Implementation and Evaluation of Tailored Intervention Strategies to Influence Antibiotic ...

303 Pages·2015·8.46 MB·English

Implementation and Evaluation of Tailored
Intervention Strategies to Influence
Antibiotic Prescribing for Community-

Acquired Pneumonia

by

Maher Ali Almatar, BPharmSc, MPharmSc

Submitted in fulfilment of the requirements for the degree of Doctor of
Philosophy

Pharmacy, School of Medicine
University of Tasmania

May 2015

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DECLARATION OF ORIGINALITY
This thesis contains no material which has been accepted for a degree or diploma
by the University or any other institution, except by way of background
information and duly acknowledged in the thesis, and to the best of the my
knowledge and belief no material previously published or written by another
person except where due acknowledgement is made in the text of the thesis, nor
does the thesis contain any material that infringes copyright.
Maher Ali Almatar
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STATEMENT OF AUTHORITY OF ACCESS
This thesis may be made available for loan and limited copying in accordance
with copyright Act 1968.
Maher Ali Almatar
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STATEMENT OF ETHICAL CONDUCT
The research associated with this thesis abides by the international and
Australian codes on human and animal experimentation, the guidelines by the
Australian Government's Office of the Gene Technology Regulator and the
rulings of the Safety, Ethics and Institutional Biosafety Committees of the
University.
Maher Ali Almatar
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Abstract
Adherence to guidelines for the management of community-acquired pneumonia (CAP)
has been shown to improve patients’ clinical outcomes. However, several studies have
indicated that the chosen antibiotic regimen is frequently not consistent with guideline
recommendations. This might lead to suboptimal treatment, either by exposing patients to a
greater risk of treatment failure or by unnecessary use of broad-spectrum antibiotics, which
contributes to the emergence of antibiotic-resistant pathogens or consequent development of
Clostridium difficile-associated diarrhoea. It has been demonstrated that active implementation
of CAP guidelines can significantly improve adherence to recommendations, which
consequently, might improve patients’ clinical outcomes.
The present research developed, implemented and evaluated tailored intervention
strategies to improve physicians’ concordance with CAP guidelines. A number of inter-related
studies were conducted as a part of this research project.
Firstly, baseline data was collected to measure the level of physicians’ adherence to
national CAP guidelines in two Tasmanian hospitals, the Royal Hobart Hospital (RHH) and
North Western Regional Hospital (NWRH). It was evident in that study that adherence to CAP
management guidelines was poor at both study sites (16.1% and 7.5% for RHH and NWRH,
respectively).
This was followed by a study to identify and quantify potential barriers to the adherence
to CAP guideline recommendations. A questionnaire was distributed to RHH doctors in non-
surgical areas of practice. Of the study population, 43.1% doctors responded to the survey; of
those who responded, 46.4% thought the influence of senior doctors on their juniors could be a
factor affecting adherence to the guidelines. Other barriers noted were a lack of guideline
awareness (39.3%), the requirement to calculate the severity of CAP (35.7%), and the
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existence of other guidelines that conflict with Therapeutic Guidelines: antibiotic, version 14
(TG14; 28.6%).
A qualitative study was then designed to determine factors that influence doctors
working within the emergency department (ED) to prescribe ceftriaxone outside the TG14
recommendations. Eight face-to-face interviews were performed with ED doctors. Five main
themes emerged as influencing decisions regarding the selection of ceftriaxone for patients
with CAP: (i) clinical intuition compared to a structured evaluation of severity, (ii) clinical
uncertainty, (iii) prior clinical experience, (iv) source of guidance and (v) prescribing
etiquette.
A questionnaire survey was then sent to infectious disease pharmacists nationally in
order to identify the strategies that have been used and perceived as successful for the
management of CAP in their institutions. Of the study population, 41 pharmacists (27.3%)
responded to the questionnaire. Of these, 90.2% pharmacists reported their hospitals having an
antimicrobial stewardship (AMS) program. Multifaceted strategies to enhance antibiotic
prescribing in ED for CAP, were mentioned as being in place in all responses. However, the
largest number of the respondents (34.1%) considered use of CAP clinical pathways to be the
most effective strategy.
Intervention strategies were subsequently developed and implemented based on the
findings from the above studies. Two interventions were implemented over two time periods:
one with general strategies across medical units and a second focused on the ED. During the
general intervention period, local CAP guidelines (based on TG14) were released. The
guidelines were developed and approved by the hospital’s medical and emergency
departments. The release of the CAP guidelines was accompanied by a multifaceted
educational package to increase awareness of the guidelines. Medical and ED teams were
targeted in the educational package, which included group sessions, wall posters and
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laminated lanyard cards summarising the local guidelines. During the second time period, two
further strategies were introduced (a CAP clinical management pathway and monthly auditing
with feedback) and targeted specifically at ED staff.
We evaluated the impact of the interventions on guideline adherence rates and clinical
outcomes (mortality rates and hospital length of stay, LOS). To evaluate the impact of the
intervention, two hospital sites were selected, one (RHH) acted as an intervention site and the
other (NWRH) as a control site where no intervention was made. The study found the
intervention had an overall impact on guideline adherence rates at the intervention site, and it
reduced overall mortality rates and LOS for patients with non-severe CAP. Compared to the
baseline data, the adherence rate increased significantly at the RHH during the intervention
period (16.1% vs 50%; p < 0.05). However, no significant improvement was indicated in the
control site (7.5% vs 19.1%; p > 0.05). The in-patient mortality was significantly lower in the
intervention group when compared to the non-intervention groups (all baseline data plus the
data from the NWRH during the intervention period) (3.4% vs 7.3%; p < 0.05). Sub-group
analysis revealed patients with non-severe CAP in the intervention group had an average LOS
0.8 days shorter than the non-intervention groups (p < 0.05).
Results from the previous study indicated a positive impact of the intervention in the
overall adherence to CAP recommendations. However, two main strategies were conducted in
two consecutive times during the intervention periods, a general intervention and an ED-
focused intervention. Therefore, a time-series analysis was conducted to determine the impact
of strategies over time at the intervention site. The rates of adherence to the CAP guidelines
during the pre-intervention (5 months) and general intervention periods (5 months) were
28.1% and 31.2%, respectively. The difference was not statistically significant. During the
ED-focused intervention period (7 months), the level of adherence with guidelines was
significantly higher at 61.5% (p < 0.05).
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Finally, we evaluated the use of ceftriaxone in all indications in two time periods, before
and after the initiation of the intervention. The aim of this study was to determine if our
intervention in CAP management could affect the use of ceftriaxone in other indications.
Concordance to the TG14 for all indications, with the exception of respiratory tract infection
(RTI), was similar between the two study periods. For the RTI, concordant use of ceftriaxone
significantly increased from 50% during the first period to 64.5% during the second study
period (p < 0.05). Among community-acquired lower respiratory tract infections, our findings
indicated a significant decrease in the unnecessary use of ceftriaxone for patients with mild
CAP and acute exacerbation of chronic obstructive pulmonary disease in the intervention
group (both 19% vs 3.2%; p < 0.05). However, there were no significant changes in the
appropriate prescribing of ceftriaxone for other indications.
In conclusion, this research project identified, with in-depth analysis, potential factors
that lead to the prescription of discordant antibiotic regimens for empirical management of
CAP. It was subsequently demonstrated that a tailored multifaceted intervention significantly
improved adherence to CAP guidelines, which consequently reduced the inappropriate
prescribing of ceftriaxone for this indication. This was associated with a decrease in mortality
rate and length of hospital stay among patients in the intervention group.

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Acknowledgments
I would like to thank all those who have supported me during my doctorate journey.
First and foremost, I would like to express my deepest appreciation and thanks to my primary
supervisor, Professor Gregory Peterson, who has been a tremendous mentor for me and who has
supported me throughout this project with his patience and knowledge whilst allowing me the space
to work in my own way. I would like to thank him for encouraging me in my research and for
allowing me to grow as an independent research scientist. I would also like to thank my co-
supervisor, Mr Angus Thompson, for his brilliant comments and suggestions. I am grateful for his
invaluably constructive criticism and friendly advice during the thesis process. I would also like to
thank my co-supervisor, Dr. Tabish Zaidi, for the good advice, support and friendship. Your advice
on my research as well as my career has been priceless. I would also like to thank my past
supervisor, Dr Christian Narkowicz, for helping to set up this project.
Most of the findings in this thesis would not have been possible without collaborations from
the antimicrobial stewardship team at the Royal Hobart Hospital. Special thanks go to Dr. Tara
Anderson and Duncan Mackenzie for their efforts and enthusiasm in developing and implementing
intervention strategies to influence antibiotic prescribing in their institution.
I would like to thank Corinne Mirkazemi and Colin Curtain for their help in my quantitative
and qualitative data analysis.
I am indebted to all my friends who have supported me over the last few years: Bassam
Alhumidan, Sultan Alshathry, Ashraf Almatar and Mohammad Alnufaili. Thank you all for your
continued friendship.
This thesis would not have been possible without the financial support of the Saudi Higher
Education Ministry, to whom I am grateful.
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I would like to thank my family, particularly my mother, Asma, for her unconditional love
and support. During my PhD journey, your words have given me the strength and belief that
nothing is imposable.
I dedicate this PhD to my two lovely kids, Ahmad and Loreen, who fill my life with joys and
love. Finally and most importantly, I would like to thank my beloved wife and my best friend,
Amirah, for her love, patience and unfailing support. Amirah, I am so lucky to have you by my side
and in my life. Life is perfect with you!

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