Antibiotic prescription in primary care from the perspective of family physicians: a qualitative study.

INTRODUCTION: Antibiotic consumption increases worldwide steadily. Turkey is now top on the list of global consumption and became a prototype of excessive use of antibiotics. In the last two decades, family physicians (FPs) have become key figures in the healthcare system. This study aims to understand the reasons for inappropriate antibiotic prescribing and elicit suggestions for improving antibiotic use in primary care from doctors themselves. METHODOLOGY: This is a qualitative semi-structured interview study with research dialogues guided by the Vancouver School of interpretive phenomenology. Fourteen FPs from different parts of Turkey were questioned on inappropriate antibiotic prescriptions and their suggestions for improving antibiotic use. RESULTS: The most important reasons for prescribing antibiotics without acceptable indications were patient expectations, defensive medical decision making, constraints due to workload, and limited access to laboratories. The most remarkable inference was the personal feeling of an insecure job environment of the FPs. The most potent suggestions for improving the quality of antibiotic prescription were public campaigns, improvements in the diagnostic infrastructures of primary care centers, and enhancing the social status of FPs. The FPs expressed strong concerns related to the complaints that patients make to administrative bodies. CONCLUSIONS: Primary care physicians work under immense pressure, stemming mainly from workload, patient expectations, and obstacles related to diagnostic processes. Improving the social status of physicians, increasing public awareness, and the facilitation of diagnostic procedures was the methods suggested for increasing antibiotic prescription accuracy.

The association between physician knowledge and inappropriate medications for older populations.

BACKGROUND: Older patients are often prescribed potentially inappropriate medications (PIMs) given their age. We measured the association between a physician's general knowledge and their PIM prescribing. METHODS: Using a 2013-2017 cross-sectional design, we related a general internist's knowledge (n = 8196) to their prescribing of PIMs to fee-for-service Medicare beneficiaries, age ≥ 66 years with part D coverage, which they saw in the outpatient setting the year after their exam (n = 875,132). Physician knowledge was based on the American Board of Internal Medicine's (ABIM) Internal Medicine Maintenance of Certification (IM-MOC) exam scores. Medications included 72 PIMs from the American Geriatric Society's Beers Criteria and appropriate alternatives to these medications. Logistic regressions controlled for physicians practice/training characteristics and patient-risk factors. RESULTS: Annually, 11.0% of patients received a PIM and 57.2% received an appropriate alternative medication. Patients seen by physicians scoring in the top versus bottom quartile were 8.6% less likely (95% confidence interval [CI]: -12.7 to -4.5, p < 0.001) to be prescribed a PIM and 4.7% more likely (95% CI: 1.7 to 7.6, p = 0.001) to be prescribed an appropriate alternative medication. The difference in PIM prescribing grew to 12.1% fewer (95% CI: -15.1 to -9.1) patients when limiting the sample to the 58.9% of patients being prescribed a PIM or appropriate alternative medication. Among patients receiving any medication, this was similar to the percent difference in PIM prescribing between solo and large practices (≥50 physicians, -10.2%, 95% CI: 13.6-6.5, p < 0.001) or between group and academic practices (-11.7%, 95% CI: -15.3 to -7.9, p < 0.001). PIM prescribing was more positively associated with patient characteristics including age, gender, and total number of medications prescribed. CONCLUSIONS: Better physician general knowledge, as measured by an ABIM exam, was associated with fewer PIM prescriptions. Future research should examine whether general educational interventions, such as MOC, effect PIM prescribing.

Patients' and Caregivers' Attitudes Toward Deprescribing in Singapore.

BACKGROUND: Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs. METHOD: A cross-sectional survey of two groups of participants was conducted using the Revised Patients' Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants' characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed. RESULTS: A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively. CONCLUSIONS: Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.

Use of Anti-Dementia Drugs Reduces the Risk of Potentially Inappropriate Medications: A Secondary Analysis of a Nationwide Survey of Prescribing Pharmacies.

AIMS: As the number of older people with dementia increases, safe pharmacotherapy in this population has attracted attention in recent years. The aims of this study were to clarify the prescribing patterns in older patients who were prescribed anti-dementia drugs and to investigate the association of potentially inappropriate medications (PIMs) with the use of anti-dementia drugs. METHODS: Adults aged ≥65 years, who were prescribed anti-dementia drugs at 585 pharmacies across Japan (N = 7,953), were surveyed. The percentage of prescriptions of anti-dementia drugs and the effect of those prescriptions on PIMs were investigated. RESULTS: Prescriptions of anti-dementia drugs were found in 4.4% of the entire study population. A multiple logistic regression analysis revealed that the use of anti-dementia drugs reduced the risk of prescribing psychotropic drugs, which represented PIMs, and that a combination of anti-dementia drugs (e.g., cholineesterase inhibitor with memantine) may reduce the risk of prescribing PIMs compared with monotherapy. CONCLUSION: The use of anti-dementia drugs was associated with fewer prescriptions of drugs considered as PIMs.

Parental self-medication with antibiotics for children promotes antibiotic over-prescribing in clinical settings in China.

BACKGROUND: Self-medication with antibiotics (SMA) is one of the most dangerous inappropriate antibiotic use behaviors. This study aims to investigate the impact of parental SMA for children before a consultation on their doctor's subsequent antibiotic prescribing behavior, including intravenous (IV) antibiotic use in the clinical setting of China. METHODS: A cross-sectional survey was conducted between June 2017 and April 2018 in three provinces of China. A total of 9526 parents with children aged 0-13 years were investigated. Data from 1275 parents who had self-medicated their children and then visited a doctor in the past month were extracted and analyzed. RESULTS: One-third (410) of the studied children had parental SMA before the consultation and 83.9% of them were subsequently prescribed antibiotics by doctors. Children with parental SMA were more likely to be prescribed antibiotics (aOR = 7.79, 95% CI [5.74-10.58]), including IV antibiotics (aOR = 3.05, 95% CI [2.27-4.11]), and both oral and IV antibiotics (aOR = 3.42, 95% CI [2.42-4.84]), than children without parental SMA. Parents with SMA behaviors were more likely to request antibiotics (aOR = 4.05, 95% CI [2.59-6.31]) including IV antibiotics (aOR = 2.58, 95% CI [1.40-4.76]), and be fulfilled by doctors (aOR = 3.22, 95% CI [1.20-8.63]). CONCLUSIONS: Tailored health education for parents is required in both community and clinical settings to discourage parental SMA for children. The doctors should not prescribe unnecessary antibiotics to reinforce parents' SMA behaviors. We recommend expanding the current IV antibiotics ban in outpatient settings of China to cover outpatient pediatrics.

Impact of oxygen therapy algorithm on oxygen usage in the emergency department.

BACKGROUND: Although oxygen is one of the oldest drugs available, it is still one of the most inappropriately administered drugs leading to over utilization of this very expensive resource. MATERIALS AND METHODS: This prospective observational study was done in a large emergency department (ED) in India. The pattern of oxygen usage was studied before and after the strict implementation of an oxygen treatment algorithm. The algorithm was taught to all doctors and nurses and its implementation was monitored regularly. The main outcome measures were proportion of patients receiving oxygen therapy, inappropriate usage, and avoidable direct medical cost to the patient. RESULTS: The 3-week pre-protocol observation phase in April 2016 included 3769 patients and the 3-week post-protocol observation phase in April 2017 included 4608 patients. The baseline demographic pattern was similar in both the pre-protocol and post-protocol groups. After the strict implementation of the algorithm, the number of patients receiving oxygen therapy decreased from 9.63% to 4.82%, a relative decrease of 51.4%. The average amount of total oxygen used decreased from 55.4 liters per person in pre-protocol group to 42.1 liters per person in the post-protocol group with a mean difference of 13.28 (95% CI 5.30-21.26; P = 0.001). Inappropriate oxygen usage decreased from 37.2% to 8.6%. There was a significant decrease in inappropriate oxygen use for indications like low sensorium (60.8% vs 21.7%) and trauma (88.5% vs 15.8%). The mortality rate in the pre-protocol phase was 2.7% as compared with 3.2% in the post-protocol phase. The total duration of inappropriate oxygen usage significantly decreased from 987 h to 89 h over the 21-day study period. CONCLUSION: The implementation of an oxygen therapy algorithm significantly reduces inappropriate oxygen use and decreases treatment cost to the patient with no additional mortality risk.

A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis.

Background: National guidelines are important instruments in reducing inappropriate antibiotic prescriptions. Low adherence to guidelines is an acknowledged problem that needs to be addressed.Method: We evaluated established characteristics for guidelines in the guidelines for lower respiratory tract infection, acute otitis media and pharyngotonsillitis in primary care. We studied how doctors used these guidelines by analysing interviews with 29 general practitioners (GPs) in Sweden.Results: We found important between-guidelines differences, which we believe affects adherence. The GPs reported persistent preconceptions about diagnosis and treatment, which we believe reduces their adherence to the guidelines.Conclusion: To increase adherence, it is important to consider doctors' preconceptions when creating new guidelines.

The complex phenomenon of dysrational antibiotics prescribing decisions in German primary healthcare: a qualitative interview study using dual process theory.

Background: Antibiotic prescription rates in primary care in Germany are moderate, but still considered too high. The ARena study (Sustainable reduction of antibiotic-induced antimicrobial resistance) was initiated to foster awareness and understanding of the growing challenge and promotes rational antibiotics use for acute, non-complicated and self-limiting infections. Methods: The present study was performed as part of the process evaluation of the ARena study. Interviews were conducted with a purposive sample of physicians participating in the ARena study to identify factors relevant to primary care physicians' decision-making when prescribing antibiotics for acute non-complicated infections. Generated data were audio-recorded. Pseudonymized verbatim transcripts were coded using a pre-defined framework. The Dual Process Theory was applied to provide understanding of individual health professional factors that induce dysrational prescribing decisions. Results: Based on medical as well as non-medical considerations, physicians developed habits in decision making on antibiotics prescribing. They acknowledged inadequate antibiotics prescribing for acute, non-complicated infections in situations involving uncertainty regarding diagnosis, prognosis, continuity of care, patient expectations and when not knowing the patient. Educative efforts empowered physicians to override habitual prescribing. A theory-driven model provides transparency as to how dysrational prescribing decisions occur and suggests remedy by providing new experiences and new recognizable patterns through educative efforts. Conclusions: Educational interventions may only change prescribing behaviours if they result in active rational rather than routine-based decision-making on antibiotics prescribing. Trial registration: ISRCTN, ISRCTN58150046.

Factors Influencing Judgments to Consult Prescription Monitoring Programs: A Factorial Survey Experiment.

BACKGROUND: Prescription monitoring programs (PMPs) can provide health care professionals with valuable information. However, few studies have explored providers' decision making for accessing PMPs. AIMS: This study aimed to identify provider characteristics and situational factors most influencing perceived importance of consulting the PMP for patients in a simulated context. DESIGN: The study used a cross-sectional factorial survey. SETTINGS: The survey was administered electronically. PARTICIPANTS/SUBJECTS: Community pharmacists, advanced practice registered nurses (APRNs), and physicians in Iowa. METHODS: Participants were recruited by mail which included a link to the online survey. The survey consisted of demographic questions, eight randomly generated vignettes, and one ranked item. The vignettes described a hypothetical prescription using eight experimental variables whose levels were randomly varied. Respondents evaluated each vignette for importance to access the PMP. Analyses used linear mixed-effects models in R (Version 3.5.0). RESULTS: A total of 138 responses were available for multilevel analysis. Women, physicians, and APRNs rated it more important to consult the PMP for a given prescription compared with men and pharmacists. Accessing a PMP was perceived as more important with cash payments, quantity dispensed, suspicion for misuse, hydromorphone and oxycodone prescriptions, and headache. Advancing age, postoperative pain, and anxiety or sleep indications were associated with less importance. CONCLUSIONS: Age, indication for prescribing, misuse, and payment mode each independently had greater importance to providers in accessing the PMP. This was the first study to isolate the influence of different controlled substances on how important it was to consult the PMP.

Prevalence of Potentially Inappropriate Medication use in older drivers.

BACKGROUND: Potentially Inappropriate Medication (PIM) use has been studied in a variety of older adult populations across the world. We sought to examine the prevalence and correlates of PIM use in older drivers. METHODS: We applied the American Geriatrics Society 2015 Beers Criteria to baseline data collected from the "brown-bag" review of medications for participants of the Longitudinal Research on Aging Drivers (LongROAD) study to examine the prevalence and correlates of PIM use in a geographically diverse, community-dwelling sample of older drivers (n = 2949). Proportions of participants who used one or more PIMs according to the American Geriatrics Society 2015 Beers Criteria, and estimated odds ratios (ORs) and 95% confidence intervals (CIs) of PIM use associated with participant characteristics were calculated. RESULTS: Overall, 18.5% of the older drivers studied used one or more PIM. The most commonly used therapeutic category of PIM was benzodiazepines (accounting for 16.6% of the total PIMs identified), followed by nonbenzodiazepine hypnotics (15.2%), antidepressants (15.2%), and first-generation antihistamines (10.5%). Compared to older drivers on four or fewer medications, the adjusted ORs of PIM use were 2.43 (95% CI 1.68-3.51) for those on 5-7 medications, 4.19 (95% CI 2.95-5.93) for those on 8-11 medications, and 8.01 (95% CI 5.71-11.23) for those on ≥12 medications. Older drivers who were female, white, or living in urban areas were at significantly heightened risk of PIM use. CONCLUSION: About one in five older drivers uses PIMs. Commonly used PIMs are medications known to impair driving ability and increase crash risk. Implementation of evidence-based interventions to reduce PIM use in older drivers may confer both health and safety benefits. TRIAL REGISTRATION: Not applicable.

Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout.

Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (ß = 0.55, SE = 0.12, p < 0.001), avoiding the patient (ß = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (ß = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.

Does inappropriate prescribing affect elderly patients' quality of life? A study from a Malaysian tertiary hospital.

PURPOSE: To investigate the association between potentially inappropriate medication (PIM)/potential prescribing omission (PPO) and the health-related quality of life (HRQoL) among community-dwelling hospitalized elderly patients. METHODS: This is a cross-sectional study that took place in a Malaysian tertiary hospital. Patients ≥ 65 years old with at least one medication on admission were recruited. The patients' prehospitalization medications were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. HRQoL was assessed using the EuroQol-5 dimensions (EQ-5D) and EuroQol-visual analog scale (EQ-VAS). The association between the presence of PIM/PPO and the patients' HRQoL was analyzed using Chi-square and Mann-Whitney U tests. Multiple linear regression models were applied to determine the effect of exposure to PIM/PPO on the patients' HRQoL, adjusting for confounders. RESULTS: Out of 517 patients who fulfilled the inclusion criteria, 502 patients (97%) accepted to be involved in the study and completed the HRQoL questionnaire. The mean (SD) age was 72.4 (5.9) years. 393 (78.3%) of the patients had problems in at least one EQ-5D dimension with pain/discomfort problem being the most reported complaint. The mean (SD) values of the EQ-5D index and the EQ-VAS were 0.734 (0.214) and 59.6 (14.2), respectively, which are lower than those seen in the general Malaysian population. PIM and PPO were found in 28.5% and 45.6% of the patients, respectively. No significant differences were found in the EQ-5D dimensions, EQ-5D index and EQ-VAS between patients who had PIM/PPO and those who did not. Age, sex, and comorbidities were significantly associated with the patients' HRQoL. CONCLUSION: PIM and PPO are not uncommon among hospitalized elderly patients; however, it does not significantly affect their HRQoL as measured by the EQ-5D-3L instrument.

Knowledge and Practices of Family and Emergency Physicians in Managing Nontraumatic Dental Conditions: A Case-based Survey.

INTRODUCTION: Physicians are often patients' first point of contact for management of nontraumatic dental conditions (NTDCs). This study's aim was to evaluate the knowledge and practices of Ontario physicians in managing NTDCs, with a specific focus on antibiotic usage. METHODS: A Web-based survey featured 4 NTDC clinical scenarios: irreversible pulpitis, localized acute apical abscess with or without systemic involvement, and chronic apical abscess. The survey link was distributed to active Ontario family and emergency physicians. The sample group was asked questions about their management of and experience with NTDCs, and demographic and practice characteristics were collected. Descriptive and multivariate logistic regression analyses were undertaken (P ≤ .05). RESULTS: Sampled Ontario physicians tend to manage NTDCs in a manner that is not consistent with evidence-based care. For irreversible pulpitis and for localized acute apical abscess with or without systemic involvement, most physicians would prescribe an antibiotic (57.4%, 84.8%, and 96.3%, respectively), and 23.5% would prescribe an antibiotic for chronic apical abscess. Approximately half the sample (52.9%) felt discomfort in managing NTDCs, and 85.3% felt they were inadequately trained to manage NTDCs. CONCLUSION: Areas that present opportunities for improvement in the physician management of NTDCs were identified, including the incorporation of further NTDC training in medical curricula and continuing medical education courses, and development and dissemination of guidelines for physicians in managing NTDCs.

Potential for physician communication to build favorable medication beliefs among older adults with hypertension: A cross-sectional survey.

Older adults suffering from hypertension form firm medication beliefs through lifetime medication management, which significantly affect their medication adherence and treatment outcomes. Understanding whether the patient-physician communication has the potential to change medication beliefs will help design an effective communication strategy to foster favorable medication beliefs. This study aims to determine whether the patient-physician communication is associated with medication beliefs among older adults with hypertension and controls socio-demographics and clinical characteristics. Further, it examines how the association varies with two different types of medication beliefs (medication overuse and harm) for each domain of communication (informative and interpersonal). A self-administered cross-sectional survey was conducted for members of seven senior centers in a metropolitan area of the United States between August and December of 2013. A total of 211 senior members suffering from hypertension completed the questionnaire, which included the Primary Care Assessment Survey (PCAS) and the Beliefs about Medicines Questionnaire (BMQ). The former had two domains of patient-physician communication-informative and interpersonal-while the latter measured medication harm and overuse beliefs. Interpersonal patient-physician communication significantly explained the medication overuse beliefs (ß = -0.28, p < 0.05), whereas neither interpersonal nor informative communication significantly explained the medication harm beliefs. Females (ß = 1.29, p < 0.01) and participants with higher education (ß = 2.66, p = 0.02) more strongly believed that medications are overprescribed. However, participants with low income more strongly believed that medications are harmful. Patient-physician communication, if it touches upon interpersonal aspects, has the potential to change medication overuse beliefs among older adults with hypertension. Identification of the significant factors which affect medication beliefs, will inform the design of a patient-centric communication program that fosters favorable medication beliefs among geriatric hypertensive patients.

Qualitative analysis of community pharmacists' opinions on their involvement in reducing potentially inappropriate prescribing.

PURPOSE: Older people are at risk of potentially inappropriate prescribing (PIP) due to polypharmacy arising from multi-morbidity. Despite available explicit criteria to reduce PIP, it is highly prevalent. Whilst community pharmacists have the required knowledge to help reduce PIP, they are not currently engaged with the problem. This study explores the views of community pharmacists on their potential involvement in reducing PIP and determines the challenges to its implementation. METHODS: Semi-structured interviews with pharmacists working in community pharmacies in Ireland. The theoretical domains framework (TDF) was used to develop the topic guide and to analyse the transcripts. Domains of highest relevance for PIP reduction were identified based on their frequency or whether the participants emphasised the impact of constructs within a domain. Local ethical approval was obtained. RESULTS: Of 18 participants, 12 were female, median age was 30 years (IQR, 27-35) with a median of 6 years (IQR, 3-8) of experience. Seven TDF domains were identified as relevant to PIP reduction. Pharmacists were uncertain about their role in reducing PIP and reluctant to challenge physicians' prescribing decisions. Challenges pertained to the environment, knowledge, social influences, professional role and identity. CONCLUSIONS: Pharmacists welcomed new responsibilities in reducing PIP as part of their daily practice but expressed a need for removal of social and environmental barriers as well as, provision of relevant guidelines and education about PIP. This study provides useful insights into the target domains for overcoming barriers of pharmacist involvement in reducing PIP.

The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people.

The area of "deprescribing" has rapidly expanded in recent years as a positive intervention to reduce inappropriate polypharmacy and improve health outcomes for (older) people with multimorbidity. While our understanding of deprescribing as a process has greatly improved and existing approaches all have patient-centered elements, there is still limited literature exploring the importance of the individual patient context in deprescribing decision-making. This is clearly an important consideration to ensure that any deprescribing approach is ethical, respectful, and successful. To address this gap in the literature, we have developed a conceptual framework in the form of a rainbow - with five different deprescribing determinants - and place the person at the center of the deprescribing process. This framework is informed by literature on patient-centered care for older people and people with multimorbidity. We illustrate the potential application of this framework to a complex patient case to highlight the importance of the different clinical, psychological, social, financial and physical deprescribing determinants, and how this approach could be adopted by those working in clinical practice.

Exploring the behavioural drivers of veterinary surgeon antibiotic prescribing: a qualitative study of companion animal veterinary surgeons in the UK.

BACKGROUND: Multi-drug resistant bacteria are an increasing concern in both human and veterinary medicine. Inappropriate prescribing and use of antibiotics within veterinary medicine may be a contributory factor to antimicrobial resistance (AMR). The 'One Health' Initiative aims to work across species and environments to reduce AMR, however; little is currently known about the factors which influence antibiotic prescribing among veterinary surgeons in companion animal practice. This paper reports on qualitative data analysis of interviews with veterinary surgeons whose practice partially or wholly focuses on companion animals (N = 16). The objective of the research was to explore the drivers of companion animal veterinary surgeons' antibiotic prescribing behaviours. The veterinary surgeons interviewed were all practising within the UK (England (n = 4), Scotland (n = 11), Northern Ireland (n = 1)). A behavioural thematic analysis of the data was undertaken, which identified barriers and facilitators to specific prescribing-related behaviours. RESULTS: Five components of prescribing behaviours were identified: 1) confirming clinical need for antibiotics; 2) responding to clients; 3) confirming diagnosis; 4) determining dose, duration and type of antibiotic; and 5) preventing infection around surgery (with attendant appropriate and inappropriate antibiotic prescribing behaviours). Barriers to appropriate prescribing identified include: business, diagnostic, fear, habitual practice and pharmaceutical factors. Facilitators include: AMR awareness, infection prevention, professional learning and regulation and government factors. CONCLUSION: This paper uses a behavioural lens to examine drivers which are an influence on veterinary surgeons' prescribing behaviours. The paper contributes new understandings about factors which influence antibiotic prescribing behaviours among companion animal veterinary surgeons. This analysis provides evidence to inform future interventions, which are focused on changing prescribing behaviours, in order to address the pressing public health concern of AMR.

Judicious antibiotic prescribing in ambulatory pediatrics: Communication is key.

Children in outpatient clinics are prescribed over 15 million courses of unnecessary antibiotics annually. Clinicians have identified parent pressure for antibiotics, parent satisfaction, and time constraints as the primary drivers of unnecessary antibiotic prescribing. Over the past decade, parents have become more aware that antibiotics only treat bacterial infections, yet continue to report an expectation for antibiotics in 50-65% of acute care visits. Parental expectations for antibiotics stem from parental concerns about symptom severity and a desire to alleviate symptoms. Clinicians can address parental concerns when they assess the severity of illness through a physical exam, provide a clear explanation for the symptoms, recommend ways to alleviate the symptoms, and provide council on when to be concerned. When clinicians fail to address parental concerns, parents are more likely to challenge the diagnosis or treatment recommendations, clinicians are more likely to perceive that parent as expecting an antibiotic, and antibiotics are significantly more likely to be prescribed. Parents that expect antibiotics are more likely to communicate using a 'candidate diagnosis' (e.g., "Johnny has strep throat.") and resist the diagnosis or treatment given. Clinicians can recognize these parental communication patterns and use specific communication practices shown to decrease unnecessary antibiotic prescribing. When parents expect antibiotics, clinicians should (1) review physical exam findings using 'no problem' commentary (e.g., "This ear is just a little red."), (2) deliver a specific diagnosis (e.g., avoid 'a virus'), (3) use a two-part negative/positive treatment recommendation (e.g., "On the one hand, antibiotics will not help. On the other hand, ibuprofen can help with pain."), and (4) provide a contingency plan. Clinicians should feel comfortable discussing the risks and benefits of antibiotics. Effective communication between parents and clinicians in outpatient clinics leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.

Older patients' perception of deprescribing in resource-limited settings: a cross-sectional study in an Ethiopia university hospital.

OBJECTIVE: To assess older patients' attitude towards deprescribing of inappropriate medications. DESIGN: This was an institutional-based, quantitative, cross-sectional survey. SETTING: Outpatient clinics of the University of Gondar Referral and Teaching Hospital in Ethiopia. PARTICIPANTS: Patients aged 65 or older with at least one medication were enrolled in the study from 1 March to 30 June 2017. Excluded patients were those who had severe physical or psychological problems and who refused to participate. MAIN OUTCOME MEASURES: Older patients' attitude towards deprescribing was measured using a validated instrument, 'the revised Patients' Attitudes towards Deprescribing' (rPATD) tool for older patients. Data were collected on sociodemographic characteristics and clinical data such as comorbidity and polypharmacy, and the main outcome was older patients' willingness to deprescribe inappropriate medications. RESULTS: Of the 351 eligible participants, 316 patients completed the survey. Of the 316 patients, 54.7% were men and were taking a median of 3 (IQR: 2-4) medications daily. Overall, most of the participants (92.1%; 95% CI 89% to 95%) were satisfied with the medications they were taking; however, still a significant number of participants (81.6%; 95% CI 77% to 86%) were willing to stop one or more of their medications if possible and agreed by their doctors. This willingness was correlated with seven items of the rPATD, including a strong correlation with the overall satisfaction of patients with the medications taken. CONCLUSION: Many older patients have shown their willingness to reduce one or more of their medications if their doctors said it was possible. Healthcare providers should be proactive in discussing and evaluating potentially inappropriate medications for better clinical decision making.

Characteristics of elderly patients with polypharmacy who refuse to participate in an in-hospital deprescribing intervention: a retrospective cross-sectional study.

BACKGROUND: Few studies have evaluated the characteristics of elderly patients with polypharmacy refusing deprescribing. The aim of this study was to evaluate the prevalence of potentially inappropriate medication (PIM) use in elderly patients accepting and refusing a deprescribing intervention and to investigate factors associated with deprescribing refusal. METHODS: We conducted a retrospective cross-sectional study by analyzing the electronic medical records from a single hospital. All consecutive patients aged 65 years or older who reported the use of five or more medications upon admission to the orthopedic ward from January 2015 to December 2016 and who were approached by a pharmacist for polypharmacy screening were included. Patients who had provided consent for the deprescribing intervention by the internal medicine physicians were defined as the acceptance group, and patients who did not were defined as the refusal group. The primary outcome was the use of any PIMs at admission, based on the 2015 American Geriatric Society Beers Criteria. Using multivariable logistic regression, predictive factors of refusing deprescribing were also evaluated. RESULTS: During the study period, 136 patients were eligible. Of those, 82 patients (60.3%) accepted the deprescribing intervention, and 54 patients (39.7%) declined the intervention. The mean age of all the patients was 81.1 years, and the mean number of medications at admission was 9.3. The overall proportion of patients taking any PIMs at admission was 77.2%. The proportion of patients taking any PIMs at admission was not different between the acceptance and refusal groups (78.0% and 75.9%, respectively; p = 0.84). None of the measured characteristics, including age, gender, residential status, comorbidity, alcohol use, smoking status, number of medications, or number of PIMs, were found to be associated with deprescribing refusal. CONCLUSION: The prevalence of any PIM use did not differ among elderly orthopedic patients with polypharmacy according to refusal or acceptance of the deprescribing intervention. Furthermore, none of the analyzed characteristics were found to be associated with deprescribing refusal. Given the high prevalence of PIM use, a strategy is needed for combating polypharmacy among elderly patients reluctant to undergo deprescribing.