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Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey

Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey
Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey
Background: deciding whether to discontinue antibiotics at early review is a cornerstone of hospital antimicrobial stewardship practice worldwide. In England this approach is described in government guidance (“Start Smart then Focus”). However, <10% of hospital antibiotic prescriptions are discontinued at review, despite evidence that 20-30% could be discontinued safely. We aimed to quantify the relative importance of factors influencing prescriber decision-making at review.
Methods: we conducted an online choice experiment, a survey method to elicit preferences. Acute/general hospital prescribers in England were asked if they would continue or discontinue antibiotic treatment in 15 hypothetical scenarios. Scenarios were described according to six attributes, including patients’ presenting symptoms and whether discontinuation would conflict with local prescribing guidelines. Respondents’ choices were analysed using conditional logistic regression.
Results: 100 respondents completed the survey. Respondents were more likely to continue antibiotics when discontinuation would ‘strongly conflict’ with local guidelines (average marginal effect (AME) on probability of continuing +0.194 (p<0.001)); when presenting symptoms more clearly indicated antibiotics (AME of urinary tract infection symptoms +0.173 (p<0.001) versus unclear symptoms); and when patients had severe frailty/comorbidities (AME=+0.101 (p<0.001)). Respondents were less likely to continue antibiotics when under no external pressure to continue (AME=-0.101 (p<0.001)). Decisions were also influenced by the risks to patient health of continuing/discontinuing antibiotic treatment.
Conclusions: guidelines that conflict with antibiotic discontinuation (e.g. pre-specify fixed durations) may discourage safe discontinuation at review. In contrast, guidelines conditional on patient factors/treatment-response could help hospital prescribers discontinue antibiotics if diagnostic information suggesting they are no longer needed is available.
1741-7015
Roope, Laurence
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Buchanan, James
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Morrell, Liz
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Pouwels, Koen
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Sivyer, Katy
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Mowbray, Fiona
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Abel, Lucy
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Cross, Elizabeth
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Yardley, Lucy
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Peto, Tim
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Walker, Sarah
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Llewelyn, Martin
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Wordsworth, Sarah
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Roope, Laurence
96f21f0d-8c20-49ff-8d29-8afb244544cd
Buchanan, James
f789ddaa-d42d-45e5-a90f-5c77986f6dc0
Morrell, Liz
c492d931-70f9-4003-843c-551b1ec274ef
Pouwels, Koen
261a42e8-52fb-4c74-b46f-68a91eff675b
Sivyer, Katy
c9831d57-7d6b-4bb6-bb3c-770ea7f9b116
Mowbray, Fiona
0a9e37a7-06c7-4926-95cb-af2d1eb22157
Abel, Lucy
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Cross, Elizabeth
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Yardley, Lucy
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Peto, Tim
fc8dfe08-1ce6-471a-90c6-8b036b52dcad
Walker, Sarah
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Llewelyn, Martin
057857ae-6823-40f9-a3be-1d8597a18f3d
Wordsworth, Sarah
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Roope, Laurence, Buchanan, James, Morrell, Liz, Pouwels, Koen, Sivyer, Katy, Mowbray, Fiona, Abel, Lucy, Cross, Elizabeth, Yardley, Lucy, Peto, Tim, Walker, Sarah, Llewelyn, Martin and Wordsworth, Sarah (2020) Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. BMC Medicine. (In Press)

Record type: Article

Abstract

Background: deciding whether to discontinue antibiotics at early review is a cornerstone of hospital antimicrobial stewardship practice worldwide. In England this approach is described in government guidance (“Start Smart then Focus”). However, <10% of hospital antibiotic prescriptions are discontinued at review, despite evidence that 20-30% could be discontinued safely. We aimed to quantify the relative importance of factors influencing prescriber decision-making at review.
Methods: we conducted an online choice experiment, a survey method to elicit preferences. Acute/general hospital prescribers in England were asked if they would continue or discontinue antibiotic treatment in 15 hypothetical scenarios. Scenarios were described according to six attributes, including patients’ presenting symptoms and whether discontinuation would conflict with local prescribing guidelines. Respondents’ choices were analysed using conditional logistic regression.
Results: 100 respondents completed the survey. Respondents were more likely to continue antibiotics when discontinuation would ‘strongly conflict’ with local guidelines (average marginal effect (AME) on probability of continuing +0.194 (p<0.001)); when presenting symptoms more clearly indicated antibiotics (AME of urinary tract infection symptoms +0.173 (p<0.001) versus unclear symptoms); and when patients had severe frailty/comorbidities (AME=+0.101 (p<0.001)). Respondents were less likely to continue antibiotics when under no external pressure to continue (AME=-0.101 (p<0.001)). Decisions were also influenced by the risks to patient health of continuing/discontinuing antibiotic treatment.
Conclusions: guidelines that conflict with antibiotic discontinuation (e.g. pre-specify fixed durations) may discourage safe discontinuation at review. In contrast, guidelines conditional on patient factors/treatment-response could help hospital prescribers discontinue antibiotics if diagnostic information suggesting they are no longer needed is available.

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Hospital prescribers Roope et al BMC Med Accepted version - Accepted Manuscript
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Accepted/In Press date: 8 June 2020

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Local EPrints ID: 441620
URI: http://eprints.soton.ac.uk/id/eprint/441620
ISSN: 1741-7015
PURE UUID: adad89f6-393a-4967-8952-99cd9b377174
ORCID for Katy Sivyer: ORCID iD orcid.org/0000-0003-4349-0102
ORCID for Fiona Mowbray: ORCID iD orcid.org/0000-0002-3297-4163
ORCID for Lucy Yardley: ORCID iD orcid.org/0000-0002-3853-883X

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Date deposited: 22 Jun 2020 16:30
Last modified: 23 Jun 2020 00:39

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Contributors

Author: Laurence Roope
Author: James Buchanan
Author: Liz Morrell
Author: Koen Pouwels
Author: Katy Sivyer ORCID iD
Author: Fiona Mowbray ORCID iD
Author: Lucy Abel
Author: Elizabeth Cross
Author: Lucy Yardley ORCID iD
Author: Tim Peto
Author: Sarah Walker
Author: Martin Llewelyn
Author: Sarah Wordsworth

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