of antibiotics in dental care is often unnecessary or inappropriate. Our objectives were to identify (i) Clusters of dentists grouped according to their appropriateness score based on proxy indicators' results; and (ii) Dentists' and patients' characteristics associated with the appropriateness of antibiotic prescriptions. METHODS: We used data of the Health Insurance reimbursement databases on antibiotics prescribed in 2019 by general dental practitioners of the Grand Est region in France. The appropriateness of antibiotic prescriptions was estimated by the results of recently published proxy indicators. We conducted a cluster analysis according to an appropriateness score calculated for each dentist, using the Ward method. We then conducted bivariate and multivariable analyses to identify characteristics associated with these clusters. RESULTS: We included 3,014 dentists, who prescribed 373,975 antibiotics in 2019, and which were grouped into three clusters: average practices (n = 1,241), better (n = 686), and worse (n = 1,087) than average practices. Overall, dentists had more appropriate prescription practices when they were male (OR for belonging to cluster with "worse than average practices" = 1.37 (p = 0.003) for female), having a predominant surgery practice (p = 0.028) in the Lorraine area (p < 0.0001) for less years (p = 0.0002), when they had healthier patients (i.e., younger, with no chronic diseases, and who received less procedures), and when they had a more prudent use of drugs in general (i.e., less prescriptions of drugs, antibiotics, and non-steroidal anti-inflammatory). CONCLUSIONS: We identified clusters and characteristics associated with the appropriateness of antibiotic prescriptions made by dentists, which might help guiding antimicrobial stewardship interventions.

Design of proxy indicators estimating the appropriateness of antibiotics prescribed by French dentists: a cross-sectional study based on reimbursement data.

Background - The literature shows that the prescription of antibiotics in dental care is often unnecessary or inappropriate. Indicators estimating the appropriateness of antibiotics prescribed by dentists based on routine databases are however not available in the literature. Our objectives were to: (i) design proxy indicators estimating the appropriateness of antibiotics prescribed by dentists; (ii) evaluate their clinimetric properties; and (iii) provide results for these proxy indicators for dentists located in a north-eastern French region.Methods - We selected and adapted proxy indicators from the literature. Using 2019 Regional Health Insurance data, we evaluated the proxy indicators' clinimetric properties (measurability, applicability, and potential room for improvement), their results with performance scores (% of dentists who reached the target value), and the case-mix stability.Results - We included 3,014 general dental practitioners, who prescribed a total of 373,975 antibiotics to 308,123 patients in 2019. We identified four proxy indicators estimating antibiotic prescribing appropriateness in dental care. All proxy indicators had good clinimetric properties. Performance scores were generally low (10.5 to 73.0%, depending on the indicator), suggesting an important room for improvement. These results showed large variations between dentists (large interquartile ranges) and according to the patients' characteristics (case-mix stability).Conclusion - These four proxy indicators might be used to guide antibiotic stewardship interventions in dental care.

Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases.

OBJECTIVES: Identifying characteristics associated with the appropriateness of antibiotic prescriptions is useful to guide antibiotic stewardship interventions. Proxy indicators estimating the appropriateness of antibiotic prescriptions at the general practitioner (GP) level have recently been validated. Our objectives were to identify (a) clusters of GPs according to their appropriateness score based on these proxy indicator results, and (b) GPs', patients' and practices' characteristics associated with inappropriate prescriptions. METHODS: We conducted a cross-sectional observational study analysing antibiotics prescribed by GPs in one large French region in 2019, using the Health Insurance databases. We identified clusters of GPs according to their appropriateness score calculated from ten proxy indicators' results. We then analysed the association between the clusters with more inappropriate practices compared with the one with less inappropriate practices, and GPs', patients', and practices' characteristics. We performed bivariate and multivariable analyses using logistic polytomous regressions. RESULTS: We included 4819 GPs who were grouped into three clusters. GPs who belong to the clusters with more inappropriate practices were more likely to practice in certain geographical area, to be male, not to have a particular medical practice, to be practicing for longer, to have more patients and consultations, to have a higher proportion of elderly patients, and to prescribe more drugs, more antibiotics and a higher proportion of broad-spectrum antibiotics. CONCLUSION: We identified clusters of practice as well as factors associated with the appropriateness of antibiotic prescriptions, using routinely collected data. This might help to guide antibiotic stewardship interventions.

Antibiotic stewardship in French nursing homes: a 2019 regional survey.

BACKGROUND: Antibiotic resistance is a growing issue in nursing homes (NHs). Antibiotic stewardship (ABS) programmes can reduce antibiotic use in NHs, but few studies have assessed to what extent they are implemented in NHs. OBJECTIVES: To describe ABS current practices and describe the opinion of NH stakeholders regarding ABS and opportunities for improvement in one French region. METHODS: We invited by e-mail the medical and nurse coordinators of all NHs of the Grand Est region, France, to participate in our survey in 2019. The online questionnaire included 35 questions covering four topics: NH characteristics, current ABS practices, attitudes towards ABS and opinions on strategies to promote ABS. A score evaluating implementation of core ABS elements was calculated using the current ABS practice responses. RESULTS: Out of 417 NHs, 75 (18%) participated in our survey. The three most implemented ABS activities were antibiotic consumption monitoring (65%), antibiotic plan documentation (56%) and antibiotic prescription guide distribution (54%). Audit and feedback, training sessions or identification of a local ABS leader ranged from 13% to 29%. Participants positively perceived ABS and most suggestions to improve ABS programmes in NH, with maximal interest in training, audit and feedback interventions. The median score for implementation of core ABS elements was 3.3 (IQR = 2.3-5.4; theoretical range 0-11), and the score distribution was not associated with any NH characteristic. CONCLUSIONS: While there is still room for improvement, NHs had a positive attitude towards ABS strategies. Some regional and national initiatives to promote ABS in NHs exist and should be actively promoted.

Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data.

BACKGROUND: Antibiotic resistance is an increasing threat to public health globally. Indicators on antibiotic prescribing are required to guide antibiotic stewardship interventions in nursing homes. However, such indicators are not available in the literature. Our main objective was to provide a set of quantity metrics and proxy indicators to estimate the volume and appropriateness of antibiotic use in nursing homes. METHODS: Recently published articles were first used to select quantity metrics and proxy indicators, which were adapted to the French nursing home context. A cross-sectional observational study was then conducted based on reimbursement databases. We included all community-based nursing homes of the Lorraine region in northeastern France. We present descriptive statistics for quantity metrics and proxy indicators. For proxy indicators, we also assessed performance scores, clinimetric properties (measurability, applicability, and room for improvement), and conducted case-mix and cluster analyses. RESULTS: A total of 209 nursing homes were included. We selected 15 quantity metrics and 11 proxy indicators of antibiotic use. The volume of antibiotic use varied greatly between nursing homes. Proxy indicator performance scores were low, and variability between nursing homes was high for all indicators, highlighting important room for improvement. Six of the 11 proxy indicators had good clinimetric properties. Three distinct clusters were identified according to the number of proxy indicators for which the acceptable target was reached. CONCLUSIONS: This set of 15 quantity metrics and 11 proxy indicators may be adapted to other contexts and could be used to guide antibiotic stewardship programs in nursing homes.

Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017.

BackgroundIn most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level.AimOur objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs' performance scores and their clinimetric properties using a large regional reimbursement database.MethodsA recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties).ResultsThe 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential.ConclusionsThe set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

[Analysis of reimbursement of dialysis patients' transport expenses in Lorraine]. / Analyse de la demande de transport des patients dialysés en Lorraine.

INTRODUCTION: Renal failure is defined as impairment of the excretory function of the kidney. Chronic Kidney Disease (CKD) gets progressively worse and end-stage renal disease (ESRD) constitutes thefinal stage. In France, overall spending generated by CKD in 2011 amounted to €3.3 billion. More than 80% of this cost was related to dialysis. Transport of patients in 2012 also cost €3.8 billion and 17% of this expenditure concerned patients with ESRD. METHODS: The aim of this study was to analyze reimbursement of transport expenses of dialysis patients in order to develop a regional action plan to optimize this reimbursement in Lorraine. PMSI-DCIR data from SNIIRAM portal were used to study the characteristics of the Lorraine population of general scheme patients (including Local Mutualist Sections) dialyzed at least once with or without reimbursement of transport expenses in 2012. RESULTS: In 2012, 1,692 patients in Lorraine received at least one dialysis session. Nearly €22 millions were reimbursed for transportation of these patients. An analysis of the population of patients treated exclusively by hemodialysis throughout 2012 showed significant differences in the cost of transport according to their age, their department and the distance of the dialysis center from their home, the type of transport and long-term disease status. DISCUSSION: Among all ofthe possible actions, patient intervention in health centers could be considered during training at the beginning of dialysis depending on the distance of the center from their home, in order to explain the modalities ofreimbursement of theirfuture transport by health insurance (the more "attractive" Personal Vehicle package, combined transportation, seated transportation card), to partially relieve health centers of this burden and to ensure that the transport is adapted to the patient's state of health.

[Analysis of the quality of care provided to diabetic patients]. / Analyse de la qualitéde la prise en charge médicale des patients diabétiques.

OBJECTIVE: The follow-up of diabetic patients in the northeast region of France was examined using the method recommended by the French High Health Authority. METHODS: Health insurance databases were used to analyze patient monitoring between 2006 and 2008, highlighting those doctors who were not providing adequate care according to good practice guidelines. A system based on academic detailing was recently set up between these doctors and the medical consultants working for the Health Insurance Service. Patient follow-up was also examined between 2008 and 2010 to assess the impact of academic detailing on care consumption. RESULTS: Regardless of the type of recommended examination, the number of patients who were examined at least once a year by a doctor involved in an academic detailing process significantly increased. By contrast, the follow-up of patients whose doctor was not involved in academic detailing remained unchanged. In some cases, the quality of follow-up care was poor. Other explanatory factors were also highlighted, including the type of treatment received by the patient, the fact of having a long-term illness and the area of residence of the patient. CONCLUSION: The impact of academic detailing highlighted in this study remains hypothetical because of the regression to the mean phenomenon. Further studies are needed to verify this hypothesis. Since the effectiveness of regular screening for diabetes complications is well established, medical consultants at the Health Insurance Service may be said to play a critical role.