Improving Veteran Health by Increasing Dental Stewardship of Antibiotics and Opioids

抗生素和阿片类药物是牙科医生开出的顶级治疗类别。有趣的是，相关因素- 这些药物类别的处方行为是相似的。我们的初步数据显示， 划线表明，1）阿片类药物的高处方者也是抗生素的高处方者，2）过度 抗生素和阿片类药物的处方很常见。然而，我们对以下问题的理解存在知识差距： 药物处方和过度处方（用于不适当的适应症和/或过量/效价/ 时间，牙医。这一差距很大，因为牙医每10个处方中就有1个处方（Rx） 抗生素和阿片类药物在美国抗生素和阿片类药物的不适当和适当使用是一个 对患者安全的风险，包括：细菌耐药性，C.艰难梭菌感染（CDI），阿片类药物过量，药物脱- 未决和转移。阿片类药物过量是令人担忧的，因为物质使用者通常寻求 阿片类药物从牙医，牙医很少使用处方药监测计划（PAPs）和死亡 继发于类阿片使用的疾病与牙科处方有关。使用抗生素预防感染 与CDI有关。感染性心内膜炎和假体指南 最近更新了牙科手术期间的关节感染预防， 需要抗生素预防的患者。然而，尽管感染预防是主要的指示剂， 对于牙医开的抗生素，我们的国家数据显示，总体上只有很小的下降（0.7%）。 牙科抗生素处方。虽然正在努力减少这些药物类的过度使用， 大多数干预措施侧重于医疗提供者。在初步数据的指导下，我们将追求3个特殊- 目的：1）评估抗生素和阿片类药物的牙科处方，并确定以下特征- 与高比例的不适当的处方; 2）描述牙医的态度，处方反 在高和低处方设施中具有高和低处方模式的人中的生物和阿片类药物; 及3）发展一项试验性的实施研究，以改善牙科处方。拟议的研究与 与HSR&D的研究优先领域（医疗保健公平弱势群体;实施科学， 证据提供者行为;和以患者为中心的护理阿片类药物使用）和2项白宫国家行动计划， 由于抗生素耐药性和药物不良事件。该合作项目的目标也与 我们的运营合作伙伴的优先事项：VA牙科服务，PBM MedSafe和抗菌剂管理员- 船特遣部队。我们建议进行一项混合方法研究，以评估抗生素和阿片类药物的牙科治疗前， 根据美国牙科协会的建议进行划线，并确定与处方相关的因素。 我们将从行政数据和与“高”和“低”处方牙医的访谈中得出三角结果， “高”和“低”处方设施。本研究的预期成果包括提供以下方面的基线数据： 牙科医生过度使用抗生素和阿片类药物的程度，识别障碍和促进因素， 证明抗生素和阿片类药物的处方，并制定一个试点实施项目，以改善 牙齿护理的质量。此外，VA提供了一个独特的机会，研究牙科处方，因为 私营部门牙医的ICD 9/10编码很少见。因此，我们的研究结果的影响可能是深远的。 这项研究是创新的，因为它将是第一项研究，据我们所知，利用国家VA数据库 回答关于牙科处方抗生素和阿片类药物的研究问题。建议的目标是， 主题是为决策者制定可执行的调查结果，以改善证据- 基于牙医开抗生素和阿片类药物的处方。我们的长期目标是改善退伍军人的牙齿护理 通过实施干预措施，增加谨慎的抗菌药物使用，减少阿片类药物过度处方， 减少严重不良事件。同时干预滥用抗生素和阿片类药物 可以更有效地改善牙医提供的循证护理。

Antibiotics and opioids are the top therapeutic categories prescribed by dentists. Interestingly, factors associ- ated with prescribing behaviors of these medication classes are similar. Our preliminary data on dental pre- scribing demonstrates that 1) high prescribers of opioids are also high prescribers of antibiotics and 2) over- prescribing of antibiotics and opioids is common. However, there is a knowledge gap in our understanding of medication prescribing and overprescribing (for inappropriate indications and/or excessive quantity/potency/ duration) by dentists. This gap is significant because dentists prescribe 1 out of every 10 prescriptions (Rx) for both antibiotics and opioids in the US. Inappropriate and appropriate use of antibiotic and opioids are a risk to patient safety, including: bacterial resistance, C. difficile infection (CDI), opioid overdose, drug de- pendence and diversion. Opioid overprescribing is concerning because substance users commonly seek opioids from dentists, dentists infrequently use prescription drug monitoring programs (PDMP) and fatalities secondary to opioid use have been linked to dental prescribing. Use of antibiotics for infection prophylaxis prior to dental procedures has been associated with CDI. Guidelines for infective endocarditis and prosthetic joint infection prophylaxis during dental procedures were recently updated, significantly reducing the number of patients requiring antibiotic prophylaxis. However, despite infection prophylaxis being the primary indica- tion for antibiotics prescribed by dentists, our national data shows only a small (0.7%) decrease in overall dental antibiotic prescribing. Although efforts are increasing to curtail overuse of these medication classes, most interventions are focused on medical providers. Guided by preliminary data, we will be pursuing 3 spe- cific aims: 1) Assess dental prescribing of antibiotics and opioid medications and identify characteristics as- sociated with high rates of inappropriate prescribing; 2) Describe dentists' attitudes towards prescribing anti- biotics and opioids among those with high and low prescribing patterns in high and low prescribing facilities; and 3) Develop a pilot implementation study to improve dental prescribing. The proposed study is aligned with the research priority areas of HSR&D (healthcare equity-vulnerable populations; implementation sci- ence-provider behavior; and patient-centered care-opioid use) and 2 White House National Action Plans fo- cused on antibiotic resistance and adverse drug events. The goals of this collaborative project also align with the priorities of our operational partners: VA Dental Services, PBM MedSafe, and the Antimicrobial Steward- ship Task Force. We propose to conduct a mixed-methods study to assess antibiotic and opioid dental pre- scribing based on American Dental Association recommendations and identify factors related to prescribing. We will triangulate results from administrative data and interviews with `high' and `low'-prescribing dentists at `high' and `low'-prescribing facilities. The expected outcomes of this study include providing baseline data on the extent of antibiotic and opioid overprescribing by dentists, identification of barriers and facilitators to im- proving prescribing of antibiotics and opioids and development of a pilot implementation project to improve the quality of dental care. Additionally, VA provides a unique opportunity to study dental prescribing because ICD9/10 coding by private sector dentists is rare. Thus, the impact of our results are likely to be far-reaching. This research is innovative in that it will be the first study, to our knowledge, utilizing national VA databases to answer research questions on dental prescribing of antibiotics and opioids. The goal of the proposed pro- ject is to develop actionable findings for decision makers that can be implemented to improve evidence- based prescribing of antibiotics and opioids by dentists. Our long-term goal is to improve Veteran dental care by implementing interventions that will increase prudent antimicrobial use, decrease opioid overprescribing and decrease serious adverse events. Simultaneously intervening on the misuse of antibiotics and opioids may more efficiently improve evidenced-based care delivered by dentists.