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Health Services Research & Development

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2023 HSR&D/QUERI National Conference Abstract

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1039 — Improving Veteran health by increasing dental stewardship of antibiotics and opioids

Lead/Presenter: Katie Suda,  COIN - Pittsburgh/Philadelphia
All Authors: Suda KJ (Center for Health Equity Research and Promotion), Sharp LK (University of Illinois at Chicago) Hughes AM (Center of Innovation for Complex Chronic Healthcare) Gibson G (VA Office of Dentistry) Jurasic MM (Center for Health Organization and Implementation Research) Fitzpatrick MA (Center of Innovation for Complex Chronic Healthcare) Gellad WF (Center for Health Equity Research and Promotion) Cunningham F (VA Pharmacy Benefits Management, VA MedSafe) Echevarria K (VA Pharmacy Benefits Management, Antimicrobial Stewardship Task Force) McGregor J (Oregon State University) Evans CT (Center of Innovation for Complex Chronic Healthcare)

Objectives:
Dentists prescribe 10% of all antibiotics and opioids the U.S. and are the top specialty prescriber of both classes. However, little is known about prescribing behaviors by dentists of these medications associated with serious adverse events. Our objective was to determine factors associated with guideline discordant prescribing of antibiotics and opioids by dentists.

Methods:
We conducted a mixed methods study using national VHA encounter and prescribing data (2015-2018) and interviews with VHA dentists (2019-2020). First, we completed a cross-sectional study of prescribing within 7 days of a dental visit to identify patient- and facility-level factors associated with guideline concordant prescribing using Poisson regression. Then, we completed one-on-one semi-structured interviews of 90 dentists that identified Theoretical Domains Framework themes influencing prescribing behavior; themes were mapped to the Capability-Opportunity-Motivation-Behaviour model (2 coder agreement K = 0.97).

Results:
Of visits associated with antibiotic pre-medication (N = 358,078) and opioids (N = 196,595) prescribed by dentists, 85% and 29% were discordant with guidelines, respectively. For antibiotics, Black (vs White) race, Hispanic (vs non-Hispanic) ethnicity, and visits located in the Western region were associated with guideline discordant prescribing, while older age and rural location were associated with guideline concordance. For opioids, Friday visits, persons with chronic oral pain or substance misuse, and the Northeast had a higher prevalence of guideline discordant prescribing, while women, older, and Black and Hispanic Veterans had a lower prevalence of guideline discordance. While guideline discordant prescribing of opioids has decreased, antibiotic discordance has increased over time. Qualitative findings identified access to resources, social influence of physicians, clinical judgement, local clinic features, and beliefs about consequences and capabilities as barriers and facilitators to evidence-based prescribing of antibiotics. For opioids, access to resources, patient opioid requests, clinical judgement, communication skills, and screening for opioid misuse while managing acute pain emerged as themes to change prescribing behavior.

Implications:
We identified that 4 out 5 antibiotics and 1 out of 4 opioids prescribed by dentists were discordant with guidelines with significant geographic variability. Interestingly, while underrepresented minorities were more likely to receive guideline discordant antibiotics, they were less likely to receive discordant opioids. Results from qualitative findings suggest that some key facilitators may be used to address guideline discordance and prescribing variation including providing resources, communication training, and managing demands of physicians and patients for dentists to prescribe.

Impacts:
Several VA initiatives have focused on opioids and antibiotics, but have concentrated on medical clinicians. In partnership with the Office of Dentistry and Academic Detailing, we developed an academic detailing program for dentists targeting acute oral pain comprised of prescribing resources, peer comparison reports, and a forum to communicate challenges. A partnership with the Antimicrobial Stewardship Task Force and Office of Dentistry has conducted a workflow study and developed educational programming for dentists and posters to raise dentist awareness of clinical guidelines and local facility-level antimicrobial stewardship resources. With changing guidelines narrowing recommendations for opioids for acute oral pain and antibiotic pre-medication, strategies to improve prescribing by dentists should continue to be expanded and implemented.