医师知道抗生素处方规定 但不一定遵守


  【24drs.com】根据针对医师、执业护士(NPs)、医师助理(PAs)共36人所进行的深度访谈,医师们知道何时该处方、何时不该处方抗生素的相关建议,但是他们不一定会遵守。
  
  疾病控制与预防中心的Guillermo Sanchez等人,在11月13日的新兴传染病期刊在线发表他们的一篇访谈研究结果。
  
  不遵守指引的原因包括,认为指引未建议的抗生素对病患的效果比较好,特别是考量到过敏或复杂的病史时;考量病患会不满意;担心相关感染;担心法律行动。
  
  医师指出,虽然会担心病患对抗生素的抗药性,但是这个顾虑一般并不会影响他们的用药选择。
  
  研究者透过数码录音电话进行深度访谈,并将录音档转录,以便准确地评估一线照护者的开方行为;受访者分别是9位小儿科医师、9位家庭医学科医师、9位内科医师、5位NPs以及5位PAs。
  
  Sanchez医师等人使用一个筛选问卷,从全国市场资料库招募潜在的参与者进行此次研究;适合的参与者必须在一线照护机构照顾病患至少一半以上的时间、年龄30岁以上,作者们排除初级照护委员会认证之外的医师、以及执业超过30年的医师。
  
  访谈前,参与者填写一份问卷,要他们对影响抗生素选用的12个因素排序,例如疾病严重度、病患需求或执业指引。然后,他们在录音访谈中和受过训练的访谈者讨论他们的答案。
  
  为了评估临床决策,每位参与者收到一个病患诊断有急性细菌感染的临床场景,请他们解释为何选用某个抗生素、为什么其它一线照护者可能会选非建议使用的抗生素。
  
  研究者发现,参与者对于广效和窄效抗生素的定义并不一致。虽然有些参与者正确地指出amoxicillin是窄效制剂,azithromycin是广效制剂,但是多数参与者并不确定这两种广被使用的抗生素的抗菌范围。
  
  此外,医师通常认为广效抗生素比较可以成功治疗感染,但是这些观点是没有根据的。这种想法常会造成选择不恰当,应该予以解决。
  
  不过,当诊断更确定,或者医师看到病患的情况相对良性时,医师们比较会选用窄效药物。
  
  这次访谈也发现一个持续已久的问题,开方者感觉到病患期待使用抗生素,如果不开抗生素,将可能会降低病患对他们的满意度。基于这种想法,受访者表示,改变患者的期待将有助于降低开处方者的压力。
  
  当被问到为什么这些信息不会改变医师的开方行为时,有些人回覆表示,健康照护提供者发现它难以改变习惯,即使他们有新信息,仍继续用他们习惯的方法开处方。
  
  至于对收到抗生素信息之模式的偏好,答案包括将信息整合到电子病历,例如当处方不符指引时会有提示讯息,或者是用智能型手机下载指引的app,或者对一些主要诊断有快速查询参考指引。
  
  作者们结论指出,造成未适当处方抗生素的原因,是像病患要求以及长期以来的习惯这些复杂因素,而不是缺乏考虑相关建议的知识。
  
  后续研究应聚焦在探讨适当处方抗生素的有效激励措施,确认其它可鼓励使用第一线制剂的沟通策略;不过,最主要还是要减少不必要的抗生素使用,需要更多研究来厘清哪里些介入方式可以改善抗生素选用情况。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7132&x_classno=0&x_chkdelpoint=Y
  

Clinicians Know, but Bend, Rules for Antibiotic Prescribing

By Marcia Frellick
Medscape Medical News

Clinicians know the recommendations regarding when and when not to prescribe antibiotics, but they do not always follow them, according to in-depth interviews with 36 physicians, nurse practitioners (NPs), and physician assistants (PAs).

Guillermo Sanchez, MPH, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues report the results of their interview-based study in an article published online November 13 in Emerging Infectious Diseases.

Reasons for straying from the guidelines range from believing that a nonrecommended antibiotic will work better for a patient, particularly when considering allergies or complicated medical histories; concern about patient dissatisfaction; fear of related infection; and concerns about legal action.

Clinicians indicated that although they are concerned patients could build up a resistance to antibiotics, those concerns do not usually affect their choice of drug.

Researchers Recorded Telephone Interviews

The researchers conducted in-depth interviews via digitally recorded telephone calls and transcribed the recordings to accurately assess primary care providers' prescribing behaviors. The breakdown of participants was nine pediatricians, nine family medicine physicians, nine internal medicine physicians, five NPs, and five PAs.

Dr. Sanchez and colleagues used a screening questionnaire to recruit potential participants from a nationwide marketing database. Eligible participants spent at least half of their time with patients in a primary care setting and were older than 30 years. The authors excluded clinicians with a board certification outside of primary care or if they had practiced medicine for more than 30 years.

Before the interview, participants filled out a questionnaire that asked them to rank 12 factors on their influence on antibiotic selection, such as illness severity, patient demand, or practice guidelines. They then discussed their answers with trained interviewees during the recorded interviews.

To evaluate clinical decision-making, each participant received a specialty-appropriate clinical vignette about a patient who had a diagnosis of an acute bacterial infection. The participant was asked to explain why he or she chose an antibiotic and why other primary care providers might choose nonrecommended antibiotics.

The researchers found that participants had inconsistent definitions of broad- and narrow-spectrum antibiotics. "Although some participants correctly identified amoxicillin as a narrow-spectrum agent, and azithromycin as a broad-spectrum agent, many participants were uncertain of the spectrum of antimicrobial activity for these 2 widely used antibiotics."

In addition, clinicians often thought broad-spectrum antibiotics would be more successful in curing an infection, although those beliefs are unfounded, the authors say. That thinking may regularly lead to inappropriate selection and should be addressed, the authors note.

Clinicians, however, were more likely to choose narrow-spectrum drugs when the diagnosis was more certain or when they saw a patient's condition as relatively benign.

The interviews also uncovered a persistent theme that prescribers feel patients expect antibiotics and will lower their ratings on satisfaction surveys if they do not leave a visit with a prescription for them. In line with that thinking, respondents said that changing patient expectations would help take the pressure off prescribers.

When asked why information has not changed some physicians' prescribing behaviors, some respondents said that healthcare providers find it hard to break habits and continue to prescribe the way they always have, even if they have new information.

As to preferences on modes of receiving information about antibiotics, answers ranged from incorporating information in electronic health records, such as a prompt to flag a prescription when it falls outside of guidelines, to having a mobile telephone app available for guidelines or having a quick reference guide easily available for major diagnoses.

The authors conclude that complicating factors such as patient demand and longtime habits, rather than lack of knowledge concerning recommendations, are driving inappropriate antibiotic prescriptions.

"Future research efforts should be aimed at investigating effective incentives for appropriate antibiotic prescribing and determining alternative communication strategies to encourage use of first-line agents. Although most efforts have focused on reducing unnecessary antibiotic use, more research is needed to clarify which interventions improve antibiotic selection," they write.

The authors have disclosed no relevant financial relationships.

Emerging Infect Dis. Published online November 13, 2014.

    
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