Jonne J. Sikkens

Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study

Importance Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs. Objective To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals. Design, Setting, and Participants The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study. Interventions We offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing. Main Outcomes and Measures Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time. Results A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found. Conclusions and Relevance Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

Validation of self-reported folic acid use in a multiethnic population: results of the Amsterdam Born Children and their Development study

OBJECTIVE To assess folic acid supplementation rates and validate the self-reporting of folic acid supplement use among pregnant women in a multiethnic cohort. DESIGN Secondary analysis of a prospective cohort study. SETTING Self-reported folic acid supplement use in the Amsterdam Born Children and their Development study cohort was compared with serum folate concentrations using non-parametric trend analysis and linear and logistic regression. SUBJECTS A total of 4234 pregnant women of various ethnic backgrounds. RESULTS Serum folate levels showed a significant positive linear trend as reported use of folic acid increased (P < 0·001), which was supported by linear regression (r = 0·49). Odds of having low serum folate concentration decreased with reported early start of folic acid intake. Young, multiparous or non-Western women reported less pre-conception folic acid intake. Non-Western women showed lower serum folate concentrations. The overall rate of over-reporting, i.e. serum folate concentrations ≤20 nmol/l while reporting the use of folic acid supplements, was 20·7 %. Women of Surinamese and Moroccan ancestry had higher odds of over-reporting (OR = 2·3; 95 % CI 1·5, 3·5 and OR = 2·3; 95 % CI 1·3, 4·0, respectively). The odds for Surinamese women remained significant after adjusting for the onset of supplement use, parity and age (OR = 1·7; 95 % CI 1·1, 2·6). CONCLUSIONS Although self-reporting is a valid method for assessing folic acid supplement use in a multiethnic population, some participants do over-report. Surinamese and possibly Moroccan women appear to over-report more often. Rates of supplementation are low, especially in non-Western women. This suggests the need for intensifying current campaigns or perhaps even additional advice to start or continue to use folic acid post-conceptionally.

Stay tuned: what is special about not shifting attention?

Background When studying attentional orienting processes, brain activity elicited by symbolic cue is usually compared to a neutral condition in which no information is provided about the upcoming target location. It is generally assumed that when a neutral cue is provided, participants do not shift their attention. The present study sought to validate this assumption. We further investigated whether anticipated task demands had an impact on brain activity related to processing symbolic cues. Methodology/Principal Findings Two experiments were conducted, during which event-related potentials were elicited by symbolic cues that instructed participants to shift their attention to a particular location on a computer screen. In Experiment 1, attention shift-inducing cues were compared to non-informative cues, while in both conditions participants were required to detect target stimuli that were subsequently presented at peripheral locations. In Experiment 2, a non-ambiguous “stay-central” cue that explicitly required participants not to shift their attention was used instead. In the latter case, target stimuli that followed a stay-central cue were also presented at a central location. Both experiments revealed enlarged early latency contralateral ERP components to shift-inducing cues compared to those elicited by either non-informative (exp. 1) or stay-central cues (exp. 2). In addition, cueing effects were modulated by the anticipated difficulty of the upcoming target, particularly so in Experiment 2. A positive difference, predominantly over the posterior contralateral scalp areas, could be observed for stay-central cues, especially for those predicting that the upcoming target would be easy. This effect was not present for non-informative cues. Conclusions/Significance We interpret our result in terms of a more rapid engagement of attention occurring in the presence of a more predictive instruction (i.e. stay-central easy target). Our results indicate that the human brain is capable of very rapidly identifying the difference between different types of instructions.

E-learning on antibiotic prescribing—the role of autonomous motivation in participation: a prospective cohort study

Abstract Objectives E-learning is increasingly used in education on antimicrobial stewardship, but participation rates are often low. Insight into factors that affect participation is therefore needed. Autonomous motivation is associated with higher achievements in medical education and could also play a role in e-learning participation. We therefore aimed to investigate the role of residents’ autonomous motivation in their participation in e-learning on antibiotic prescribing. Methods We performed a multicentre cohort study in two academic and two teaching hospitals. Residents who filled out questionnaires on antibiotic knowledge, the perceived importance of antibiotics and motivation [Self-Regulation Questionnaire – Academic (SRQ-a)] received e-learning access. We used the SRQ-a to calculate relative autonomous motivation (RAM), an index that estimates the amount of autonomous motivation compared with the amount of controlled motivation. We then analysed associations between RAM and participation in e-learning with logistic regression. Results Eighty-six residents participated (74% female, mean age 30 years). Overall e-learning participation was 58% (n = 50). Participation was 41% in residents with negative RAM (i.e. more controlled motivation) and 62% in residents with positive RAM (i.e. more autonomous motivation). RAM was positively associated with participation, adjusted for residency in an academic hospital (adjusted OR 2.6, 95% CI 1.5–4.6). Conclusions Participation in non-obligatory e-learning on antibiotic prescribing is higher in residents with more autonomous motivation. Interventions to increase autonomous motivation could improve participation. Preceding e-learning on antibiotic prescribing with face-to-face education, to explain the importance of the subject, could enhance autonomous motivation and thus optimize e-learning efficiency.