Abstract: Guideline-concordant therapies have been proven to be associated with improved health and economic outcomes in the treatment of community-acquired pneumonia (CAP). However, actual use of CAP guidelines remains poor, but using tailored interventions looks promising. Based on local observations, we assessed the impact of low-intensity interventions to improve guideline use.
Abstract: BACKGROUND: To improve physicians' antimicrobial practice, it is important to identify barriers to and facilitators of guideline adherence and assess their relative importance. The theory of planned behavior permits such assessment and has been previously used for evaluating antibiotic use. According to this theory, guideline use is fueled by 3 factors: attitude, subjective norm (perceived social pressure regarding guidelines), and perceived behavioral control (PBC; perceived ability to follow the guideline). The authors aim to explore factors affecting guideline use in their hospital. METHODS: Starting from their earlier observations, the authors constructed a questionnaire based on the theory of planned behavior, with an additional measure of habit strength. After pilot testing, the survey was distributed among physicians in a major teaching hospital. RESULTS: Of 393 contacted physicians, 195 completed questionnaires were received (50.5% corrected response rate). Using multivariate analysis, the overall intention toward using antibiotic guidelines was not very predictable (model R(2) = .134). Habit strength (relative weight = .391) and PBC (relative weight = .354) were the principal significant predictors. A moderator effect of respondents' position (staff member v. resident) was found, with staff members' intention being significantly influenced only by habit strength and residents' intention by PBC. Regarding previously identified barriers, education on antibiotics and guidelines was rated unsatisfactory. CONCLUSIONS: These divergent origins of influence on guideline adherence point to different approaches for improvement. As habits strongly influence staff members, methods that focus on changing habits (e.g., automated decision support systems) are possible interventions. As residents' intention seems to be guided mainly by external influences and experienced control, this may make feedback, convenient guideline formats, and guideline familiarization more suitable.
Abstract: The aim of this study was to determine the opinions and problems concerning the use of a local antibiotic hospital guideline in a 1900-bed tertiary-care, university teaching hospital.
Abstract: To quantify the impact of different guideline implementation interventions to improve treatment of community-acquired pneumonia (CAP) in a hospital setting.
Abstract: In order to preserve the activity of antibiotics against antimicrobial resistance, antibiotic treatment guidelines have become essential in modern medicine. However, after publication many guidelines experience a large array of barriers impeding their use in daily practice. Interventions that overcome these barriers are needed to improve guideline use. However, while most interventions have moderate effects and multifaceted and restrictive interventions have more impact than single and persuasive ones, there is little knowledge on how interventions should be selected, which factors will determine their yield and how they actually work. In the General Introduction is explained how tailoring according present barriers and the use of theories on behaviour and behavioural change, such as the Theory of Planned Behaviour, may improve intervention selection and understanding. Furthermore, the research questions of this PhD project are described and how they relate to this issue. At the end, a description of the Belgian situation is provided with its history of high antibiotic use in the community and in hospitals. Although the initiatives from the recent years have lead to lower antibiotic consumption in the community and hospitals, total antibiotic use remains high in Belgium and is again on the rise with broad-spectrum antibiotics being the most consumed ones.
The first part of this PhD-project consisted of a literature review on which interventions are already used and prove to be efficient to improve the use of community-acquired pneumonia guidelines, discussed in Chapter 2. Over 10,000 articles were searched and from 30 eligible articles concerning 27 different studies, the interventions were listed, grouped and compared with the available clinical, economical and process outcomes. Educational meetings and distribution of written material were the two most used interventions with most individual studies showing positive overall results. In general however, no significant relation between number or type of implementation interventions and improvement of outcomes could be detected. For audit and feedback, the benefit of this commonly used but complex and expensive intervention has been shown to be low or absent and not necessarily balanced by higher outcome improvement. Other hospital-specific factors were found to have a much greater impact on the rate of improvement than the used interventions alone. Reducing variability in the studies' methodology and providing sufficient quantitative and qualitative data would also be needed for a better understanding of intervention implementation.
In Chapter 3, the aim was to identify these hospital-specific factors that can either improve or impede the use of the local antibiotic guidelines in two different hospitals. Using focus groups with hospital physicians covering all major disciplines (internal medicine and surgery) and levels of experience (residents and staff members) we observed that local antibiotic guidelines experience the same barriers as other guidelines such as presence although some new barriers emerged too. More importantly, different groups with diverging opinions on and requirements from guideline contents, interpretation and supportive measures were observed within the same hospital. Providing additional support and follow-up of antibiotic guideline use through multidisciplinary collaboration with infectious diseases specialists, microbiologists or clinical pharmacists looks promising. If clinical pharmacists are to be involved however, additional efforts will be needed to improve their credibility amongst physicians.
In order to validate the findings above and identify the more influential barriers and facilitators, a survey based on the Theory of Planned Behaviour with an additional measure for Habit Strength was constructed and distributed in two hospitals, which is reported in Chapter 4. This survey identified the importance of habits on antibiotic guideline use and confirmed the presence of separate groups stipulating different antibiotic policies. Staff members’ intentions to use antibiotic guidelines experienced substantial influence of existing habits, giving preference to interventions that aim to break habits and give direct proposals such as automated decision support systems, support from other disciplines or financial incentives. On the other hand, residents’ intention is more guided by external influences and the amount of control they experience. This makes convenient guideline formats, familiarization and guidance on how the local guidelines are actually devised and used, and feedback the preferred interventions. Attitudes appeared to have a mixed influence on intention to use antibiotic guidelines, possibly dependent on the type of hospital. Multidisciplinary collaboration is a valuable alternative but may depend on physicians’ familiarity with the specified discipline.
Chapter 5 described a follow-up study of antibiotic management of community-acquired pneumonia in the same two hospitals. Using a validated set of quality indicators, overall adherence to the local pneumonia guideline and the impact on this outcome of low-intensity and low-cost interventions in one hospital were assessed. This was combined with an in globo evaluation of the on-line guidelines by use of an electronic tracker. In general, guideline compliance was good with up to 70% of the patients receiving guideline compliant antibiotic therapy. While the interventions to improve antibiotic guideline use were successful in increasing the use of the on-line version, this did not lead to a further increase of patients receiving compliant therapy. On the contrary, a temporal but significant decrease in compliance was observed, probably due to the concurrent A/H1N1 influenza pandemic during fall 2009. Furthermore, evaluation of current antibiotic management in the two observed hospitals showed considerable room for improvement in therapy streamlining, intravenous-oral switch and duration of antibiotic therapy.
In the General Discussion the reasons for these unexpected results were explained. Modifications to current interventions and options for other, future interventions are discussed for both hospitals, taking into account the results from the previous chapters although these recommendations remain untested. We also proposed an “antibiotic management bundle” that can improve overall antibiotic management. For both clinical and non-clinical hospital pharmacists suggestions are made how they can each help to improve antibiotic use. Health care policy makers need to reconsider the current position and authority of the antimicrobial management teams while both should stimulate an increased use of already available information technology. When community-acquired pneumonia guidelines are updated, guideline developers need to incorporate the widely adopted scoring systems to decrease multiple interpretations and different treatments. Future research should clarify the impact of different physician groups and the effect of large-scale events such as epidemics on antibiotic use. Furthermore, more local studies of good quality are needed on the role of an “antibiotic” pharmacist.
