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IIR 17-039 – HSR&D Study

 
IIR 17-039
Improving Veteran Health by Increasing Dental Stewardship of Antibiotics and Opioids
Katie J. Suda PharmD MS
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: July 2018 - March 2023

BACKGROUND/RATIONALE:
Background/Rationale: Antibiotics and opioids are the top therapeutic categories prescribed by dentists. Interestingly, factors associated with prescribing behaviors of these medication classes are similar. Our preliminary data on dental prescribing 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, Clostridium difficile infection (CDI), opioid overdose, drug dependence 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 indication 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.

OBJECTIVE(S):
Objective(s): Guided by preliminary data, we will be pursuing three specific aims: 1) Assess dental prescribing of antibiotics and opioid medications and identify characteristics associated with high rates of inappropriate prescribing; 2) Describe dentists' attitudes towards prescribing antibiotics 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 science-provider behavior; and patient-centered care-opioid use) and two White House National Action Plans focused 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 Stewardship Task Force.

METHODS:
Methods: We propose to conduct a mixed-methods study. Administrative data will assess antibiotic and opioid dental prescribing based on American Dental Association recommendations and identify factors related to prescribing. One-on-one qualitative interviews with 'high' and 'low'-prescribing dentists at 'high' and 'low'-prescribing facilities will assess perceptions of antibiotic and opioid prescribing, adverse drug events and facilitators and barriers to the use of prescribing resources. Non-VA sites are not included. We will triangulate our results to develop a pilot implementation project.

FINDINGS/RESULTS:
Findings/Results: The project start date is planned for July 1, 2018.

IMPACT:
Impact: 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 project is to develop actionable findings for decision makers that can be implemented to improve evidence-based prescribing of antibiotics and opioids by dentists.


External Links for this Project

NIH Reporter

Grant Number: I01HX002452-01A1
Link: https://reporter.nih.gov/project-details/9502714

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PUBLICATIONS:

Journal Articles

  1. Sharp LK, Solanki P, Boyer T, Vivo A, Kale I, Hughes AM, Gibson G, Jurasic MM, Evans CT, Suda KJ. A qualitative exploration of dentists' opioid prescribing decisions within U.S. veterans affairs facilities. Pain. 2022 Aug 17. [view]
  2. Suda KJ, Fitzpatrick MA, Gibson G, Jurasic MM, Poggensee L, Echevarria K, Hubbard CC, McGregor JC, Evans CT. Antibiotic prophylaxis prescriptions prior to dental visits in the Veterans' Health Administration (VHA), 2015-2019. Infection control and hospital epidemiology. 2022 Nov 1; 43(11):1565-1574. [view]
  3. Singh N, Poggensee L, Huang Y, Evans CT, Suda KJ, Bulman ZP. Antibiotic susceptibility patterns of viridans group streptococci isolates in the United States from 2010 to 2020. JAC-antimicrobial resistance. 2022 Jun 1; 4(3):dlac049. [view]
  4. Carlsen DB, Durkin MJ, Gibson G, Jurasic MM, Patel U, Poggensee L, Fitzpatrick MA, Echevarria K, McGregor J, Evans CT, Suda KJ. Concordance of antibiotic prescribing with the American Dental Association acute oral infection guidelines within Veterans' Affairs (VA) dentistry. Infection control and hospital epidemiology. 2021 Dec 1; 42(12):1422-1430. [view]
  5. Koppen L, Suda KJ, Rowan S, McGregor J, Evans CT. Dentists' prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health. Journal of the American Dental Association (1939). 2018 Aug 1; 149(8):721-730. [view]
  6. Evans CT, Fitzpatrick MA, Poggensee L, Gonzalez B, Gibson G, Jurasic MM, Echevarria K, McGregor JC, Gellad WF, Suda KJ. High prescribing of antibiotics is associated with high prescribing of opioids in medical and dental providers. Pharmacotherapy. 2022 Sep 1; 42(9):716-723. [view]
  7. Suda KJ, Evans CT, Gibson G, Jurasic MM, Poggensee L, Gonzalez B, Hubbard CC, Vivo A, Cunningham FE, McGregor JC, Gellad WF. Opioid Prescribing by Dentists in the Veterans Health Administration. American journal of preventive medicine. 2022 Sep 1; 63(3):371-383. [view]
  8. Evans CT, Fitzpatrick MA, Poggensee L, Gonzalez B, Gibson G, Jurasic MM, Echevarria K, McGregor JC, Cunningham F, Gellad WF, Suda KJ. Outpatient Prescribing of Antibiotics and Opioids by Veterans Health Administration Providers, 2015-2017. American journal of preventive medicine. 2021 Nov 1; 61(5):e235-e244. [view]
  9. Caniff KE, Young LR, Truong S, Gibson G, Jurasic MM, Poggensee L, Fitzpatrick MA, Evans CT, Suda KJ. Postextraction infection and antibiotic prescribing among veterans receiving dental extractions. Infection control and hospital epidemiology. 2021 Dec 1; 42(12):1431-1436. [view]
  10. Hughes AM, Lin E, Hussain RA, Gibson G, Jurasic MM, Sharp LK, Hubbard CC, Poggensee LE, Evans CT, McGregor JC, Gellad WF, Suda KJ. The feasibility of academic detailing for acute oral pain management in outpatient dentistry: A pilot study. Journal of the American Pharmacists Association : JAPhA. 2022 Aug 5. [view]
  11. Suda KJ, Henschel H, Patel U, Fitzpatrick MA, Evans CT. Use of Antibiotic Prophylaxis for Tooth Extractions, Dental Implants, and Periodontal Surgical Procedures. Open forum infectious diseases. 2018 Jan 1; 5(1):ofx250. [view]
VA Cyberseminars

  1. Suda KJ. Antibiotic Prescribing in Dental Clinics. [Cyberseminar]. VHA Antimicrobial Stewardship Task Force. 2018 Jul 25. [view]


DRA: Substance Use Disorders, Infectious Diseases
DRE: Treatment - Observational, TRL - Applied/Translational
Keywords: Effectiveness, Patient-Provider Interaction, Pharmacology
MeSH Terms: none

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