How do general practitioners access guidelines and utilise electronic medical records to make clinical decisions on antibiotic use? Results from an Australian qualitative study.

OBJECTIVE: This study aimed to explore how general practitioners (GPs) access and use both guidelines and electronic medical records (EMRs) to assist in clinical decision-making when prescribing antibiotics in Australia. DESIGN: This is an exploratory qualitative study with thematic analysis interpreted using the Theory of Planned Behaviour (TPB) framework. SETTING: This study was conducted in general practice in Victoria, Australia. PARTICIPANTS: Twenty-six GPs from five general practices were recruited to participate in five focus groups between February and April 2018. RESULTS: GPs expressed that current EMR systems do not provide clinical decision support to assist with antibiotic prescribing. Access and use of guidelines were variable. GPs who had more clinical experience were less likely to access guidelines than younger and less experienced GPs. Guideline use and guideline-concordant prescribing was facilitated if there was a practice culture encouraging evidence-based practice. However, a lack of access to guidelines and perceived patients' expectation and demand for antibiotics were barriers to guideline-concordant prescribing. Furthermore, guidelines that were easy to access and navigate, free, embedded within EMRs and fit into the clinical workflow were seen as likely to enhance guideline use. CONCLUSIONS: Current barriers to the use of antibiotic guidelines include GPs' experience, patient factors, practice culture, and ease of access and cost of guidelines. To reduce inappropriate antibiotic prescribing and to promote more rational use of antibiotic in the community, guidelines should be made available, accessible and easy to use, with minimal cost to practicing GPs. Integration of evidence-based antibiotic guidelines within the EMR in the form of a clinical decision support tool could optimise guideline use and increase guideline-concordant prescribing.

Seasonal, interannual, and long-term variation in sport fish contamination, San Francisco Bay.

This study documents changes in contamination over time at seasonal, interannual, and decadal time scales for sport fish collected in San Francisco Bay. Samples from seven fish species were prepared according to common consumption practices (muscle fillets either with or without skin) and analyzed for trace metals (mercury and selenium) and trace organochlorine contaminants (PCBs, DDTs, chlordanes, and dieldrin). In 2000, sport fish samples exceeded human health screening values for mercury, PCBs, DDTs, selenium, and dieldrin but did not exceed screening values for chlordanes. On a seasonal time scale, white croaker (Genyonemus lineatus) exhibited significantly lower PCB and lipid concentrations in spring, and a general increase in concentrations in other seasons. When monitoring data were compared among 1994, 1997, and 2000, analysis of variance indicated that concentrations of mercury, PCBs, DDTs, and chlordanes varied significantly among years for several fish species. Interannual variation in DDTs often correlated to changes in sampled fish size or lipid content among years. Interannual variation in mercury and PCBs was evident in striped bass (Morone saxatilis) but absent in shiner surfperch (Cymatogaster aggregata), leopard shark (Triakis semifasciata), and white croaker. The higher interannual variability of striped bass contaminant concentrations may result from migratory behavior and wide home ranges. Chlordanes significantly declined between 1994 and 2000 in white croaker and striped bass. Of the historical data analyzed (1986-2000), only DDT concentrations in white sturgeon (Acipenser transmontanus) showed evidence of a significant decline. Neither PCBs nor selenium showed evidence of a trend in white sturgeon. Between 1970 and 2000, mercury concentrations in striped bass showed no evidence of a trend. The absence of recent trends in mercury may result from the presence of widespread and historic sources, with use reductions occurring in the early 20th century. In contrast to mercury, apparent recent declines in fish tissue DDT and chlordane concentrations may result from use curtailment in the 1970s and 1980s.

Contaminant concentrations in sport fish from San Francisco Bay, 1997.

In 1997, seven sport fish species were sampled from seven popular fishing areas in San Francisco Bay. Mercury exceeded a human health screening value in 44 of 84 (52%) samples. All collected samples of leopard shark and striped bass exceeded the mercury screening value of 0.23 microg/g wet weight. PCBs exceeded the screening value in 51 of 72 (71%) samples. DDT, chlordane, and dieldrin, had lower numbers of samples above screening values: 16 of 72 (22%) for DDT, 11 of 72 (15%) for chlordanes, and 27 of 72 (37%) for dieldrin. Concentrations of PCBs and other trace organics were highest in white croaker and shiner surfperch, the two species with the highest fat content in their muscle tissue. Fish from one location, Oakland Harbor, had significantly elevated wet weight concentrations of mercury, PCBs, DDTs, and chlordanes compared to other locations. Removal of skin from white croaker fillets reduced lipid concentrations by 27-49% and concentrations of trace organics by 33-40%.