Article Text

Documenting the indication for antimicrobial prescribing: a scoping review
  1. Sharon Saini1,
  2. Valerie Leung2,3,
  3. Elizabeth Si1,
  4. Certina Ho1,4,
  5. Anne Cheung5,
  6. Dan Dalton6,
  7. Nick Daneman2,7,8,9,
  8. Kelly Grindrod10,
  9. Rita Ha11,
  10. Warren McIsaac12,13,
  11. Anjali Oberai14,15,
  12. Kevin Schwartz2,16,
  13. Anastasia Shiamptanis17,
  14. Bradley J Langford18
  1. 1 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
  2. 2 Public Health Ontario, Toronto, Ontario, Canada
  3. 3 Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
  4. 4 Institute for Safe Medication Practices, Toronto, Ontario, Canada
  5. 5 West Park Healthcare Centre, Toronto, Ontario, Canada
  6. 6 CareRx, Ottawa, Ontario, Canada
  7. 7 Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  8. 8 ICES, Toronto, Ontario, Canada
  9. 9 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  10. 10 University of Waterloo, Waterloo, Ontario, Canada
  11. 11 North York Family Health Team, Toronto, Ontario, Canada
  12. 12 Sinai Health System, Toronto, Ontario, Canada
  13. 13 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  14. 14 Wawa Family Health Team, Wawa, Ontario, Canada
  15. 15 Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
  16. 16 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  17. 17 New Brunswick College of Pharmacists, Moncton, New Brunswick, Canada
  18. 18 Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, Ontario, Canada
  1. Correspondence to Dr Bradley J Langford, Infection Prevention and Control, Public Health Ontario, Toronto, Canada; brad.langford{at}


Background Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.

Objectives We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.

Eligibility criteria Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.

Sources of evidence A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.

Charting and analysis Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.

Results We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%–100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.

Conclusion There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

  • medication safety
  • antibiotic management
  • general practice
  • healthcare quality improvement
  • implementation science

Data availability statement

Data are available on reasonable request.

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Key points

What is already known on this topic

  • Documenting an indication when prescribing antimicrobials is considered best practice, but a thorough understanding of the evidence evaluating this approach is needed.

What this study adds

  • Despite wide variability in antimicrobial indication documentation, there is growing interesting in the importance of this practice from an antimicrobial stewardship and patient safety perspective. Emerging evidence demonstrates that antimicrobial indication documentation, particularly on the prescription, may be associated with improved prescribing and patient outcomes.

How this study might affect research, practice and/or policy

  • This scoping review provides a basis for future work on antimicrobial indication documentation, including an understanding of the barriers and facilitators to implementation. Considerations identified in our review may help guide high quality, prospective, setting-specific research to provide a more robust evidence base for this practice.


The rise in antimicrobial resistance has prompted global stewardship initiatives to mitigate the impact of inappropriate use on this public health threat. One of the strategies that aims to improve antimicrobial use is proactively documenting the indication. When the indication (also known as the reason or purpose for use) is not included on the prescription, patients, pharmacists and other clinicians may be unaware of the reason the drug is prescribed. As such, it has been proposed that including the indication on the prescription is considered the ‘sixth right’ for the necessary components of a medication order, in addition to right patient, the right drug, the right dose, the right time and the right route.1

Documenting the indication, specifically for antimicrobials, is considered best practice across all healthcare settings due to the potential benefits of preventing errors, improving communication, empowering patients, aiding in research and surveillance efforts and encouraging appropriate antimicrobial prescribing by clinicians.1–3 Several organisations, such as the US Centers for Disease Control and the UK National Institute for Health and Care Excellence (NICE) recommend documentation of indication for antibiotics to support antimicrobial stewardship efforts.2 4 The indication documentation can facilitate other interventions including prospective audit and feedback5 and optimisation of postdischarge duration of therapy,6 which have been shown to improve antimicrobial use.

Existing strategies that facilitate indication documentation include mandatory indications (where an indication is required to proceed with ordering a medication),7 accountable justification (where the prescriber is prompted to provide a justification for certain potentially inappropriate prescribing situations)8 and indication-based prescribing (where treatment options are presented based on prescriber-selected indication).9 However, an inventory of such strategies in the context of antimicrobial use and the evidence to support these approaches has not been fully elucidated. There are opportunities to better understand the scope of the literature on antimicrobial indication documentation and its potential impact on prescribing, utilisation and clinical outcomes. An assessment of the current status of the indication documentation literature and gaps in research may help to spur future efforts to implement and evaluate this antimicrobial stewardship strategy.

We performed a scoping review to evaluate the evidence relating to antimicrobial indication documentation to better understand its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in any healthcare setting.


Protocol and registration

This scoping review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).10 The protocol for this scoping review was registered at the Center for Open Science (

Eligibility criteria and information sources

Published peer-reviewed literature (1946 to July 2021) and grey literature including conference abstracts in English language were eligible for inclusion. Conference proceedings were eligible given the broad aim of this scoping review to capture data from a wide variety of settings, recognising that, due to the quality improvement nature of this work, it may not always be published in peer reviewed journals. The following databases were searched on 6 July 2021: MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts. Targeted searches of health department, pharmacy, infectious diseases, primary care and patient safety websites and conferences as well as broad Google searches using the concepts antibiotic, indication and prescription were applied to help identify additional relevant grey literature between 15 July and 13 August 2021.

Any publication evaluating the implementation of, or outcomes associated with, indication documentation for antimicrobial prescribing to humans was eligible for inclusion. Documentation of indication either on the prescription or elsewhere in the patient’s health record was considered eligible. Although the ideal location for improved communication is on the prescription,1 we included a broader definition of documentation to include the health record in general since electronic health records are increasingly accessible to the healthcare team, patients and caregivers. A modification to the protocol was made to exclude studies describing indication documentation for all medications, given the volume of literature focusing exclusively on antimicrobial agents. We also excluded commentaries and narrative reviews.

Search strategy

Searches were conducted in collaboration with a medical librarian. General search concepts included: indication or reason or purpose for use or accountable justification and antimicrobial agents and medication prescription. The full published literature search strategy is available in online supplemental file A.

Supplemental material

Study screening

Potentially eligible citations were imported into citation management software (Covidence, Melbourne Australia). We performed two-stage screening in duplicate by two authors (SS, BL): (1) screening of title and abstract for eligible studies (Kappa 0.64) and (2) screening of full text (Kappa 0.65) studies identified from title and abstract screening. A list of eligibility criteria was provided to reviewers to ensure consistency in selection. Any disagreements were resolved by consensus.

Data items

Data extraction was performed by a single author (SS) and cross-checked by a second author (BL). A standardised spreadsheet incorporating drop-down options was piloted on three studies and modified to incorporate variables for extraction. These variables included: study author; year; setting; region; study design; indication documentation details (where antimicrobial indication was documented including on the prescription or elsewhere in the health record, whether computerised provider order entry (CPOE) was used; format of documentation) intervention details (if any) and study outcomes.

Quality appraisal

Given the broad nature of this scoping review, including many potential study designs and objectives, a critical appraisal was not performed.

Synthesis of results

Studies were categorised by their main objectives. Interventions were classified according to the Cochrane Effective Practice and Organisation of Care taxonomy, a standardised approach to categorising health systems interventions.11 We evaluated indication documentation with respect to the prevalence (how often the antimicrobial indication was included), accuracy (how well the indication matched the true diagnosis) and clarity (the interpretability, sufficiency or specificity of the indication). We also identified and inductively categorised approaches for indication documentation and grouped studies by themes in terms of strategies to measure and improve indication documentation. In order to better identify opportunities to improve antimicrobial indication documentation, barriers and facilitators data were classified according to the Capability, Opportunity, Motivation (COM-B) model.12 The COM-B model proposes that there are three drivers of decision making: capability (knowledge, skills), opportunity (physical and social environment) and motivation (internal processes that influence decisions). In order to change a behaviour, one or more of these aspects must be identified and addressed. Results were presented descriptively in terms of numeric values and percentages including medians and ranges.


Of 2113 studies screened, 183 were assessed for eligibility via full-text screening and 108 were included in the review. The most common reasons for study exclusion were that the study was not specific to antimicrobial agents (n=32), study did not address documentation of indication (n=22) and study was not retrievable (n=9). An additional 15 citations were identified from the grey literature search for a total of 123 publications (figure 1).13–135 Of the 123 studies, 64 were peer reviewed, 53 were conference proceedings and 6 were online documents (eg, reports).

Most studies were retrospective (n=49) or cross-sectional (n=43) in design, followed by prospective studies (n=24), qualitative or mixed-methods (n=4) and randomised-controlled trials (n=3). Hospital setting was the most common (n=109), whereas community (n=13) and long-term care (n=1) were much less common.

The majority of publications were from Europe (n=59), followed by North America (n=35), Oceania (n=15), Asia (n=8), Africa (n=5) and multiple regions (n=1). There was a substantial increase in publications over the period of study: pre-2010 (n=1); 2010–2019 (n=92); 2020–2021 (n=30).

Most publications assessed indication documentation for antimicrobial agents as a broad category (n=103), fewer studies evaluated the more specific category of individual classes of antimicrobial agents (eg, restricted, targeted or broader spectrum classes of antimicrobial agents) (n=19).

Publication objectives could be largely classified into one of four non-mutually exclusive categories: (1) measuring indication documentation including describing the prevalence and context of indication documentation (n=52) and assessing the accuracy and clarity of documented indication (n=14); (2) evaluating interventions to improve documentation prevalence and accuracy (n=33); (3) assessing the impact of indication documentation on clinical and utilisation outcomes (n=19) and (4) describing the barriers and enablers to indication documentation (n=10). Table 1 provides an overview of the types of strategies and studies used to evaluate antimicrobial indication documentation.

Table 1

Classifying the literature on antimicrobial indication documentation

Most studies evaluated the use of indication or reason for use; however, there were six studies that described the use of accountable justification (ie, where a rationale is required for potentially inappropriate prescribing such as antibiotics for upper respiratory tract infection),45 48 50 85 87 99 and two that used both indication and justification.98 119

Prevalence and context of indication documentation

Overall, 52 studies reported the prevalence of indication documentation.13–15 17 19 21 23 26–29 40 45–47 49 53 60 61 65 67 71 72 74 75 78 82 83 87 89 91 92 97 100–102 106 108 109 109 110 112 114 115 117 124–129 135 The median reported prevalence of indication documentation was 75%; however, there was a wide range across studies from 4% to 100% of antimicrobial orders with an indication documented, with an IQR of 51%–85%. This wide variation was seen in both community (median 60%, range 4%–86% prevalence, n=5 studies) and hospital settings (median 78%, range 10%–100%).

Of the 52 studies reporting prevalence of indication documentation, 19 (36%) of the studies evaluated indication documentation by reviewing the electronic and/or paper prescription. In 12 (23%) studies, indication documentation was examined elsewhere in the health record (eg, progress notes). Seventeen (33%) studies did not specify the location of the indication documentation, and four studies (8%) evaluated documentation either in the prescription or elsewhere in the health record. Indication documentation was reported to be more prevalent when looking at the health record (median 79%, range 10%–100%) compared with the prescription itself (median 63%, range 4%–95%), although a wide range was seen across studies. Thirteen studies used an electronic order entry system to capture indication.

Nine studies (17%) indicated there were local standards or policies describing the need for indication documentation.

Accuracy and quality of indication documentation

Accuracy of documentation

There were 14 studies that assessed the accuracy of antimicrobial indication documentation (ie, how well the indication matched the true diagnosis).25 38 57 64 70 77 80 81 83 103 111 116 122 130 All studies took place in a hospital setting and all but one used electronic order entry to capture indication. Out of 142 551 prescriptions with an indication documented, 48 905 were considered accurate when compared with the gold standard of diagnosis as per chart review (n=11), diagnostic code (n=1), either diagnostic code or chart review (n=1) or unspecified method (n=1). The median reported indication accuracy was 78% (IQR: 74%–82%, range: 25%–100%).

Clarity of documentation

Seven studies evaluated the clarity (ie, interpretability, sufficiency or specificity) of indication documentation. One study found that out of 62 prescriptions that had an indication, only 47% were adequate based on audit standards, and the remaining provided indications that were not assessable or had insufficient information.84 The use of structured documentation (ie, drop-down/fixed options) as opposed to free-text entry of indication also varied between studies. Studies reported a wide range of use of a free text field, 4.6%–70%.32 61 80 81 122 132 Authors noted that free-text was often used when an indication could not be categorised based on the drop-down options available, when there was an alternate term for an indication, or for the purposes of more in-depth description of a patient’s presentation.132

Evaluation of interventions to improve prevalence of indication documentation

There were 32 studies18 20 22 30 33–37 39 41–44 58 59 62 63 66 68 69 86 88 93 96 105 107 113 120 123 131 134 that assessed interventions to increase the prevalence of antimicrobial indication documentation and one study that evaluated an intervention to improve indication accuracy.24 Most studies were in the hospital setting (n=30, 94%). The most common intervention was a combination of multiple strategies (n=11), followed by audit and feedback (n=8), health information systems (n=3), educational meetings (n=2), educational materials (n=2), reminders (n=1), continuous quality improvement (n=1), clinical practice guidelines (n=1) and other strategies (n=4). Sites that used a combination approach evaluated multiple strategies to influence indication documentation, including but not limited to: educational sessions; peer comparison (providing individualised data in comparison to the prescriber’s peer group); audit and feedback; quality improvement (Plan Do Study Act cycles); electronic order entry and accountable justification (online supplemental table 2). Most studies (n=27, 84%) were associated with an improvement in the frequency of antibiotic indication documentation (median absolute increase in documentation: 25%, IQR: 18%–44%, range −16% to 84%).

Supplemental material

Evaluation of interventions to improve accuracy of indication documentation

One study aiming to improve indication accuracy was associated with a decrease in accuracy of indication selection after implementation of a drop-down menu for indication selection on an electronic order set.24 The authors indicated that prescribers intentionally selected inaccurate indications in order to bypass an approval process required for unapproved indications (a phenomenon the authors referred to as ‘gaming the system’).

Impact of indication documentation on patient and prescribing outcomes

Nineteen (19) studies evaluated the association between antimicrobial indication documentation and prescribing, utilisation and patient outcomes.32 50–52 55 56 63 73 76 79 85 90 94 99 104 119 121 129 133 Three studies were randomised controlled trials; the rest were observational studies. The three randomised controlled trials were part of the same research programme to evaluate accountable justification, along with other behaviourally informed interventions to reduce inappropriate antibiotic prescribing for respiratory infections in the community setting. The studies included a pilot cluster-RCT,99 a cluster-RCT85 and an assessment of sustainability 12 months after stopping the intervention.76 Fourteen studies (73.7%) were in the hospital setting, with the remaining in the community. Most studies evaluated the use of mandatory indications (n=7), prompted indications (eg, through the use of order sets, reminders, standards) (n=7) or accountable justification (n=5). Two studies evaluated the use of indication-based prescribing (where an indication is first selected, followed by an abbreviated list of medication choices based on the selected indication). These interventions were facilitated via changes to the electronic health record or prescribing process with or without other supportive interventions such as education (see online supplemental table 3).

Half of these studies (n=10) evaluated appropriateness of the actual antimicrobial prescribing (eg, guideline concordant antibiotic selection) and six studies evaluated antimicrobial utilisation outcomes (eg, prescribing rate or antibiotic days of therapy). Other outcomes that were assessed included prescribing error rate (n=1), economic outcome (ie, cost-effectiveness) (n=1), adherence to restriction criteria (n=1) and patient outcome (ie, clinical success) (n=1).

Of 19 studies, a benefit associated with indication documentation was identified in 17 studies, with 1 study reporting no change in antibiotic utilisation and 1 study reporting a decrease in appropriateness after stopping an accountable justification intervention. Benefits were reported for each strategy: mandatory indications, prompted indications and accountable justification, but heterogeneity in study design and outcomes measured precluded quantitative comparison. Across studies reporting appropriateness, the median increase in appropriateness reported was 19%, IQR: 13%–35%, range: 0.5%–56%) (see online supplemental table 3).

Barriers and facilitators to antimicrobial indication documentation

Ten studies evaluated the qualitative aspects of indication documentation through surveys (n=6), interviews (n=2) or an assessment by the authors evaluating the indication documentation process (n=2).24 25 31 35 54 61 86 89 95 118 Physicians were most commonly consulted (n=6), followed by other healthcare workers, such as microbiologists, physician assistants and nurse practitioners (n=3). Pharmacists were consulted in two studies and one study simply indicated healthcare workers were surveyed.

These studies largely focused on barriers and facilitators to documenting the indication on the antimicrobial prescription. Whereas seven papers focused on all antimicrobials, three looked at a restricted list of antimicrobials specific to the institution. The most common barriers associated with documenting indication included uncertainty in diagnosis, time, logistical challenges and alert fatigue. Facilitators included awareness of stewardship, reduced errors, improved communication, use of reminders/prompts and electronic health systems (table 2).

Table 2

Classifying the barriers and facilitators to indication documentation, using the COM-B model for behaviour change


This scoping review revealed a growing interest in evaluating and improving antimicrobial indication documentation; of the 123 publications that were included, 30 studies were recently published between 2020 and 2021. This recent interest in antimicrobial indication documentation may be related to the rising importance of antimicrobial stewardship along with more widespread implementation of CPOE. The literature describes a wide variation in practice of antimicrobial indication documentation, likely reflecting variability in prescribing and stewardship practices across facilities, healthcare settings and regions.

The literature also described a variety of interventions to improve indication documentation with most studies using multipronged strategies; these strategies were generally associated an overall improvement in documentation prevalence. In addition, almost all studies that evaluated the impact of indication documentation on outcomes found a benefit with respect to patient, utilisation or prescribing outcomes including appropriateness.

To advance our understanding of how strategies to improve antibiotic indication documentation can be more effectively integrated into clinical practice, we mapped barriers and facilitators identified in the literature using the COM-B Model for Behaviour Change. For example, overcoming barriers such as lack of time and logistical challenges that are associated with opportunity may require incentives, rewards and environmental restructuring (eg, electronic order entry, drop down menu). Alert fatigue may reduce prescribers’ capability and motivation to provide an indication. Thus, strategies to reduce alert fatigue by minimising interruptions and increasing the ease of indication documentation, may help facilitate this desired behaviour.136

The results of this scoping review are consistent with findings in studies that evaluated medications in general which have shown that documenting indication results in similar improvements in prescribing outcomes.137–139 Similar barriers have also been identified: alert fatigue and prescribers overriding mandatory fields;140 time pressure141 and ambiguity in medication indications.142 An additional barrier is prescribers being hesitant to document indications due to concerns of patient privacy.141 143 For example, prescribers felt that documenting the indication on the prescription could increase patient anxiety or contribute to patients not accessing care (eg, for sexually transmitted infections), which could also be relevant to antibiotic prescriptions depending on the indication. This privacy concern was echoed by some patient participants as well.141 As such, there may be a few exceptions where indication is not documented due to the sensitive nature of the diagnosis.

There is evidence that diagnoses can be strategically altered to improve perceived performance (eg, using a diagnosis of respiratory failure instead of pneumonia to increase hospital reimbursement).144 This potential unintended consequence, termed ‘gaming’ may require further evaluation in the context of providing an indication for antimicrobial prescribing, especially when appropriateness is being monitored.

Despite these barriers, there is a general theme across all publications that indication documentation associated with prescribing is a best practice with numerous benefits to the quality of patient care1 9 which has been echoed by a recent scoping review evaluating the inclusion of the reason for use when sending prescriptions to pharmacists.145 Our findings help substantiate current recommendations and best practice statements from a number of jurisdictions and organisations that relate to documentation of indication for antimicrobial prescriptions.2 4 146 These entities frequently position this practice as a patient safety and/or antimicrobial stewardship strategy by highlighting the benefits of antimicrobial indication for assessment (facilitates patient-level evaluation of antibiotic use, eg, for prospective audit and feedback),2 3 147 continuity of care (facilitates communication about reason for use across providers and healthcare settings),3 147–149 surveillance (facilitates population-level evaluation of antibiotic use, eg, to explain antimicrobial use metrics),2 146 safety check (indication provides a second check, especially for sound-alike and look-alike drugs)150 151 and accountability (increases social accountability for prescribing by sharing indication with all team members).3

While our scoping review included a large number of studies from both peer-reviewed and grey literature from different settings and regions, an important limitation is the generalisability of the studies to real world practice. For example, our estimate of a median of 75% prevalence of documentation may be attributed to publication bias and/or institutions having a greater interest in antimicrobial stewardship and/or ability to facilitate indication documentation, thus evaluating this practice. We did not perform a quality appraisal, and given that all but three studies were observational in nature, there is a high risk of bias. A further limitation is that a large number of studies did not specify where the indication was being documented; this is an important consideration as search through the patient records or medical charts to find the indication can be onerous and a barrier to antimicrobial stewardship efforts. Therefore, future initiatives should include further evaluation of local context (eg, policies and expectations related to indication documentation, electronic order entry) and accessibility of indication information for all members of the healthcare team. We provide a practical visual summary of our findings and opportunities for future research in online supplemental figure 1).

Given the high degree of heterogeneity across studies, a meta-analysis pooling the results to estimate the overall impact of indication prescribing on prescribing and patient outcomes was not performed. Future high quality research is required to further understand the impact of this strategy on appropriateness in all healthcare settings. Additionally, there is a need for a larger number of randomised controlled trials and studies looking at additional outcomes such as patient experience, effectiveness of care and hospitalisations.


There is growing interest in the importance of documenting an indication when prescribing an antimicrobial agent. The frequency, accuracy and clarity of antimicrobial indication documentation is variable within and between different healthcare settings. Several studies have shown that multipronged approaches can be used to improve this practice, but there are key barriers including time pressures, alert fatigue and logistics associated with implementation. Emerging evidence demonstrates that antimicrobial indication documentation may be associated with improved prescribing and patient outcomes, but larger setting-specific prospective trials are needed to provide a more robust evidence base for this practice.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


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  • Contributors SS, VL and BJL contributed to conceptualisation of the project. All authors contributed to methodology. SS, VL, ES and BJL contributed to data curation. BL performed the formal analysis. SS and BJL wrote the original draft. All authors contributed to review and editing of manuscript. BJL is the guarantor of this study.

  • Funding This scoping review was carried out as part of the authors’ routine work.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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