Improving Veteran Health by Increasing Dental Stewardship of Antibiotics and Opioids

抗生素和阿片类药物是牙医开出的主要治疗药物类别。有趣的是，相关因素- 使用处方时，这些药物类别的行为是相似的。我们关于牙科治疗前的初步数据 划线显示，1)阿片类药物高处方者也是抗生素高处方者，2)过度- 开抗生素和阿片类药物是很常见的。然而，我们在认识上存在着差距。 药物处方和过量处方(针对不适当的适应症和/或过多的数量/效力/ 持续时间)由牙医提供。这一差距很大，因为牙医每10张处方中就有1张(处方) 抗生素和阿片类药物在美国都是如此。不适当和适当地使用抗生素和阿片类药物是一种 对患者安全的风险，包括：细菌耐药性、艰难梭菌感染(CDI)、阿片类药物过量、药物依赖 悬垂和转移视线。阿片类药物过量处方令人担忧，因为药物使用者通常寻求 来自牙医的阿片类药物，牙医很少使用处方药监测程序(PDMP)和死亡 继发于阿片类药物的使用与牙科处方有关。抗生素在感染预防中的应用 之前的牙科手术一直与CDI有关。感染性心内膜炎和人工心内膜指南 最近更新了牙科手术期间的关节感染预防措施，显著减少了 需要抗生素预防的患者。然而，尽管预防感染是主要的指标- 对于牙医开出的抗生素，我们的全国数据显示总体只有很小的下降(0.7%) 开牙科抗生素处方。尽管正在加大力度减少这些药物类别的过度使用， 大多数干预措施都集中在医疗提供者身上。在初步数据的指导下，我们将追踪3个物种- CICIC的目标：1)评估抗生素和阿片类药物的牙科处方，并确定以下特征- 与高比例的不适当处方有关；2)描述牙医对开出抗精神病药物的态度 在高处方设施和低处方设施中具有高和低处方模式的人中的生物制剂和阿片类药物； 以及3)开展试点实施研究，以改善牙科处方。拟议的研究是一致的 与HSR&D的研究优先领域(医疗保健公平-弱势人群；实施SCI- ENS-提供者行为；以及以患者为中心的护理-阿片类药物的使用)和2个白宫国家行动计划- 原因是抗生素耐药性和不良药物事件。该协作项目的目标也与 我们运营合作伙伴的优先事项：退伍军人管理局牙科服务、PBM MedSafe和抗菌素管家- 舰艇特遣部队。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牙科预适应。 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。 我们将对行政管理数据和对开出“高”和“低”处方的牙医的采访结果进行三角测量，网址为 “高”和“低”--处方设施。这项研究的预期结果包括提供以下基线数据 牙科医生过度使用抗生素和阿片类药物的程度，识别注射的障碍和促进剂。 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，退伍军人管理局为研究牙科处方提供了一个独特的机会，因为 私人牙医对ICD9/10进行编码的情况很少见。因此，我们的结果可能会产生深远的影响。 这项研究的创新之处在于，据我们所知，这将是第一次利用国家VA数据库进行研究 回答有关抗生素和阿片类药物牙科处方的研究问题。拟议的PRO的目标是- 目标是为决策者开发可操作的结果，这些结果可以实施，以改善证据- 根据牙医开出的抗生素和阿片类药物处方。我们的长期目标是改善退伍军人的牙科护理 通过实施干预措施，增加谨慎的抗菌药物使用，减少阿片类药物的过度处方 减少严重不良事件。同时干预滥用抗生素和阿片类药物 可能会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.