Mejl Hulscher

Barriers to optimal antibiotic use for community-acquired pneumonia at hospitals: a qualitative study

Background: Physician adherence to key recommendations of guidelines for community-acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change. Methods: The authors used semistructured interviews with care providers in three Dutch medium-sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana). Results: Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline-adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow-spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians’ attitude of “never change a winning team”. Conclusions: Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.

Implementation of protocolized tight control and biological dose optimization in daily clinical practice: results of a pilot study

Objectives: To assess the effects of education, guideline development, and individualized treatment advice on rheumatologist adherence to tight control-based treatment and biological dose optimization in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and spondyloarthropathy (SpA) patients. Method: This pilot study, among two rheumatologists and two specialized nurses in a general hospital, combined education, feedback, local guideline development, and individualized treatment advice. Outcomes (baseline and 1 year post-intervention) were the percentage of patients with a Disease Activity Score in 28 joints (DAS28) or Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) measured during the visit, mean DAS28/BASDAI, and the percentage of patients using a reduced biological dose. DAS28 outcomes only applied to RA and PsA patients, BASDAI outcomes only applied to SpA patients whereas outcomes on biological dose applied to all patients. Results: A total of 232 patients (67% RA, 15% PsA, 18% SpA; 58% female, mean age 56 ± 15 years) were included in the study. The percentage of DAS28 and BASDAI measurements performed increased after the intervention [DAS28 15–51%, odds ratio (OR) 3.3, 95% confidence interval (CI) 2.1–5.5; BASDAI 23–50%, OR 2.2, 95% CI 1.0–5.5], with mean DAS28 and BASDAI scores remaining similar (DAS28: mean difference 0.1, 95% CI −0.3 to 0.5; BASDAI: mean difference 0.03, 95% CI −1.8 to 1.9). Use of a reduced biological dose increased from 10% to 61% (OR 3.9, 95% CI 2.4–6.5). Conclusions: A multicomponent intervention strategy aimed at rheumatologists can lead to improved adherence to tight control-based treatment and a reduction in the use of biologicals in RA, SpA, and PsA patients.

Choosing wisely in daily practice: a mixed methods study on determinants of antinuclear antibody testing by rheumatologists

Objectives: To explore the relationship between antinuclear antibody (ANA) overuse and rheumatologist-related factors before and after an intervention aimed at reducing ANA overuse. Method: In this mixed methods study we performed surveys among rheumatologists (n = 20) before and after the ANA intervention (education and feedback). We identified clinician-related determinants of ANA overuse (demographic characteristics, cognitive bias, numeracy, personality, thinking styles, and knowledge) by multivariate analysis. Two focus group meetings with rheumatologists were held 6 months after the intervention to explore self-reported determinants. Results: Questionnaires were completed by all rheumatologists and eight participated in the focus groups. Rheumatologists with more work experience and a less extravert personality ordered more ANA tests before the intervention [β = 0.01, 95% confidence interval (CI) 0.003 to 0.02, p = 0.01 and β = −0.11, 95% CI −0.21 to −0.01, p = 0.04, respectively; R2 = 47%]. After the intervention, female rheumatologists changed less than their male colleagues with regard to the number of ANA tests ordered (β = 0.15, 95% CI 0.03–0.26, p = 0.02; R2 = 25%). During the focus groups, seven themes were identified that influenced improvement in ANA overuse: determinants related to the intervention and the study, individual health professionals, patients, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Conclusions: We identified several determinants that together explained a sizable part of the variance observed in the ANA outcomes at baseline and in the change in ANA outcomes afterwards. Furthermore, the focus groups yielded additional factors suggesting a complex interplay of determinants influencing rheumatologists’ ANA ordering behaviour.

Using typing techniques in a specific outbreak: the ethical reflection of public health professionals

Typing techniques are laboratory methods used in outbreak management to investigate the degree to which microbes found within an outbreak are related. Knowledge about relational patterns between microbes benefits outbreak management, but inevitably also tells us something about the relational patterns of the people hosting them. Since the technique is often used without explicit consent of all individuals involved, this may raise ethical questions. The aim of this study was to unravel the complex ethical deliberation of professionals over the use of such techniques. We organised group discussions (n = 3) with Dutch outbreak managers (n = 23). The topic list was based on previously identified ethical issues and discussions were analysed for recurrent themes. We found that outbreak managers first and foremost reflect on the balance of individual harm with public health benefit. This key question was approached by way of discussing four more specific ethical themes: (1) justification of governmental intervention, (2) responsibility to prevent infections, (3) scientific uncertainty and (4) legal consequences. The themes found in this study, rephrased into accessible questions, represent the shared ethical understanding of professionals and can help to articulate the ethical dimensions of using molecular science in response to infectious disease outbreaks.

THU0645-HPR Perceived Barriers and Facilitators for bDMARD Dose Optimization: A Qualitative Study into Ra Patients' Perspectives

Background Although bDMARDs are effective in treating RA, they are associated with high costs and (rare) dose-dependent side effects. It is therefore desirable to find and use the lowest effective dose in individual patients. Several studies have shown that dose reduction or interval lengthening of bDMARDs using the tight control principle can be successful in RA patients while preserving stable low disease activity.1 Unfortunately, bDMARD dose optimization is still limited in clinical practice.2 The successful implementation of bDMARD dose optimization could, among other factors, be influenced by patients attitudes and beliefs. Insight into RA patients barriers and facilitators to bDMARD dose optimization might help to improve implementation. Objectives To investigate the self-reported barriers and facilitators for bDMARD dose optimization in RA patients. Methods We performed semi-structured interviews with RA patients who used or had used a bDMARD. Patients were recruited at the Sint Maartenskliniek through purposive sampling. Patients with varying characteristics were included, looking at type of bDMARD, treating rheumatologist and experience with tapering/stopping. The interviews were performed by one researcher (18 by telephone, 4 face-to-face), audio-recorded and transcribed verbatim. Two researchers analyzed the transcriptions by inductive thematic analysis using the qualitative data analysis software MAXQDA. Results 22 RA patients were interviewed (68.2% female; age: 61.8±7.6 years; disease duration: 13.2±9.4 years; 90.9% current bDMARD user). RA patients overall attitude towards bDMARD optimization was positive. Nine main themes emerged from the interviews: disease activity, functioning/pain, adverse effects, practical use of bDMARDs, attitude towards medication, previous experiences with tapering/stopping, social aspects, organizational aspects and costs. Within these themes, a total of 43 barriers and facilitators were identified. These include affective factors (e.g. fear), cognitive factors (e.g. beliefs) and practical factors (e.g. organization of care, costs). Conclusions RA patients perceive several barriers and facilitators that influence their willingness to attempt tapering or stopping their bDMARD treatment. The results of this study could be used to target strategies aiming at implementation of bDMARD optimization in clinical practice. References Van Herwaarden N, van der Maas A, Minten MJ, van den Hoogen FH, Kievit W, van Vollenhoven RF et al. Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ 2015; 350:h1389. Zhang J, Xie F, Delzell E, Yun H, Lewis JD, Haynes K et al. Impact of biologic agents with and without concomitant methotrexate and at reduced doses in older rheumatoid arthritis patients. Arthritis Care Res 2015; 67(5):624–632. Disclosure of Interest None declared

Preparedness and the importance of meeting the needs of healthcare workers: a qualitative study on Ebola

n Summaryn n Backgroundn Healthcare workers (HCWs) face specific challenges in infectious disease outbreaks, which provide unusual, new events with exposure risk. The fear of infection or new, unknown tasks in an unfamiliar setting, for example, may complicate outbreak management.n n n Aimn To gain insight into how healthcare organizations can prepare to meet the needs of their HCWs by capturing the experiences of HCWs with patients with suspected Ebola virus disease.n n n Methodsn We conducted 23 in-depth interviews with HCWs, of whom 20 worked in a Dutch university hospital and three worked in a regional ambulance service. We invited HCWs who cared for patients with suspected Ebola or who were on the team preparing for admission of such patients in the period 2014–2015.n n n Findingsn The HCWs were stressed and anxious, but most rated their overall experience as positive. We categorized the reported experiences in three main themes, namely, experiences related to: (i) the novelty of the threat, (ii) the risk of infection and fear of transmission, and (iii) the excessive attention. Our results underline the importance of a supportive working environment suitable for crises.n n n Conclusionn The experiences of HCWs dealing with patients with suspected Ebola can direct improvements in generic preparedness for highly transmissible diseases.n n

AB1028 Development and Validation of A Patient Questionnaire on Rheumatoid Arthritis Disease Related Knowledge in The Treat To Target Era: Preliminary Results

Background Patient involvement and personalisation of healthcare has become increasingly important in managing chronic diseases. Knowledge about their disease and its treatment is an important precondition for patients to be able to be involved in their own care.[1] Hence, EULAR recommends education to be an integral and continuous element of Rheumatoid Arthritis (RA) management, so that patient can be involved in their RA care. An instrument to assess patients knowledge about their disease and its treatment can provide insight into the effectiveness of healthcare professionals education efforts. Moreover, it can be used as an instrument to personalize education based on individual patients knowledge gaps. Currently available patient knowledge questionnaires were developed before the introduction of biologicals as well as treat to target strategies in rheumatoid arthritis (RA). Therefore we started the development and validation of an RA knowledge questionnaire for patients. Objectives To propose an instrument to measure factual disease related knowledge in RA patients with additional focus on knowledge related to modern treatment methods. Methods Content to be covered by the instrument was adopted from existing questionnaires. Consensus was reached on relevant content by a RAND modified Delphi scoring procedure by six rheumatology nurses and six rheumatologists, and a subsequent consensus meeting among six rheumatology nurses and four rheumatologists. Six rheumatology nurses and five rheumatologists provided written feedback on a preliminary pool of items written to assess the identified content domains. Subsequently, a focus group among nine patients was organised to identify additional content areas that might have been omitted from the item pool. Readability, feasibility and comprehensiveness of the resulting pool of 63 items were rated by eight patients from the focus group. Results Cross-sectional data of 340 patients recruited from Bernhoven rheumatology department were used to evaluate psychometric properties. Preliminary analysis suggests that 21 (27%) items should be discarded based on an item total point biserial correlation <0.30. Confirmatory factor analysis with weighted least squares estimation on the polychoric correlation matrix suggested acceptable fit for a unidimensional measurement model for the remaining 45 items (CFI =0.95, TLI=0.95, RMSEA=0.02, WRMR=0.95). Internal consistency was also high for 45 items, with Cronbachs α=0.92. Conclusions These preliminary results suggest that the questionnaire is a valid and reliable measure for assessing factual disease related knowledge in RA patients. Further validation efforts based on modern item response theory based approaches are ongoing as well as work directed at developing a calibrated item bank, tailored short-forms and a computerized adaptive testing algorithm. References Joseph-Williams N, Elwyn G, Edwards A. Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient education and counseling. 2014;94(3):291–309. Acknowledgement We thank all rheumatology nurses, rheumatologists and patients who have helped in the development or validation of the questionnaire. Disclosure of Interest M. de Jonge Grant/research support from: Dutch Arthritis Foundation (Reumafonds), M. Oude Voshaar: None declared, A. Huis: None declared, M. van de Laar: None declared, M. Hulscher: None declared, P. van Riel: None declared