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Validation of the Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) quality assessment tool
A Khanina1,2,3, A P Douglas1,2,3, D K Yeoh1,2,4
1The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria 3000, Australia.
Background:
The Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) was developed to undertake streamlined quality audits of antifungal prescribing. The validity and reliability of such tools is not characterized.
Objectives:
To assess the validity and reliability of the AF-NAPS quality assessment tool.
Methods:
Case vignettes describing antifungal prescribing were prepared. A steering group was assembled to determine gold-standard classifications for appropriateness and guideline compliance. Infectious diseases physicians, antimicrobial stewardship (AMS) and specialist pharmacists undertook a survey to classify appropriateness and guideline compliance of prescriptions utilizing the AF-NAPS tool. Validity was measured as accuracy, sensitivity and specificity compared with gold standard. Inter-rater reliability was measured using Fleiss' kappa statistics. Assessors' responses and comments were thematically analysed to determine reasons for incorrect classification.
Results:
Twenty-eight clinicians assessed 59 antifungal prescriptions. Overall accuracy of appropriateness assessment was 77.0% (sensitivity 85.3%, specificity 68.0%). Highest accuracy was seen amongst specialist (81%) and AMS pharmacists (79%). Prescriptions with lowest accuracy were in the haematology setting (69%), use of echinocandins (73%), mould-active azoles (75%) and for prophylaxis (71%). Inter-rater reliability was fair overall (0.3906), with moderate reliability amongst specialist pharmacists (0.5304). Barriers to accurate classification were incorrect use of the appropriateness matrix, knowledge gaps and lack of guidelines for some indications.
Conclusions:
The AF-NAPS is a valid tool, assisting assessors to correctly classify appropriate prescriptions more accurately than inappropriate prescriptions. Specialist and AMS pharmacists had similar performance, providing confidence that both can undertake AF-NAPS audits to a high standard. Identified reasons for incorrect classification will be targeted in the online tool and educational materials.
Insights
The Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) tool accurately assesses antifungal prescribing, particularly for appropriate cases. Specialist and antimicrobial stewardship pharmacists demonstrated strong performance, validating its use in quality audits.
Area of Science:
- Clinical Pharmacy
- Infectious Diseases
- Antimicrobial Stewardship
Background:
- The Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) was developed for quality audits of antifungal prescribing.
- The validity and reliability of the AF-NAPS tool required characterization.
Purpose of the Study:
- To assess the validity and reliability of the AF-NAPS quality assessment tool.
- To evaluate the accuracy, sensitivity, and specificity of the AF-NAPS tool against a gold standard.
Main Methods:
- Case vignettes of antifungal prescribing were used for assessment.
- Infectious diseases physicians and pharmacists classified prescriptions using the AF-NAPS tool.
- Validity was measured by accuracy, sensitivity, and specificity; inter-rater reliability was assessed using Fleiss' kappa statistics.
Main Results:
- Overall accuracy for appropriateness assessment was 77.0% (sensitivity 85.3%, specificity 68.0%).
- Specialist pharmacists (81%) and antimicrobial stewardship (AMS) pharmacists (79%) showed the highest accuracy.
- Fair overall inter-rater reliability (0.3906) was observed, with moderate reliability among specialist pharmacists (0.5304).
Conclusions:
- The AF-NAPS tool is valid, with better accuracy for appropriate prescriptions.
- Specialist and AMS pharmacists performed similarly, supporting their use in AF-NAPS audits.
- Barriers identified include incorrect matrix use, knowledge gaps, and lack of guidelines, which will inform future tool and educational material development.
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