Interventions to improve antimicrobial prescribing of doctors in training

166 Pages·2017·3.85 MB·English

by  Papoutsi C

HEALTH SERVICES AND DELIVERY RESEARCH
VOLUME 6 ISSUE 10 FEBRUARY 2018
ISSN 2050-4349
Interventions to improve antimicrobial prescribing
of doctors in training (IMPACT): a realist review
Chrysanthi Papoutsi, Karen Mattick, Mark Pearson, Nicola Brennan,
Simon Briscoe and Geoff Wong
DOI 10.3310/hsdr06100

Interventions to improve antimicrobial
prescribing of doctors in training
(IMPACT): a realist review
Chrysanthi Papoutsi,1* Karen Mattick,2 Mark Pearson,3
Nicola Brennan,4 Simon Briscoe3 and Geoff Wong1
1Nuffield Department of Primary Care Health Sciences, University of Oxford,
Oxford, UK
2Centre for Research in Professional Learning, University of Exeter, Exeter, UK
3National Institute for Health Research Collaboration for Leadership in Applied
Health Research and Care for the South West Peninsula, Institute of Health
Research, University of Exeter Medical School, Exeter, UK
4Collaboration for the Advancement of Medical Education Research and
Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University,
Plymouth, UK
*Corresponding author
Declared competing interests of authors: Geoff Wongis amember of the Health Technology
Assessment Primary Care,Community and Preventive Interventions Panel. MarkPearson’srole was
supported by theNational Institute for Health Research (NIHR) Collaboration for Leadership in Applied
Health Research and Care South West Peninsula.
Published February 2018
DOI: 10.3310/hsdr06100
This reportshould be referenced as follows:
Papoutsi C, Mattick K, Pearson M,Brennan N, Briscoe S, WongG. Interventions to improve
antimicrobial prescribing of doctors in training (IMPACT): arealist review. Health ServDeliv Res
2018;6(10).

Health Services and Delivery Research
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DOI:10.3310/hsdr06100 HEALTHSERVICESANDDELIVERYRESEARCH2018 VOL.6 NO.10
Abstract
Interventions to improve antimicrobial prescribing of
doctors in training (IMPACT): a realist review
Chrysanthi Papoutsi,1* Karen Mattick,2 Mark Pearson,3
Nicola Brennan,4 Simon Briscoe3 and Geoff Wong1
1Nuffield Department of PrimaryCare HealthSciences, University of Oxford, Oxford, UK
2Centre forResearch in Professional Learning, University ofExeter, Exeter, UK
3National Institute for HealthResearch Collaboration for Leadershipin Applied Health Research
and Careforthe South West Peninsula, Institute ofHealth Research, University of Exeter Medical
School, Exeter, UK
4Collaboration forthe Advancement ofMedical Education Research andAssessment, Peninsula
Schools ofMedicine and Dentistry, Plymouth University, Plymouth, UK
*Corresponding author [email protected]
Background: Interventions to improve the antimicrobial prescribing practices of doctors have been
implemented widely to curtail theemergence and spread of antimicrobial resistance, buthave been met
with varying levelsof success.
Objectives: This study aimed to generate an in-depth understanding of howantimicrobial prescribing
interventions ‘work’ (or do notwork) for doctors in training by takinginto accountthe wider context in
which prescribing decisions areenacted.
Design: The review followed arealist approach to evidence synthesis, which usesan interpretive,
theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.
Setting: Primary andsecondary care.
Participants: Not applicable.
Interventions: Studies related to antimicrobial prescribing for doctors in training.
Main outcome measures:Not applicable.
Data sources:EMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process &Other Non-Indexed Citations
(via Ovid), PsycINFO (viaOvid), WebofSciencecorecollectionlimitedtoScienceCitationIndexExpanded
(SCIE)andConferenceProceedingsCitationIndex–Science(CPCI-S)(viaThomsonReuters),Cochrane
CentralRegisterofControlledTrials(CENTRAL),CochraneDatabaseofSystematicReviews,theHealth
TechnologyAssessment(HTA)database(allviaTheCochraneLibrary),AppliedSocialSciencesIndexand
Abstracts(ASSIA)(viaProQuest),GoogleScholar(GoogleInc.,MountainView,CA,USA)andexpert
recommendations.
Review methods: Clearly boundedsearches of electronic databases were supplemented bycitation
tracking and greyliterature. Following quality standards for realist reviews, the retrieved articles were
systematically screened and iteratively analysed to develop theoretically driven explanations. A programme
theory was produced with input from astakeholder groupconsisting of practitioners andpatient
representatives.
©Queen’sPrinterandControllerofHMSO2018.ThisworkwasproducedbyPapoutsietal.underthetermsofacommissioningcontractissuedbytheSecretaryofStatefor
Health.Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournals v
providedthatsuitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbe
addressedto:NIHRJournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonScience
Park,SouthamptonSO167NS,UK.
ABSTRACT
Results: Atotal of 131 articles were included. The overarching programme theory developed from the
analysis of thesearticles explains how and whydoctors in training decide to passively complywith or
actively follow (1) seniors’ prescribing habits, (2) theway seniors takeinto accountprescribing aids and
seek theviews of other health professionals and(3) the way seniors negotiate patient expectations. The
programme theory also explains what drives willingness or reluctance to askquestions about antimicrobial
prescribing or to challenge thedecisions madeby seniors. The review outlines how theseoutcomes result
from complex inter-relationships between the contexts of practice doctors in training areembedded in
(hierarchicalrelationships,powerfulprescribingnorms,unclearrolesandresponsibilities,implicitexpectations
aboutknowledgelevelsandapplicationinpractice)andthemechanismstriggeredinthesecontexts(fearof
criticismandindividualresponsibility,reputationmanagement,positionintheclinicalteamandappearing
competent).Drawingonthesefindings,wesetoutexplicitrecommendationsforoptimaltailoring,design
andimplementationofantimicrobialprescribinginterventionstargetedatdoctorsintraining.
Limitations: Most articles included in the review discussed hospital-based, rather than primary, care.
In cases whenfew data were available to fully capture all thenuances between context, mechanisms
and outcomes, we havebeen explicit about the strength of our arguments.
Conclusions: This review contributes to our understanding of how antimicrobial prescribing interventions
for doctors intraining canbe better embedded in thehierarchical and interprofessional dynamics of
different health-care settings.
Future work: Morework isrequired to understand howinterprofessional support for doctors in training
can contribute to appropriate prescribing in thecontext of hierarchical dynamics.
Study registration: This study isregistered as PROSPERO CRD42015017802.
Funding: TheNational Institute for Health Research HealthServices and Delivery Research
programme.
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NIHRJournalsLibrary www.journalslibrary.nihr.ac.uk
DOI:10.3310/hsdr06100 HEALTHSERVICESANDDELIVERYRESEARCH2018 VOL.6 NO.10
Contents
List oftables ix
List offigures xi
List ofsupplementary materials xiii
Glossary xv
List ofabbreviations xvii
PlainEnglish summary xix
Scientific summary xxi
Chapter 1Background 1
Doctors in training and antimicrobial prescribing 2
Review questions 3
Objectives 3
Review questions 3
Chapter 2Review methods 5
Stakeholder group 5
Patient andpublic involvement 6
Steering group 7
Step1: locating existing theories 7
Step2: searching for evidence 8
Main search 8
Additional search 10
Step3: selecting articles 12
Step4: extracting and organising data 13
Step5: synthesising the evidence and drawingconclusions 15
Engagement with substantive theory 16
Step6: writing up andquality considerations 17
Results of thereview 17
Main search 17
Additionalsearch 19
Chapter 3Findings 21
Part A: making decisions about antimicrobial prescribing and prescribing support 22
Influence of the formal medical hierarchy 22
Influence of implicit and explicit rules or‘norms’ 24
Influence of individual responsibility and accountability perceptions 26
Role modelling prioritisation of conflicting goals 27
Influence of the hierarchy onusing sources of support 28
Perceptions of guidelinecredibility and use 31
Influence of patient expectations 32
Influence of antimicrobial specialists 34
Interprofessional influence and support 36
©Queen’sPrinterandControllerofHMSO2018.ThisworkwasproducedbyPapoutsietal.underthetermsofacommissioningcontractissuedbytheSecretaryofStatefor
Health.Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournals vii
providedthatsuitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbe
addressedto:NIHRJournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonScience
Park,SouthamptonSO167NS,UK.
CONTENTS
Influence of optimal role modelling 38
Suboptimal role modelling 39
The impact of service needs versuslearning priorities 41
Part B: asking for adviceand challenging decisions 43
Seeking assistance 43
Challenging prescribing decisions 45
Challenging effectively 48
Prevalence of collective norms 49
Changing contexts 51
Overall programme theory 54
Drawing on substantive theory 55
Chapter 4Discussion 59
Summary of keyfindings 59
Implications 60
Education and feedbackinterventions 60
Competencies and supervision for collaborative prescribing 60
Input from other professional groups 61
Antimicrobial prescribing support aids 61
Monitoring and accountability 61
Participatory design 62
Knowledge-to-action framework 62
Actionable findings 65
Principles for tailoring antimicrobial prescribing interventions for doctors in training 65
Dissemination 69
Animation video 69
Strengths and limitations 70
Chapter 5Conclusions 73
Future research 73
Acknowledgements 75
References 77
Appendix 1Literature searches 91
Appendix 2Characteristics of all studies included in the review 101
Appendix 3Details of coding applied tothe literature included inthe review 129
viii
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