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 ).

Assessing undergraduate medical education through a generalist lens.

PROBLEM BEING ADDRESSED: Medical schools aim to integrate the values of generalism into their undergraduate programs. However, currently no program has been described to measure the degree to which formal curricular materials represent generalist principles. OBJECTIVE OF PROGRAM: To quantify the generalism principles present in undergraduate medical education learning materials and to provide recommendations to enhance generalism content. PROGRAM DESCRIPTION: A review of the literature and accreditation documents was conducted to identify key elements of medical generalism. An evidence-informed tool, the Toronto Generalism Assessment Tool, was developed and applied to the new preclerkship undergraduate cases at the University of Toronto in Ontario. The findings regarding the presence of generalism principles and recommendations to enhance generalism content were provided to case developers. The recommendations were valued and were incorporated into subsequent iterations of the cases. CONCLUSION: This is the first report of a successful evidence-informed program to assess the degree of generalism reflected in undergraduate medical education curricular documents. This program can be used by other institutions wishing to review their curricula through a generalist lens.

Family Medicine Journal Club: To Tweet or Not to Tweet?

BACKGROUND AND OBJECTIVES: Online journal clubs have recently become popular, but their effectiveness in promoting meaningful discussion of the evidence is unknown. We aimed to understand the learner experience of a hybrid online-traditional family medicine journal club. METHODS: We used a qualitative descriptive study to understand the experience of medical students and residents at the University of Toronto with the hybrid online-traditional family medicine journal club, including perceived useful and challenging aspects related to participant engagement and fostering discussion. The program, informed by the literature and needs assessment, comprised five sessions over a 6-month period. Learners led the discussion between the distributed sites via videoconferencing and Twitter. Six of 12 medical students and 33 of 57 residents participated in one of four focus groups. Thematic data analysis was performed using the constant comparison method. RESULTS: While participants could appreciate the potential of an online component to journal club to connect distributed learners, overall, they preferred the small group, face-to-face format that they felt produced richer and more meaningful discussion, higher levels of engagement, and a better learning opportunity. Videoconferencing and Twitter were seen as diminishing rather than enhancing their learning experience and they challenged the assumption that millennials would favor the use of social media for learning. CONCLUSIONS: Our study demonstrates that for discussion-based teaching activities such as journal club, learners prefer a small-group, face-to-face format. Our findings have implications for the design of curricular programs for distributed medical learners.