Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients.

Objective: Audit and feedback is an antimicrobial stewardship (AMS) strategy, with the potential to also optimize antimicrobial use in non-audited patients. This study aimed to determine whether audit and feedback reduce antimicrobial use in both audited and non-audited patients. Design: Before-after trial with a 1-year intervention period and 2.5-year historical cohort. Setting: 750-bed community hospital in the Netherlands. Patients: All patients admitted to the urology wards during the 3.5-year study period were observed. Patients were classified as using antimicrobials if any antimicrobial was used for therapeutic reasons. Patients using antimicrobials prophylactically were excluded from measurements. Intervention: The AMS team provided audit and feedback on antimicrobial use for patients using antimicrobials for 2 days. Retrospectively, antimicrobial use and length of stay (LOS) were compared with the historical cohort. Results: Audits modified antimicrobial treatment in 52.8% of the cases. De-escalating, stopping, and switching from intravenous to oral treatment accounted for 72% of these modifications. Compared to patients from the cohort, who also used antimicrobials for 2 days, antimicrobial use decreased from 14.21 DDD/patient (95% CI, 13.08-15.34) to 11.45 DDD/patient (95% CI, 8.26-14.64; P = .047) for audited patients. Furthermore, mean LOS decreased from 7.42 days (95% CI, 6.79-8.06) to 6.13 days (95% CI, 5.38-6.89; P = .031). However, looking at all patients admitted to the urology wards, the percentage of patients using antimicrobials and total antimicrobial use remained unchanged. Conclusions: Audit and feedback reduce antimicrobial use and LOS, but only for audited patients. Positive effects are not automatically transferred to patients for whom no audits have been performed.

Determinants associated with work participation in patients with established rheumatoid arthritis taking tumor necrosis factor inhibitors.

OBJECTIVE: Reduced work participation (WP) is a common problem for patients with rheumatoid arthritis (RA) and generates high costs for society. Therefore, it is important to explore determinants of WP at the start of tumor necrosis factor inhibitor (TNFi) treatment, and for changes in WP after 2 years of TNFi treatment. METHODS: Within the Dutch Rheumatoid Arthritis Monitoring (DREAM) biologic register, WP data were available from 508 patients with RA younger than 65 years and without an (early) retirement pension. WP was registered at start of TNFi treatment and after 2 years of followup and was measured by single patient-reported binary questions whether they had work, paid or voluntary, or had a disability allowance or a retirement pension. Determinants measured at baseline were age, sex, disease duration, functional status [through Health Assessment Questionnaire-Disability Index (HAQ-DI)], 28-joint Disease Activity Score (DAS28), rheumatoid factor, presence of erosions, number of previous disease-modifying antirheumatic drugs, and number of comorbidities. During the 2 years of followup, HAQ-DI response and European League Against Rheumatism response were measured. Univariate analyses (excluded if p value was > 0.2) and multivariate (excluded if p value was > 0.1) logistic regression analyses were used. RESULTS: Determinants associated with WP at baseline were having a better HAQ-DI (OR 0.32, p = 0.000) and male sex (OR 0.65, p = 0.065). After 2 years of TNFi therapy, 11.8% (n = 60) started to work and 13.6% (n = 69) stopped working. Determinants associated with starting to work were better baseline HAQ-DI (OR 0.58), positive RF (OR 2.73), and young age (OR 0.96); and for stopping work, worse baseline HAQ-DI (OR 2.74), low HAQ-DI response (OR 0.31), and comorbidity (OR 2.67), all with p < 0.1. CONCLUSION: Young patients with RA and a high functional status without any comorbidity will have a better chance of working. This supports the main goal in the management of RA: to suppress disease activity as soon and as completely as possible to prevent irreversible destruction of the joints, and thus maintain a good functional status of the patient. Because of the low proportion of variance explained by the models in this study, other factors besides the ones studied are associated with WP.

An exploration of chronic pain patients' perceptions of home telerehabilitation services.

OBJECTIVES: To explore patients' perceptions regarding prospective telerehabilitation services and the factors that facilitate or impede patients' intentions to use these services. DESIGN: Using semi-structured interviews, patients reflected on the pros and cons of various scenarios of prospective telerehabilitation services. Patients' arguments were first arranged according to the Unified Theory of Acceptance and Use of Technology (UTAUT). Next, using inductive analysis, the data for each UTAUT component were analysed and arranged into subthemes. SETTING AND PARTICIPANTS: Twenty-five chronic pain patients were selected from a rehabilitation centre in the Netherlands. RESULTS: Overall, participants considered telerehabilitation helpful as a complementary or follow-up treatment, rather than an autonomous treatment. Arguments mainly related to the UTAUT constructs of 'performance expectancy' and 'facilitating conditions'. Patients valued the benefits such as reduced transportation barriers, flexible exercise hours and the possibility to better integrate skills into daily life. However, many patients feared a loss of treatment motivation and expressed concerns about both reduced fellow sufferer contact and reduced face-to-face therapist contact. Few arguments related to 'social norms' and 'effort expectancy'. CONCLUSIONS: The effect of telerehabilitation on healthcare strongly depends on patients' willingness to use. Our study showed that chronic pain patients valued the benefits of telerehabilitation but hesitate to use it as an autonomous treatment. Therefore, future initiatives should maintain traditional care to some degree and focus on patients' attitudes as well. Either by giving information to increase patients' confidence in telerehabilitation or by addressing reported drawbacks into the future design of these services. Further quantitative studies are needed to explore patients' intentions to use telerehabilitation.