151
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Affiliation(s)
- Carl Llor
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University
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Brookes-Howell L, Wood F, Verheij T, Prout H, Cooper L, Hood K, Melbye H, Torres A, Godycki-Cwirko M, Fernandez-Vandellos P, Ystgaard MF, Falk Taksdal T, Krawczyk J, Butler CC. Trust, openness and continuity of care influence acceptance of antibiotics for children with respiratory tract infections: a four country qualitative study. Fam Pract 2014; 31:102-10. [PMID: 24165374 DOI: 10.1093/fampra/cmt052] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinician-parent interaction and health system influences on parental acceptance of prescribing decisions for children with respiratory tract infections (RTIs) may be important determinants of antibiotic use. OBJECTIVE To achieve a deeper understanding of parents' acceptance, or otherwise, of clinicians' antibiotic prescribing decisions for children with RTIs. METHODS Qualitative interviews with parents of child patients who had recently consulted in primary care with a RTI in four European countries, with a five-stage analytic framework approach (familiarization, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation). RESULTS Fifty of 63 parents accepted clinicians' management decisions, irrespective of antibiotic prescription. There were no notable differences between networks. Parents ascribed their acceptance to a trusting and open clinician-patient relationship, enhanced through continuity of care, in which parents felt able to express their views. There was a lack of congruence about antibiotics between parents and clinicians in 13 instances, mostly when parents disagreed about clinicians' decision to prescribe (10 accounts) rather than objecting to withholding antibiotics (three accounts). All but one parent adhered to the prescribing decision, although some modified how the antibiotic was administered. CONCLUSIONS Parents from contrasting countries indicated that continuity of care, open communication in consultations and clinician-patient trust was important in acceptance of management of RTI in their children and in motivating adherence. Interventions to promote appropriate antibiotic use in children should consider a focus on eliciting parents' perspectives and promoting and building on continuity of care within a trusting clinician-patient relationship.
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Affiliation(s)
- Lucy Brookes-Howell
- South East Wales Trials Unit, Institute for Translation, Innovation, Methodology and Engagement and
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153
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Abstract
PURPOSE Communication experts have suggested that it is good practice to ask patients' directly whether they expect to receive antibiotics as part of asking about the triad of ideas, concerns, and expectations for health care. Our aim was to explore the views and experiences of family physicians about using this strategy with their patients, focusing the interview on the problem of eliciting expectations of antibiotics as a possible treatment for upper respiratory tract infections. METHODS We conducted a qualitative study using semistructured interviews with 20 family physicians in South Wales, United Kingdom, and performing thematic analysis. RESULTS Family physicians assumed most patients or parents wanted antibiotics, as well as wanting to be "checked out" to make sure the illness was "nothing serious." Physicians said they did not ask direct questions about expectations, as that might lead to confrontation. They preferred to elicit expectations for antibiotics in an indirect manner, before performing a physical examination. The majority described reporting their findings of the examination as a "running commentary" so as to influence expectations and help avoid generating resistance to a soon-to-be-made-explicit plan not to prescribe antibiotics. The physicians used the running commentary to preserve and enhance the physician-patient relationship. CONCLUSIONS Real-world family physicians use indirect methods to explore expectations for treatment and, on the basis of their physical examination, build an argument for reassuring the patient or parent. In contrast to proposed models in the communication literature, interventions to promote appropriate antibiotic prescribing might include a focus on training in communication skills that (1) integrates these indirect methods as part of building collaborative physician-patient relationships and (2) uses the running commentary of examination findings to facilitate participation in clinical decisions.
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Affiliation(s)
- Mohammed Mustafa
- Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Cardiff, United Kingdom
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154
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Francis NA, Phillips R, Wood F, Hood K, Simpson S, Butler CC. Parents' and clinicians' views of an interactive booklet about respiratory tract infections in children: a qualitative process evaluation of the EQUIP randomised controlled trial. BMC Fam Pract 2013; 14:182. [PMID: 24289324 PMCID: PMC4219394 DOI: 10.1186/1471-2296-14-182] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/21/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND 'When should I worry?' is an interactive booklet for parents of children presenting with respiratory tract infections (RTIs) in primary care and associated training for clinicians. A randomised controlled trial (the EQUIP study) demonstrated that this intervention reduced antibiotic prescribing and future consulting intentions. The aims of this qualitative process evaluation were to understand how acceptable the intervention was to clinicians and parents, how it was implemented, the mechanisms for any observed effects, and contextual factors that could have influenced its effects. METHODS Semi-structured interviews were conducted with 20 parents and 13 clinicians who participated in the trial. Interviews were audio-recorded and transcribed verbatim. Data were analysed using a framework approach, which involved five stages; familiarisation, development of a thematic framework, indexing, charting, and interpretation. RESULTS Most parents and clinicians reported that the 'When should I worry' interactive booklet (and online training for clinicians) was easy to use and valuable. Information on recognising signs of serious illness and the usual duration of illness were most valued. The interactive use of the booklet during consultations was considered to be important, but this did not always happen. Clinicians reported lack of time, lack of familiarity with using the booklet, and difficulty in modifying their treatment plan/style of consultation as barriers to use. Increased knowledge and confidence amongst clinicians and patients were seen as key components that contributed to the reductions in antibiotic prescribing and intention to consult seen in the trial. This was particularly pertinent in a context where decisions about the safe and appropriate management of childhood RTIs were viewed as complex and parents reported frequently receiving inconsistent messages. CONCLUSIONS The 'When should I worry' booklet, which is effective in reducing antibiotic prescribing, has high acceptability for clinicians and parents, helps address gaps in knowledge, increases confidence, and provides a consistent message. However, it is not always implemented as intended. Plans for wider implementation of the intervention in health care settings would need to address clinician-related barriers to implementation. TRIAL REGISTRATION ISRCTN46104365.
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Affiliation(s)
- Nick A Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK.
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155
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Waldron CA, Thomas-Jones E, Pickles T, Hood K, Harman K, Downing H, Martinson K, Peters M, Hay AD, Butler CC. Recruitment to diagnosis of urinary tract infections in young children (DUTY) study: an evaluation of the successful methods used in a primary care, prospective cohort study. Trials 2013. [PMCID: PMC3981687 DOI: 10.1186/1745-6215-14-s1-p37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Coenen S, Francis N, Kelly M, Hood K, Nuttall J, Little P, Verheij TJM, Melbye H, Goossens H, Butler CC. Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients with acute cough. PLoS One 2013; 8:e76691. [PMID: 24194845 PMCID: PMC3806785 DOI: 10.1371/journal.pone.0076691] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/23/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Outpatients with acute cough who expect, hope for or ask for antibiotics may be more unwell, benefit more from antibiotic treatment, and be more satisfied with care when they are prescribed antibiotics. Clinicians may not accurately identify those patients. OBJECTIVE To explore whether patient views (expecting, hoping for or asking for antibiotics) are associated with illness presentation and resolution, whether patient views are accurately perceived by clinicians, and the association of all these factors with antibiotic prescribing and patient satisfaction with care. METHODS Prospective observational study of 3402 adult patients with acute cough presenting in 14 primary care networks. Correlations and associations tested with multilevel logistic regression and McNemar 's tests, and Cohen's Kappa, positive agreement (PA) and negative agreement (NA) calculated as appropriate. RESULTS 1,213 (45.1%) patients expected, 1,093 (40.6%) hoped for, and 275 (10.2%) asked for antibiotics. Clinicians perceived 840 (31.3%) as wanting to be prescribed antibiotics (McNemar's test, p<0.05). Their perception agreed modestly with the three patient views (Kappa's = 0.29, 0.32 and 0.21, PA's = 0.56, 0.56 and 0.33, NA's = 0.72, 0.75 and 0.82, respectively). 1,464 (54.4%) patients were prescribed antibiotics. Illness presentation and resolution were similar for patients regardless their views. These associations were not modified by antibiotic treatment. Patient expectation and hope (OR:2.08, 95% CI:[1.48,2.93] and 2.48 [1.73,3.55], respectively), and clinician perception (12.18 [8.31,17.84]) were associated with antibiotic prescribing. 2,354 (92.6%) patients were satisfied. Only those hoping for antibiotics were less satisfied when antibiotics were not prescribed (0.39 [0.17,0.90]). CONCLUSION Patient views about antibiotic treatment were not useful for identifying those who will benefit from antibiotics. Clinician perceptions did not match with patient views, but particularly influenced antibiotic prescribing. Patients were generally satisfied with care, but those hoping for but not prescribed antibiotics were less satisfied. Clinicians need to more effectively elicit and address patient views about antibiotics.
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Affiliation(s)
- Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Primary and Interdisciplinary Care Antwerp, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Nick Francis
- Cochrane Institutes of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Mark Kelly
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Jacqui Nuttall
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Paul Little
- Primary Care Medical Group, University of Southampton Medical School, Southampton, United Kingdom
| | - Theo J. M. Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Hasse Melbye
- General Practice Research Unit, Institute of Community Medicine, University of Tromso, Tromso, Norway
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Christopher C. Butler
- Cochrane Institutes of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
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157
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Cals JWL, van Leeuwen ME, Chappin FHF, de Bont EGPM, Dinant GJ, Butler CC. "How Do You Feel about Antibiotics for This?" A Qualitative Study of Physician Attitudes towards a Context-Rich Communication Skills Method. Antibiotics (Basel) 2013; 2:439-49. [PMID: 27029312 PMCID: PMC4790273 DOI: 10.3390/antibiotics2030439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 11/25/2022] Open
Abstract
To explore experiences with and views of general practitioners (GPs) on a physician communication training method in primary care and its applicability and implementation in daily practice, we performed a semi-structured qualitative study of GPs’ experience of training in and implementing a communication skills training program for managing lower respiratory tract infection (LRTI) which included a seminar, simulated patient consultation together with providing and receiving feedback on ones own transcript, and a seminar in a structured approach to the LRTI consultation. Seventeen out of 20 eligible GPs who had participated in the IMPAC3T trial and were allocated to receiving enhanced physician communication training for managing lower respiratory tract infection participated. GPs’ experiences with the physician communication training method and its specific components were positive. The method gave GPs additional tools for managing LRTI consultations and increased their sense of providing evidence-based management. During the study, GPs reported using almost all communication items covered in the training, but some GPs stated that the communication skills diluted over time, and that they continued to use a selected set of the skills. The general communication items were most regularly used. Implementation of the method in daily practice helped GPs to prescribe fewer antibiotics in LRTI with the only perceived disadvantage being time-pressure. This study suggests that GPs felt positive about the physician communication training method for enhanced management of LRTI in primary care. GPs continued to use some of the communication items, of which general communication items were the most common. Furthermore, GPs believed that implementation of the communication skills in daily practice helped them to prescribe fewer antibiotics. The context-rich communication method could have wider application in common conditions in primary care.
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Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Mirjam E van Leeuwen
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Fleur H F Chappin
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Eefje G P M de Bont
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Geert-Jan Dinant
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK.
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158
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Mills TC, Rautanen A, Elliott KS, Parks T, Naranbhai V, Ieven MM, Butler CC, Little P, Verheij T, Garrard CS, Hinds C, Goossens H, Chapman S, Hill AVS. IFITM3 and susceptibility to respiratory viral infections in the community. J Infect Dis 2013; 209:1028-31. [PMID: 23997235 PMCID: PMC3952664 DOI: 10.1093/infdis/jit468] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Interferon-inducible transmembrane proteins 1, 2, and 3 (IFITM 1,2, and 3) are viral restriction factors that mediate cellular resistance to several viruses. We have genotyped a possible splice-site altering single-nucleotide polymorphism (rs12252) in the IFITM3 gene in 34 patients with H1N1 influenza and severe pneumonia, and >5000 individuals comprising patients with community-acquired mild lower respiratory tract infection and matched controls of Caucasian ancestry. We found evidence of an association between rs12252 rare allele homozygotes and susceptibility to mild influenza (in patients attending primary care) but could not confirm a previously reported association between this single-nucleotide polymorphism and susceptibility to severe H1N1 infection.
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Affiliation(s)
- Tara C Mills
- Wellcome Trust Centre for Human Genetics, University of Oxford, and
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159
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Wood F, Prout H, Bayer A, Duncan D, Nuttall J, Hood K, Butler CC. Consent, including advanced consent, of older adults to research in care homes: a qualitative study of stakeholders' views in South Wales. Trials 2013; 14:247. [PMID: 23937972 PMCID: PMC3750808 DOI: 10.1186/1745-6215-14-247] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 07/24/2013] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Care home residents, especially those lacking capacity to provide consent for themselves, are frequently excluded from research, thus limiting generalisability of study findings. We set out to explore stakeholders' views about the ethical and practical challenges associated with recruiting care home residents into research studies. METHODS Qualitative individual interviews with care home residents (n = 14), their relatives (n = 14), and general practitioners (GPs) (n = 10), and focus groups (n = 2) with care home staff. Interviews focused on the issues of older adults consenting to research in care homes, including advanced consent, in general and through reference to a particular study on the use of probiotics to prevent Antibiotic Associated Diarrhoea. Data were analysed using a thematic approach incorporating themes that had been identified in advance, and themes derived from the data. Researchers discussed evidence for themes, and reached consensus on the final themes. RESULTS Respondents were generally accepting of low risk observational studies and slightly less accepting of low risk randomised trials of medicinal products. Although respondents identified some practical barriers to informed consent, consenting arrangements were considered workable. Residents and relatives varied in the amount of detail they wanted included in information sheets and consent discussions, but were generally satisfied that an advanced consent model was acceptable and appropriate. Opinions differed about what should happen should residents lose capacity during a research study. CONCLUSIONS Research staff should be mindful of research guidance and ensure that they have obtained an appropriate level of informed consent without overwhelming the participant with unnecessary detail. For research involving medicinal products, research staff should also be more explicit when recruiting that consent is still valid should an older person lose capacity during a trial provided the individual did not previously state a wish to be withdrawn if they lose capacity, and provided they do not indicate objection or resistance after loss of capacity.
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Affiliation(s)
- Fiona Wood
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4XNWales, UK
| | - Hayley Prout
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4XNWales, UK
| | - Antony Bayer
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4XNWales, UK
| | - Donna Duncan
- South East Wales Trials Unit, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff, CF14 4XNWales, UK
| | - Jacqueline Nuttall
- South East Wales Trials Unit, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff, CF14 4XNWales, UK
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff, CF14 4XNWales, UK
| | - Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4XNWales, UK
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160
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Crocker JC, Evans MR, Powell CVE, Hood K, Butler CC. Why some children hospitalized for pneumonia do not consult with a general practitioner before the day of hospitalization. Eur J Gen Pract 2013; 19:213-20. [PMID: 23815375 DOI: 10.3109/13814788.2013.795538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Early consultation in primary care may provide an opportunity for early intervention in children developing pneumonia, but little is known about why some children do not consult a general practitioner (GP) before hospitalization. OBJECTIVES To identify differences between children who consulted a GP and children who did not consult a GP before the day of hospital presentation with pneumonia or empyema. METHODS Carers of children aged six months to 16 years presenting to hospital with pneumonia or empyema completed a questionnaire, with a subset participating in an interview to identify physical, organizational and psychological barriers to consultation. Responses from those who had consulted a GP before the day of hospital presentation were compared with those who had not on a range of medical, social and environmental variables. RESULTS Fifty seven (38%) of 151 participants had not consulted a GP before the day of hospital presentation. On multivariate analysis, illness duration ≥ 3 days (odds ratio [OR] 4.36, 95% confidence interval [CI]: 1.67-11.39), prior antibiotic use (OR: 10.35, 95% CI: 2.16-49.55) and home ownership (OR: 3.17, 95% CI: 1.07-9.37) were significantly associated with early GP consultation (P < 0.05). Interviews with 28 carers whose children had not seen a GP before the day of presentation revealed that most had not considered it and/or did not think their child's initial symptoms were serious or unusual; 11 (39.3%) had considered consulting a GP but reported barriers to access. CONCLUSION Lack of early GP consultation was strongly associated with rapid evolution of pneumonia.
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Affiliation(s)
- Joanna C Crocker
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University , Cardiff , UK
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161
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Crocker JC, Powell CV, Hood K, Butler CC, Evans MR. Previous general practitioner consulting behaviour as a predictor of pneumonia in children. Eur Respir J 2013; 41:1233-4. [DOI: 10.1183/09031936.00145712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Francis NA, Melbye H, Kelly MJ, Cals JWL, Hopstaken RM, Coenen S, Butler CC. Variation in family physicians' recording of auscultation abnormalities in patients with acute cough is not explained by case mix. A study from 12 European networks. Eur J Gen Pract 2013; 19:77-84. [PMID: 23544624 DOI: 10.3109/13814788.2012.733690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology. OBJECTIVES To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms. METHODS Clinicians recorded whether 'diminished vesicular breathing', 'wheezes', 'crackles' and 'rhonchi' were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients' gender, age, comorbidities, smoking status and symptoms. RESULTS 2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3-30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi. CONCLUSION There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.
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Affiliation(s)
- Nick A Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK.
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163
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Butler CC, Simpson SA, Hood K, Cohen D, Pickles T, Spanou C, McCambridge J, Moore L, Randell E, Alam MF, Kinnersley P, Edwards A, Smith C, Rollnick S. Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial. BMJ 2013; 346:f1191. [PMID: 23512758 PMCID: PMC3601942 DOI: 10.1136/bmj.f1191] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the effect of training primary care health professionals in behaviour change counselling on the proportion of patients self reporting change in four risk behaviours (smoking, alcohol use, exercise, and healthy eating). DESIGN Cluster randomised trial with general practices as the unit of randomisation. SETTING General practices in Wales. PARTICIPANTS 53 general practitioners and practice nurses from 27 general practices (one each at all but one practice) recruited 1827 patients who screened positive for at least one risky behaviour. INTERVENTION Behaviour change counselling was developed from motivational interviewing to enable clinicians to enhance patients' motivation to change health related behaviour. Clinicians were trained using a blended learning programme called Talking Lifestyles. MAIN OUTCOME MEASURES Proportion of patients who reported making beneficial changes in at least one of the four risky behaviours at three months. RESULTS 1308 patients from 13 intervention and 1496 from 14 control practices were approached: 76% and 72% respectively agreed to participate, with 831 (84%) and 996 (92%) respectively screening eligible for an intervention. There was no effect on the primary outcome (beneficial change in behaviour) at three months (362 (44%) v 404 (41%), odds ratio 1.12 (95% CI 0.90 to 1.39)) or on biochemical or biometric measures at 12 months. More patients who had consulted with trained clinicians recalled consultation discussion about a health behaviour (724/795 (91%) v 531/966 (55%), odds ratio 12.44 (5.85 to 26.46)) and intended to change (599/831 (72%) v 491/996 (49%), odds ratio 2.88 (2.05 to 4.05)). More intervention practice patients reported making an attempt to change (328 (39%) v 317 (32%), odds ratio 1.40 (1.15 to 1.70)), a sustained behaviour change at three months (288 (35%) v 280 (28%), odds ratio 1.36 (1.11 to 1.65)), and reported slightly greater improvements in healthy eating at three and 12 months, plus improved activity at 12 months. Training cost £1597 per practice. DISCUSSION Training primary care clinicians in behaviour change counselling using a brief blended learning programme did not increase patients reported beneficial behaviour change at three months or improve biometric and a biochemical measure at 12 months, but it did increase patients' recollection of discussing behaviour change with their clinicians, intentions to change, attempts to change, and perceptions of having made a lasting change at three months. Enduring behaviour change and improvements in biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling without additional intervention. TRIAL REGISTRATION ISRCTN 22495456.
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Affiliation(s)
- Christopher C Butler
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK.
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Cals JWL, de Bock L, Beckers PJHW, Francis NA, Hopstaken RM, Hood K, de Bont EGPM, Butler CC, Dinant GJ. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med 2013; 11:157-64. [PMID: 23508603 PMCID: PMC3601394 DOI: 10.1370/afm.1477] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of the study was to assess the long-term effect of family physicians' use of C-reactive protein (CRP) point-of-care testing and/or physician training in enhanced communication skills on office visit rates and antibiotic prescriptions for patients with respiratory tract infections. METHODS We conducted a 3.5-year follow-up of a pragmatic, factorial, cluster-randomized controlled trial; 379 patients (20 family practices in the Netherlands) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available (88% of original trial cohort). Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year (PPPY), and the percentage of the episodes for which patients were treated with antibiotics during follow-up. RESULTS The mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group (P = .12). In the communication skills training group, there was a mean of 0.36 PPPY episodes of respiratory tract infections, and in the no training group the mean was 0.57 PPPY (P = .09). During follow-up 30.7% of all episodes of respiratory tract infection were treated with antibiotics in the CRP test group compared with 35.7% in the no test group (P = .36). Family physicians trained in communication skills treated 26.3% of all episodes of respiratory tract infection with antibiotics compared with 39.1% treated by family physicians without training in communication skills (P = .02) CONCLUSIONS Family physicians' use of CRP point-of-care testing and/or training in enhanced communication skills did not significantly affect office visit rates related to respiratory tract infections. Patients who saw a family physician trained in enhanced communication skills were prescribed significantly fewer antibiotics during episodes of respiratory tract infection in the subsequent 3.5 years.
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Affiliation(s)
- Jochen W L Cals
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, The Netherlands.
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Little P, Stuart B, Moore M, Coenen S, Butler CC, Godycki-Cwirko M, Mierzecki A, Chlabicz S, Torres A, Almirall J, Davies M, Schaberg T, Mölstad S, Blasi F, De Sutter A, Kersnik J, Hupkova H, Touboul P, Hood K, Mullee M, O'Reilly G, Brugman C, Goossens H, Verheij T. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis 2012; 13:123-9. [PMID: 23265995 DOI: 10.1016/s1473-3099(12)70300-6] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lower-respiratory-tract infection is one of the most common acute illnesses managed in primary care. Few placebo-controlled studies of antibiotics have been done, and overall effectiveness (particularly in subgroups such as older people) is debated. We aimed to compare the benefits and harms of amoxicillin for acute lower-respiratory-tract infection with those of placebo both overall and in patients aged 60 years or older. METHODS Patients older than 18 years with acute lower-respiratory-tract infections (cough of ≤28 days' duration) in whom pneumonia was not suspected were randomly assigned (1:1) to either amoxicillin (1 g three times daily for 7 days) or placebo by computer-generated random numbers. Our primary outcome was duration of symptoms rated "moderately bad" or worse. Secondary outcomes were symptom severity in days 2-4 and new or worsening symptoms. Investigators and patients were masked to treatment allocation. This trial is registered with EudraCT (2007-001586-15), UKCRN Portfolio (ID 4175), ISRCTN (52261229), and FWO (G.0274.08N). FINDINGS 1038 patients were assigned to the amoxicillin group and 1023 to the placebo group. Neither duration of symptoms rated "moderately bad" or worse (hazard ratio 1.06, 95% CI 0.96-1.18; p=0.229) nor mean symptom severity (1.69 with placebo vs 1.62 with amoxicillin; difference -0.07 [95% CI -0.15 to 0.007]; p=0.074) differed significantly between groups. New or worsening symptoms were significantly less common in the amoxicillin group than in the placebo group (162 [15.9%] of 1021 patients vs 194 [19.3%] of 1006; p=0.043; number needed to treat 30). Cases of nausea, rash, or diarrhoea were significantly more common in the amoxicillin group than in the placebo group (number needed to harm 21, 95% CI 11-174; p=0.025), and one case of anaphylaxis was noted with amoxicillin. Two patients in the placebo group and one in the amoxicillin group needed to be admitted to hospital; no study-related deaths were noted. We noted no evidence of selective benefit in patients aged 60 years or older (n=595). INTERPRETATION When pneumonia is not suspected clinically, amoxicillin provides little benefit for acute lower-respiratory-tract infection in primary care both overall and in patients aged 60 years or more, and causes slight harms. FUNDING European Commission Framework Programme 6, UK National Institute for Health Research, Barcelona Ciberde Enfermedades Respiratorias, and Research Foundation Flanders.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK.
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Wood F, Phillips C, Brookes-Howell L, Hood K, Verheij T, Coenen S, Little P, Melbye H, Godycki-Cwirko M, Jakobsen K, Worby P, Goossens H, Butler CC. Primary care clinicians' perceptions of antibiotic resistance: a multi-country qualitative interview study. J Antimicrob Chemother 2012; 68:237-43. [PMID: 22949622 DOI: 10.1093/jac/dks338] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To explore and compare primary care clinicians' perceptions of antibiotic resistance in relation to the management of community-acquired lower respiratory tract infection (LRTI) in contrasting European settings. METHODS Qualitative interview study with 80 primary care clinicians in nine European countries. Data were subjected to a five-stage analytical framework approach (familiarization; developing a thematic framework from the interview questions and the themes emerging from the data; indexing; charting; and mapping to search for interpretations in the data). Preliminary analysis reports were sent to all network facilitators for validation. RESULTS Most clinicians stated that antibiotic resistance was not a problem in their practice. Some recommended enhanced feedback about local resistance rates. Northern European respondents generally favoured using the narrowest-spectrum agent, motivated by containing resistance, whereas southern/eastern European respondents were more motivated by maximizing the potential of a rapid treatment effect and so justified empirical use of broad-spectrum antibiotics. Antibiotic treatment failure was ascribed largely to viral aetiology rather than resistant bacteria. Clinicians generally agreed that resistance will become more serious without enhanced antibiotic stewardship or new drug discovery. CONCLUSIONS If current rates of antibiotic resistance are likely to result in important treatment failures, then provision of local resistance data is likely to enhance clinicians' sense of importance of the issue. Interventions to enhance the quality of antibiotic prescribing in primary care should address perceptions, particularly in the south and east of Europe, that possible advantages to patients from antibiotic treatment in general, and from newer broad-spectrum compared with narrow-spectrum agents, outweigh disadvantages to patients and society from associated effects on antibiotic resistance.
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Affiliation(s)
- Fiona Wood
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UK.
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Brookes-Howell L, Elwyn G, Hood K, Wood F, Cooper L, Goossens H, Ieven M, Butler CC. 'The body gets used to them': patients' interpretations of antibiotic resistance and the implications for containment strategies. J Gen Intern Med 2012; 27:766-72. [PMID: 22065334 PMCID: PMC3378752 DOI: 10.1007/s11606-011-1916-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 04/25/2011] [Accepted: 09/26/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Interventions promoting evidence based antibiotic prescribing and use frequently build on the concept of antibiotic resistance but patients and clinicians may not share the same assumptions about its meaning. OBJECTIVE To explore patients' interpretations of 'antibiotic resistance' and to consider the implications for strategies to contain antibiotic resistance. DESIGN Multi country qualitative interview study. PARTICIPANTS One hundred and twenty-one adult patients from primary care research networks based in nine European countries who had recently consulted a primary care clinician with symptoms of Lower Respiratory Tract Infection (LRTI). APPROACH Semi-structured interviews with patients following their consultation and subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports. RESULTS The dominant theme was antibiotic resistance as a property of a 'resistant human body', where the barrier to antibiotic effectiveness was individual loss of responsiveness. Less commonly, patients correctly conceptualized antibiotic resistance as a property of bacteria. Nevertheless, the over-use of antibiotics was a strong central concept in almost all patients' explanations, whether they viewed resistance as located in either the body or in bacteria. CONCLUSIONS Most patients were aware of the link between antibiotic use and antibiotic resistance. The identification of the misinterpretation of antibiotic resistance as a property of the human body rather than bacterial cells could inform clearer clinician-patient discussions and public health interventions through emphasising the transferability of resistance, and the societal contribution individuals can make through more appropriate antibiotic prescribing and use.
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Affiliation(s)
- Lucy Brookes-Howell
- South East Wales Trials Unit, Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, Wales, UK.
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Francis NA, Cals JW, Butler CC, Hood K, Verheij T, Little P, Goossens H, Coenen S. Severity assessment for lower respiratory tract infections: potential use and validity of the CRB-65 in primary care. Prim Care Respir J 2012; 21:65-70. [PMID: 21938349 DOI: 10.4104/pcrj.2011.00083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To explore the potential use of the CRB-65 rule (based on Confusion, Respiratory rate, Blood pressure and age >65 years) in adults with lower respiratory tract infection (LRTI) in primary care. METHODS Primary care clinicians in 13 European countries recorded antibiotic treatment and clinical features for adults with LRTI. Patients recorded daily symptoms. Multilevel regression models determined the association between an elevated CRB-65 score and prolonged moderately severe symptoms, hospitalisation, and time to recovery. Sensitivity analyses used zero imputation. RESULTS Respiratory rate and blood pressure were recorded in 22.7% and 31.9% of patients, respectively. A total of 2,690 patients completed symptom diaries. The CRB-65 could be calculated for 339 (12.6%). A score of >1 was not significantly associated with prolonged moderately severe symptoms (odds ratio (OR) 0.42, 95% CI 0.04 to 4.19) or hospitalisations (OR 3.12, 95% CI 0.16 to 60.24), but was associated with prolonged time to self-reported recovery when using zero imputation (hazard ratio (HR) 0.75, 95% CI 0.64 to 0.88). CONCLUSIONS Respiratory rate and blood pressure are infrequently measured in adults with LRTI. We found no evidence to support using the CRB-65 rule in the assessment of LRTI in primary care. However, it is unclear whether it is of value if used only in patients where the primary care clinician suspects pneumonia.
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Affiliation(s)
- Nick A Francis
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK.
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Francis NA, Gillespie D, Nuttall J, Hood K, Little P, Verheij T, Coenen S, Cals JW, Goossens H, Butler CC. Antibiotics for acute cough: an international observational study of patient adherence in primary care. Br J Gen Pract 2012; 62:e429-37. [PMID: 22687236 PMCID: PMC3361123 DOI: 10.3399/bjgp12x649124] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 11/09/2011] [Accepted: 01/09/2012] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Non-adherence to acute antibiotic prescriptions is poorly described and may impact on clinical outcomes, healthcare costs, and interpretation of research. It also results in leftover antibiotics that could be used inappropriately. AIM To describe adherence to antibiotics prescribed for adults presenting with acute cough in primary care, factors associated with non-adherence, and associated recovery. DESIGN AND SETTING Prospective observational cohort study in general practices in 14 European primary care networks. METHOD GPs recorded patient characteristics and prescribing decisions for adults with acute cough or clinical presentation suggestive of lower respiratory tract infection. Patients recorded antibiotic consumption and daily symptoms over 28 days. Rates of adherence to prescribed antibiotics were assessed, and factors associated with non-adherence were identified using logistic regression. Recovery was compared using a Cox proportional hazards model. RESULTS Of 2520 patients prescribed immediate or no antibiotics at the index consultation, 282 (11.2%) took an antibiotic during the follow-up period that was not prescribed for them at the index consultation. Of these, 38.1% had no reconsultations during this period. Prior duration of symptoms, antibiotic treatment duration, antibiotic choice, and primary care network were all associated with adherence. There was no difference in time to recovery between those who were prescribed antibiotics at the index consultation and were fully adherent, partially adherent, and non-adherent. CONCLUSION Non-adherence to antibiotics for acute cough or lower respiratory tract infection is common. Duration of treatment, choice of antibiotic, and setting were associated with adherence but adherence to treatment was not associated with differences in recovery.
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Affiliation(s)
- Nick A Francis
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK.
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Brookes-Howell L, Hood K, Cooper L, Coenen S, Little P, Verheij T, Godycki-Cwirko M, Melbye H, Krawczyk J, Borras-Santos A, Jakobsen K, Worby P, Goossens H, Butler CC. Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care. BMJ Open 2012; 2:e000795. [PMID: 22619265 PMCID: PMC3364454 DOI: 10.1136/bmjopen-2011-000795] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/16/2012] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement. DESIGN Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports. SETTING Primary care. PARTICIPANTS 80 primary care clinicians randomly selected from primary care research networks based in nine European cities. RESULTS Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines. CONCLUSIONS Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.
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Affiliation(s)
| | - Kerenza Hood
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
| | - Lucy Cooper
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Samuel Coenen
- Centre for General Practice, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Community Clinical Sciences Division, University of Southampton, Southampton, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Łódź, Łódź, Poland
| | - Hasse Melbye
- Institute of Community Medicine, University of Tromsø, Tromsø, Norway
| | - Jaroslaw Krawczyk
- Department of Family and Community Medicine, Medical University of Łódź, Łódź, Poland
| | | | - Kristin Jakobsen
- Institute of Community Medicine, University of Tromsø, Tromsø, Norway
| | - Patricia Worby
- Research and Innovation Services, University of Southampton, Southampton, UK
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
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Robling M, McNamara R, Bennert K, Butler CC, Channon S, Cohen D, Crowne E, Hambly H, Hawthorne K, Hood K, Longo M, Lowes L, Pickles T, Playle R, Rollnick S, Thomas-Jones E, Gregory JW. The effect of the Talking Diabetes consulting skills intervention on glycaemic control and quality of life in children with type 1 diabetes: cluster randomised controlled trial (DEPICTED study). BMJ 2012; 344:e2359. [PMID: 22539173 PMCID: PMC3339876 DOI: 10.1136/bmj.e2359] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the effectiveness on glycaemic control of a training programme in consultation skills for paediatric diabetes teams. DESIGN Pragmatic cluster randomised controlled trial. SETTING 26 UK secondary and tertiary care paediatric diabetes services. PARTICIPANTS 79 healthcare practitioners (13 teams) trained in the intervention (359 young people with type 1 diabetes aged 4-15 years and their main carers) and 13 teams allocated to the control group (334 children and their main carers). INTERVENTION Talking Diabetes programme, which promotes shared agenda setting and guiding communication style, through flexible menu of consultation strategies to support patient led behaviour change. MAIN OUTCOME MEASURES The primary outcome was glycated haemoglobin (HbA(1c)) level one year after training. Secondary outcomes were clinical measures (hypoglycaemic episodes, body mass index, insulin regimen), general and diabetes specific quality of life, self reported and proxy reported self care and enablement, perceptions of the diabetes team, self reported and carer reported importance of, and confidence in, undertaking diabetes self management measured over one year. Analysis was by intention to treat. An integrated process evaluation included audio recording a sample of 86 routine consultations to assess skills shortly after training (intervention group) and at one year follow-up (intervention and control group). Two key domains of skill assessment were use of the guiding communication style and shared agenda setting. RESULTS 660/693 patients (95.2%) provided blood samples at follow-up. Training diabetes care teams had no effect on HbA(1c) levels (intervention effect 0.01, 95% confidence interval -0.02 to 0.04, P=0.5), even after adjusting for age and sex of the participants. At follow-up, trained staff (n=29) were more capable than controls (n=29) in guiding (difference in means 1.14, P<0.001) and agenda setting (difference in proportions 0.45, 95% confidence interval 0.22 to 0.62). Although skills waned over time for the trained practitioners, the reduction was not significant for either guiding (difference in means -0.33, P=0.128) or use of agenda setting (difference in proportions -0.20, -0.42 to 0.05). 390 patients (56%) and 441 carers (64%) completed follow-up questionnaires. Some aspects of diabetes specific quality of life improved in controls: reduced problems with treatment barriers (mean difference -4.6, 95% confidence interval -8.5 to -0.6, P=0.03) and with treatment adherence (-3.1, -6.3 to -0.01, P=0.05). Short term ability to cope with diabetes increased in patients in intervention clinics (10.4, 0.5 to 20.4, P=0.04). Carers in the intervention arm reported greater excitement about clinic visits (1.9, 1.05 to 3.43, P=0.03) and improved continuity of care (0.2, 0.1 to 0.3, P=0.01). CONCLUSIONS Improving glycaemic control in children attending specialist diabetes clinics may not be possible through brief, team-wide training in consultation skills. TRIAL REGISTRATION Current Controlled Trials ISRCTN61568050.
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Affiliation(s)
- Mike Robling
- South East Wales Trials Unit, Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK.
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van Vugt SF, Butler CC, Hood K, Kelly MJ, Coenen S, Goossens H, Little P, Verheij TJ. Predicting benign course and prolonged illness in lower respiratory tract infections: a 13 European country study. Fam Pract 2012; 29:131-8. [PMID: 21980004 DOI: 10.1093/fampra/cmr081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinicians and patients are often uncertain about the likely clinical course of community-acquired lower respiratory tract infection (LRTI) in individual patients. We therefore set out to develop a prediction rule to identify patients at risk of prolonged illness and those with a benign course. METHODS We determined which signs and symptoms predicted prolonged illness (moderately bad symptoms lasting >3 weeks after consultation) in 2690 adults presenting in primary care with LRTI in 13 European countries by using multilevel modelling. RESULTS 212 (8.1%) patients experienced prolonged illness. Illness that had lasted >5 days at the time of presentation, >1 episode of cough in the preceding year, chronic use of inhaled pulmonary medication and diarrhoea independently predicted prolonged illness. Applying a rule based on these four variables, 3% of the patients with ≤ 1 variable present (n = 955, 37%) had prolonged illness. Patients with all four variables present had a 30% chance of prolonged illness (n = 71, 3%). CONCLUSIONS Most patients with acute cough (>90%) recover within 3 weeks. A prediction rule containing four clinical items had predictive value for the risk of prolonged illness, but given its imprecision, appeared to have little clinical utility. Patients should be reassured that they are most likely to recover within three weeks and advised to re-consult if their symptoms persist beyond that period.
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Affiliation(s)
- S F van Vugt
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, Evans MR, Alam MF, Bekkers MJ, Evans J, Moore L, Howe R, Hayes J, Hare M, Hood K. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ 2012; 344:d8173. [PMID: 22302780 PMCID: PMC3270575 DOI: 10.1136/bmj.d8173] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care. DESIGN Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation. SETTING 68 general practices with about 480,000 patients in Wales, United Kingdom. PARTICIPANTS 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed. INTERVENTIONS Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care. MAIN OUTCOME MEASURES Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs. RESULTS The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice. CONCLUSION The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.
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Affiliation(s)
- Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK.
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Greene G, Hood K, Little P, Verheij T, Goossens H, Coenen S, Butler CC. Towards clinical definitions of lower respiratory tract infection (LRTI) for research and primary care practice in Europe: an international consensus study. Prim Care Respir J 2012; 20:299-306, 6 p following 306. [PMID: 21509421 DOI: 10.4104/pcrj.2011.00034] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS Antibiotic prescriptions for lower respiratory tract infection (LRTI) account for a large proportion of antibiotic consumption. Many of these prescriptions do not benefit patients and contribute to antibiotic resistance. Research to improve evidence-based management requires clear definitions of clinical entities. We aimed to generate definitions for common LRTIs that are applicable to clinical practice and low-intensity investigation research settings in European primary care. METHODS Candidate definitions identified through a systematic review and a nominal group meeting were put to a Delphi panel of selected experts from Europe and the US over three rounds. The definitions achieving high consensus were then tested for face validity by an expert panel. RESULTS 253 papers met our search criteria. The nominal group meeting generated highly-ranked definitions for two LRTIs. The Delphi panel considered five candidate definitions derived from the systematic review and nominal group meeting, and agreed upon definitions and open comments that the expert panel assessed for face validity. CONCLUSIONS We combined empirical evidence with expert opinion for the development of a set of relevant clinical and research definitions for the four most common LRTIs presenting in general practice.
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Affiliation(s)
- Giles Greene
- Department of Primary care and Public Health, Cardiff University, Neuadd Meirionnydd Health Park, Cardiff, UK.
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Abstract
BACKGROUND Impetigo is a common, superficial bacterial skin infection, which is most frequently encountered in children. There is no generally agreed standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This is an updated version of the original review published in 2003. OBJECTIVES To assess the effects of treatments for impetigo, including non-pharmacological interventions and 'waiting for natural resolution'. SEARCH METHODS We updated our searches of the following databases to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials, and we handsearched the reference lists of new studies found in the updated search. SELECTION CRITERIA Randomised controlled trials of treatments for non-bullous, bullous, primary, and secondary impetigo. DATA COLLECTION AND ANALYSIS Two independent authors undertook all steps in data collection. We performed quality assessments and data collection in two separate stages. MAIN RESULTS We included 57 trials in the first version of this review. For this update 1 of those trials was excluded and 12 new trials were added. The total number of included trials was, thus, 68, with 5578 participants, reporting on 50 different treatments, including placebo. Most trials were in primary impetigo or did not specify this.For many of the items that were assessed for risk of bias, most studies did not provide enough information. Fifteen studies reported blinding of participants and outcome assessors.Topical antibiotic treatment showed better cure rates than placebo (pooled risk ratio (RR) 2. 24, 95% confidence interval (CI) 1.61 to 3.13) in 6 studies with 575 participants. In 4 studies with 440 participants, there was no clear evidence that either of the most commonly studied topical antibiotics (mupirocin and fusidic acid) was more effective than the other (RR 1.03, 95% CI 0.95 to 1.11).In 10 studies with 581 participants, topical mupirocin was shown to be slightly superior to oral erythromycin (pooled RR 1.07, 95% CI 1.01 to 1.13). There were no significant differences in cure rates from treatment with topical versus other oral antibiotics. There were, however, differences in the outcome from treatment with different oral antibiotics: penicillin was inferior to erythromycin, in 2 studies with 79 participants (pooled RR 1.29, 95% CI 1.07 to 1.56), and cloxacillin, in 2 studies with 166 participants (pooled RR 1.59, 95% CI 1.21 to 2.08).There was a lack of evidence for the benefit of using disinfectant solutions. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments (RR 1.15, 95% CI 1.01 to 1.32).The reported number of side-effects was low, and most of these were mild. Side-effects were more common for oral antibiotic treatment compared to topical treatment. Gastrointestinal effects accounted for most of the difference.Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported. AUTHORS' CONCLUSIONS There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. Due to the lack of studies in people with extensive impetigo, it is unclear if oral antibiotics are superior to topical antibiotics in this group. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. There is a lack of evidence to support disinfection measures to manage impetigo.
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Affiliation(s)
- Sander Koning
- Erasmus Medical CenterDepartment of General PracticePO Box 2040Room Ff303RotterdamNetherlands3000 CA
| | - Renske van der Sande
- Erasmus Medical CenterDepartment of General PracticePO Box 2040Room Ff303RotterdamNetherlands3000 CA
| | - Arianne P Verhagen
- Erasmus Medical CenterDepartment of General PracticePO Box 2040Room Ff303RotterdamNetherlands3000 CA
| | - Lisette WA van Suijlekom‐Smit
- Erasmus MC ‐ Sophia Children's HospitalDepartment of Paediatrics, Paediatric RheumatologyPO Box 2060RotterdamNetherlands3000 CB
| | - Andrew D Morris
- University of Wales College of MedicineDepartment of DermatologyCardiffWalesUK
| | - Christopher C Butler
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordUKOX2 6GG
| | - Marjolein Berger
- Erasmus Medical CenterDepartment of General PracticePO Box 2040Room Ff303RotterdamNetherlands3000 CA
- University Medical Centre GroningenDepartment of General PracticeGroningenNetherlands
| | - Johannes C van der Wouden
- Erasmus Medical CenterDepartment of General PracticePO Box 2040Room Ff303RotterdamNetherlands3000 CA
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Crocker JC, Evans MR, Butler CC, Hood K, Powell CVE. Carers' perspectives on the presentation of community-acquired pneumonia and empyema in children: a case series. BMJ Open 2012; 2:bmjopen-2012-001500. [PMID: 22952163 PMCID: PMC3437434 DOI: 10.1136/bmjopen-2012-001500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To describe carers' perceptions of the development and presentation of community-acquired pneumonia or empyema in their children. DESIGN Case series. SETTING Seven hospitals with paediatric inpatient units in South Wales, UK. PARTICIPANTS Carers of 79 children aged 6 months to 16 years assessed in hospital between October 2008 and September 2009 with radiographic, community-acquired pneumonia or empyema. METHODS Carers were recruited in hospital and participated in a structured face-to-face or telephone interview about the history and presenting features of their children's illnesses. Responses to open questions were initially coded very finely and then grouped into common themes. Cases were classified into two age groups: 3 or more years and under 3 years. RESULTS The reported median duration of illness from onset until the index hospital presentation was 4 days (IQR 2-9 days). Pain in the torso was reported in 84% of cases aged 3 or more years and was the most common cause for carer concern in this age group. According to carer accounts, clinicians sometimes misjudged the origin of this pain. Almost all carers reported something unusual about the index illness that had particularly concerned them-mostly non-specific physical symptoms and behavioural changes. CONCLUSIONS Pain in the torso and carer concerns about unusual symptoms in their child may provide valuable additional information in a clinician's assessment of the risk of pneumonia in primary care. Further research is needed to confirm the diagnostic value of these features.
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Affiliation(s)
- Joanna C Crocker
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Meirion R Evans
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Colin V E Powell
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
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Brookes-Howell L, Hood K, Cooper L, Little P, Verheij T, Coenen S, Godycki-Cwirko M, Melbye H, Borras-Santos A, Worby P, Jakobsen K, Goossens H, Butler CC. Understanding variation in primary medical care: a nine-country qualitative study of clinicians' accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection. BMJ Open 2012; 2:bmjopen-2011-000796. [PMID: 22918670 PMCID: PMC4401816 DOI: 10.1136/bmjopen-2011-000796] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES There is a wide variation between European countries in antibiotic prescribing for patients in primary care with lower respiratory tract infection (LRTI) that is not explained by case mix and clinical factors alone. Variation in antibiotic prescribing that is not warranted by differences in illness and clinical presentation may increase selection of resistant organisms, contributing to the problem of antibiotic resistance. This study aimed to investigate clinicians' accounts of non-clinical factors that influence their antibiotic prescribing decision for patients with LRTI, to understand variation and identify opportunities for addressing possible unhelpful variation. DESIGN Multicountry qualitative semistructured interview study, with data subjected to a five-stage analytic framework approach (familiarisation, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation), and with interviewers commenting on preliminary analytic themes. SETTING Primary care. PARTICIPANTS Eighty primary care clinicians randomly selected from primary care research networks based in nine European cities. RESULTS Clinicians' accounts identified non-clinical factors imposed by the healthcare system operating within specific regional primary care research networks, including patient access to antibiotics before consulting a doctor (Barcelona and Milan), systems to reduce patient expectations for antibiotics (Southampton and Antwerp) and lack of consistent treatment guidelines (Balatonfüred and Łódź). Secondly, accounts revealed factors related to specific characteristics of clinicians regardless of network (professional ethos, self-belief in decision-making and commitment to shared decision-making). CONCLUSIONS Addressing healthcare system factors (eg, limiting patients' self-management with antibiotics before consulting in primary care, increased public awareness and provision of more consistent guidelines) may assist in reducing unhelpful variation in antibiotic prescribing. Promoting clinicians' receptivity to change, confidence in decision-making and readiness to invest in explaining prescribing decisions may also be beneficial. As factors were emphasised differently between networks, local flexibility in interventions is likely to maximise effectiveness.
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Affiliation(s)
- Lucy Brookes-Howell
- South East Wales Trials Unit, Institute for Translation, Innovation, Methodology and Engagement (TIME), Cardiff University, Cardiff, Wales, UK
| | - Kerenza Hood
- South East Wales Trials Unit, Institute for Translation, Innovation, Methodology and Engagement (TIME), Cardiff University, Cardiff, Wales, UK
| | - Lucy Cooper
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, England, UK
| | - Paul Little
- Community Clinical Sciences Division, University of Southampton, Southampton, England, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Samuel Coenen
- Centre for General Practice, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Łódź, Łódź, Poland
| | - Hasse Melbye
- Institute of Community Medicine, University of Tromsø, Tromsø, Norway
| | | | - Patricia Worby
- Research and Innovation Services, University of Southampton, Southampton, England, UK
| | - Kristin Jakobsen
- Institute of Community Medicine, University of Tromsø, Tromsø, Norway
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales, UK
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Wood F, Brookes-Howell L, Hood K, Cooper L, Verheij T, Goossens H, Little P, Godycki-Cwirko M, Adriaenssens N, Jakobsen K, Butler CC. A multi-country qualitative study of clinicians' and patients' views on point of care tests for lower respiratory tract infection. Fam Pract 2011; 28:661-9. [PMID: 21653924 DOI: 10.1093/fampra/cmr031] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Point of care tests (POCTs) are being promoted to better target antibiotic prescribing with the aim of improving outcomes and containing antibiotic resistance. OBJECTIVE We aimed to explore clinician and patient views about POCTs to assist with the diagnosis and management of lower respiratory tract infection (LRTI) in primary care. METHODS Multi-country European qualitative interview study with 80 primary care clinicians and 121 adult patients in nine primary care networks who had recently consulted with symptoms of acute cough/LRTI. Transcripts were subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports. RESULTS Clinicians who did not routinely use POCTs for acute cough/LRTI felt that the tests' advantages included managing patient expectations for antibiotics. Perceived disadvantages included questionable test performance, problems interpreting results, a detraction from clinical reasoning, costs, time and patients not wanting, or demanding, the tests. Clinicians who routinely used POCTs echoed these disadvantages. Almost all patients would be happy to be managed with the addition of a POCT. Patients with experience of POCTs accepted it as part of routine care. CONCLUSIONS Acceptability of POCTs to clinicians is likely to be improved if tests perform well on accuracy, time to result, simplicity and cost. Including POCTs in the routine management of acute cough/LRTI is likely to be acceptable to most patients.
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Affiliation(s)
- Fiona Wood
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK.
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Cals JWL, Ament AJHA, Hood K, Butler CC, Hopstaken RM, Wassink GF, Dinant GJ. C-reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial. J Eval Clin Pract 2011; 17:1059-69. [PMID: 20666881 DOI: 10.1111/j.1365-2753.2010.01472.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES An economic evaluation of general practitioner (GP) use of C-reactive protein (CRP) point of care test, GP communication skills training, and both GP use of CRP and communication skills training on antibiotic use for lower respiratory tract infections (LRTIs) in general practice. METHODS Cost-effectiveness analysis with a time horizon of 28 days alongside a factorial, cluster randomized trial in 431 patients with LRTIs recruited by 40 GPs. INTERVENTIONS usual care (control group), GP use of CRP point of care test, GP communication skills training, and both CRP use and communication skills training. MAIN OUTCOME MEASURE health care costs. Cost-effectiveness, using the primary outcome measure antibiotic prescribing at index consultation, was assessed by incremental cost-effectiveness ratios (ICER). To adjust for skewed data and clustering, we used non-parametric bootstrapping re-sampling to derive percentile intervals for the mean difference in total costs and the mean difference in effectiveness between the groups. Various implementation scenarios according to GP preference were modelled with corresponding net monetary benefit (NMB) curves based on a given willingness-to-pay (λ) for a 1% lower antibiotic prescribing rate. RESULTS The total mean cost per patient in the usual care group was €35.96 with antibiotic prescribing of 68%, €37.58 per patient managed by GPs using CRP tests (antibiotic prescribing 39%, ICER €5.79), €25.61 per patient managed by GPs trained in enhanced communication skills (antibiotic prescribing 33%, dominant) and €37.78 per patient managed by GPs using both interventions (antibiotic prescribing 23%, ICER €4.15). The interventions are cost-effective in any combination (yielding NMB at no willingness-to-pay), taking into account GPs' preferences where at least 15% of GPs chose to implement the communication skills training. CONCLUSIONS The two strategies, both singly and combined, are cost-effective interventions to reduce antibiotic prescribing for LRTI, at no, or low willingness-to-pay. Taking GP preferences into account will optimize investment in strategies to reduce antibiotic prescribing for LRTI.
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Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, the Netherlands.
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Godycki-Cwirko M, Hood K, Nocun M, Muras M, Goossens H, Butler CC. Presentation, antibiotic management and associated outcome in Polish adults presenting with acute cough/LRTI. Fam Pract 2011; 28:608-14. [PMID: 21555340 DOI: 10.1093/fampra/cmr019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE In-depth knowledge of existing practice is required to inform interventions aimed at antibiotic prescribing quality improvement. We set out to describe the presentation, antimicrobial management and associated outcome of adults presenting in general practice with acute cough/lower respiratory tract infection (LRTI) in Poland. METHODS Observational study of 301 adults with acute cough/LRTI. Clinicians completed a case report form (CRF) describing presentation, history and management and patients completed a symptom diary for up to 28 days after consultation. RESULTS Two hundred and twenty-one patients (with CRF and symptom diary completed) were analysed. The median duration of feeling unwell before presentation was 4 days. Clinicians recorded an average of eight symptoms for patients at presentation. Apart from cough, patients most commonly reported feeling generally unwell (91.9%), limitation of normal activities (80.5%), coryza (80.1%) and phlegm production (76.0%). Auscultation abnormalities were present in 55.0%. Overall, medicines were prescribed for 95.0%; 72.4% were prescribed antibiotics [mostly macrolides/lincosamides (38.8%) and amoxicillin/co-amoxiclav (36.3%)) with 11.3% advised to take antibiotics only if still necessary after a specified delay. Mucolytics were prescribed for 61.1%. Antibiotic prescription was strongly associated with a diagnosis of LRTI and the presence of auscultation abnormalities. The median duration of cough after presentation was 8 days. CONCLUSIONS Antibiotics continue to be frequently prescribed for acute cough/LRTI in Poland, and the decision to prescribe was strongly associated with clinicians' findings of abnormalities on auscultation and diagnosis of LRTI. Delayed prescribing was infrequent. Mucolytics were commonly prescribed despite evidence of no effect.
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Affiliation(s)
- Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
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183
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Crocker JC, Powell CVE, Evans MR, Hood K, Butler CC. Paediatric pneumonia or empyema and prior antibiotic use in primary care: a case–control study. J Antimicrob Chemother 2011; 67:478-87. [DOI: 10.1093/jac/dkr462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- Alastair D Hay
- Academic Unit of Primary Health Care, NIHR National School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK.
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186
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Oppong R, Coast J, Hood K, Nuttall J, Smith RD, Butler CC. Resource use and costs of treating acute cough/lower respiratory tract infections in 13 European countries: results and challenges. Eur J Health Econ 2011; 12:319-329. [PMID: 20364288 DOI: 10.1007/s10198-010-0239-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 03/15/2010] [Indexed: 05/29/2023]
Abstract
The objectives of this study were to estimate the resource use and cost of treating acute cough/lower respiratory tract infection (acute cough/LRTI) in 13 European countries, to explore reasons for differences in cost and to document the challenges that researchers face when collecting information on cost alongside multinational studies. Data on resource use and cost were collected alongside an observational study in 14 primary care networks across 13 European countries and a mean cost was generated for each network. The results show that the mean cost (standard deviation) of treating acute cough/LRTI in Europe ranged from euro23.88 (34.67) in Balatonfüred (Hungary) to euro116.47 (34.29) in Jonkoping (Sweden). The observed differences in costs were statistically significant (P < 0.01). Major cost drivers include general practitioner visits and drug costs in all networks, whilst differences in health systems and regional factors could account for differences in cost between networks. The major barrier to conducting multinational cost studies are barriers associated with identifying cost information.
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Affiliation(s)
- Raymond Oppong
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Public Health Building, Birmingham, B15 2TT, UK.
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187
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Nuttall J, Hood K, Verheij TJM, Little P, Brugman C, Veen RER, Goossens H, Butler CC. Building an international network for a primary care research program: reflections on challenges and solutions in the set-up and delivery of a prospective observational study of acute cough in 13 European countries. BMC Fam Pract 2011; 12:78. [PMID: 21794112 PMCID: PMC3176157 DOI: 10.1186/1471-2296-12-78] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 07/27/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Implementing a primary care clinical research study in several countries can make it possible to recruit sufficient patients in a short period of time that allows important clinical questions to be answered. Large multi-country studies in primary care are unusual and are typically associated with challenges requiring innovative solutions. We conducted a multi-country study and through this paper, we share reflections on the challenges we faced and some of the solutions we developed with a special focus on the study set up, structure and development of Primary Care Networks (PCNs). METHOD GRACE-01 was a multi-European country, investigator-driven prospective observational study implemented by 14 Primary Care Networks (PCNs) within 13 European Countries. General Practitioners (GPs) recruited consecutive patients with an acute cough. GPs completed a case report form (CRF) and the patient completed a daily symptom diary. After study completion, the coordinating team discussed the phases of the study and identified challenges and solutions that they considered might be interesting and helpful to researchers setting up a comparable study. RESULTS The main challenges fell within three domains as follows:i) selecting, setting up and maintaining PCNs;ii) designing local context-appropriate data collection tools and efficient data management systems; andiii) gaining commitment and trust from all involved and maintaining enthusiasm.The main solutions for each domain were:i) appointing key individuals (National Network Facilitator and Coordinator) with clearly defined tasks, involving PCNs early in the development of study materials and procedures.ii) rigorous back translations of all study materials and the use of information systems to closely monitor each PCNs progress;iii) providing strong central leadership with high level commitment to the value of the study, frequent multi-method communication, establishing a coherent ethos, celebrating achievements, incorporating social events and prizes within meetings, and providing a framework for exploitation of local data. CONCLUSIONS Many challenges associated with multi-country primary care research can be overcome by engendering strong, effective communication, commitment and involvement of all local researchers. The practical solutions identified and the lessons learned in implementing the GRACE-01 study may assist in establishing other international primary care clinical research platforms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00353951.
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Affiliation(s)
- Jacqueline Nuttall
- South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Kerenza Hood
- South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Theo JM Verheij
- University Medical Center Utrecht, Julius Center for Health, Sciences and Primary Care, Universiteitsweg 100, Stratenum, 6th Floor, 6.111, 3584 CX Utrecht, The Netherlands
| | - Paul Little
- University of Southampton, Southampton, SO16 5ST, UK
| | - Curt Brugman
- University Medical Center Utrecht, Julius Center for Health, Sciences and Primary Care, Universiteitsweg 100, Stratenum, 6th Floor, 6.111, 3584 CX Utrecht, The Netherlands
| | - Robert ER Veen
- University Medical Center Utrecht, Julius Center for Health, Sciences and Primary Care, Universiteitsweg 100, Stratenum, 6th Floor, 6.111, 3584 CX Utrecht, The Netherlands
| | - Herman Goossens
- Campus Drie Eiken, D.S313, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Christopher C Butler
- South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
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Abstract
BACKGROUND Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial. OBJECTIVES To examine the evidence for treating children with hearing loss associated with OME with systemic or topical intranasal steroids. SEARCH STRATEGY We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 26 August 2010. SELECTION CRITERIA Randomised controlled trials of oral and topical intranasal steroids, either alone or in combination with another agent such as an oral antibiotic. We excluded publications in abstract form only; uncontrolled, non-randomised or retrospective studies; and studies reporting outcomes by ears (rather than children). DATA COLLECTION AND ANALYSIS The authors independently extracted data from the published reports using standardised data extraction forms and methods. We assessed the quality of the included studies using the Cochrane 'Risk of bias' tool. We expressed dichotomous results as a risk ratio (RR) and continuous data as weighted mean difference (WMD), both with 95% confidence intervals (CI). Where feasible we pooled studies using a random-effects model and performed tests for heterogeneity between studies. In trials with a cross-over design, we did not use post cross-over treatment data. MAIN RESULTS We included 12 medium to high-quality studies with a total of 945 participants. No study documented hearing loss associated with OME prior to randomisation. The follow-up period was generally limited, with only one study of intranasal steroid reporting outcome data beyond six months. There was no evidence of benefit from steroid treatment (oral or topical) in terms of hearing loss associated with OME. Pooled data using a fixed-effect model for OME resolution at short-term follow up (< 1 month) showed a significant effect of oral steroids compared to control (RR 4.48; 95% CI 1.52 to 13.23; Chi² 2.75, df = 2, P = 0.25; I² = 27%). Oral steroids plus antibiotic also resulted in an improvement in OME resolution compared to placebo plus antibiotic at less than one month follow up, using a random-effects model (RR 1.99; 95% CI 1.14 to 3.49; five trials, 409 children). However, there was significant heterogeneity between studies (P < 0.01, I² = 69%). There was no evidence of beneficial effect on OME resolution at greater than one month follow up with oral steroids (used alone or with antibiotics) or intranasal steroids (used alone or with antibiotics) at any follow-up period. There was also no evidence of benefit from steroid treatment (oral or topical) in terms of symptoms. AUTHORS' CONCLUSIONS While oral steroids, especially when used in combination with an oral antibiotic, lead to a quicker resolution of OME in the short term, there is no evidence of longer-term benefit and no evidence that they relieve symptoms of hearing loss. We found no evidence of benefit from treatment of OME with topical intranasal steroids, alone or in combination with an antibiotic, either at short or longer-term follow up.
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Affiliation(s)
- Sharon A Simpson
- School of Medicine, Cardiff UniversityDepartment of Primary Care and Public HealthHeath ParkCardiffUKCF14 4XN
| | - Ruth Lewis
- Cardiff UniversityDepartment of Primary Care and Public HealthCentre for Health Sciences / North Wales Clinical SchoolSchool of Medicine, Gwenfro BuildingWrexhamUKLL13 7YP
| | - Judith van der Voort
- University Hospital of WalesDepartment of Paediatric NephrologyDivision of PaediatricsHeath ParkCardiffUKCF4 4XN
| | - Christopher C Butler
- School of Medicine, Cardiff UniversityDepartment of Primary Care and Public HealthHeath ParkCardiffUKCF14 4XN
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Godycki-Cwirko M, Nocun M, Butler CC, Muras M, Fleten N, Melbye H. Sickness certification for patients with acute cough/LRTI in primary care in Poland and Norway. Scand J Prim Health Care 2011; 29:13-8. [PMID: 21189105 PMCID: PMC3347931 DOI: 10.3109/02813432.2010.544898] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the frequency and duration of sickness certificates issued by GPs to Polish and Norwegian working adults with acute cough/lower respiratory tract infection (LRTI). DESIGN Cross-sectional observational study with clinicians from nine primary care centres in Poland and 11 primary care centres in Norway. GPs filled out a case report form for all patients, including information on antibiotic prescribing, sickness certification, and advice to stay off work. SETTING Primary care research networks in Poland and Norway. SUBJECTS Working adults with a new or worsening cough or clinical presentation suggestive of LRTI. MAIN OUTCOME MEASURES Issuing sickness certificates and advising patients to stay off work. RESULTS GPs recorded similar symptoms and signs in patients in the two countries. Antibiotics were prescribed more often in Polish than in Norwegian patients (70.4% vs. 27.1%, p < 0.0001). About half of the patients received a formal sickness certificate (50.5% in Norway and 52.0% in Poland). The proportion of patients advised to stay off work was significantly higher in the Polish sample compared with the Norwegian sample (75.2% vs. 56.1%, p = 0.002). Norwegian GPs less often issued sick certificates for more than seven days (5.6% vs. 36.9%, p < 0.0001). CONCLUSION The overall proportion of sickness certification for acute cough/LRTI was similar in Norwegian and Polish patients. However, in the Polish sample, GPs more often advised patients to take time off work without issuing a sick note. When sickness certificates were issued, duration of longer than seven days was more common in Polish than in Norwegian patients.
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Affiliation(s)
- Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Lodz, Kopcinskiego 20, Lodz,Poland.
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O'Brien K, Stanton N, Edwards A, Hood K, Butler CC. Prevalence of urinary tract infection (UTI) in sequential acutely unwell children presenting in primary care: exploratory study. Scand J Prim Health Care 2011; 29:19-22. [PMID: 21323495 PMCID: PMC3347928 DOI: 10.3109/02813432.2011.554268] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown. OBJECTIVES To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI. DESIGN Exploratory, observational study. SETTING Four general practices in South Wales. SUBJECTS A total of 99 sequential attendees with acute illness aged less than five years. MAIN OUTCOME MEASURE UTI defined by >10(5) organisms/ml on laboratory culture of urine. RESULTS Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections. CONCLUSION Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.
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Affiliation(s)
- Kathryn O'Brien
- The Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff, Wales, UK.
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191
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Francis NA, Crocker JC, Gamper A, Brookes-Howell L, Powell C, Butler CC. Missed opportunities for earlier treatment? A qualitative interview study with parents of children admitted to hospital with serious respiratory tract infections. Arch Dis Child 2011; 96:154-9. [PMID: 21047831 DOI: 10.1136/adc.2010.188680] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify potential opportunities for earlier intervention among children who develop a complicated respiratory tract infection (RTI). DESIGN Qualitative, face-to-face, individual interview study, either in hospital or at home, with parents of children admitted to hospital with a complicated RTI. SETTING Participants were recruited from a large UK teaching hospital, and described events (largely) prior to hospital admission. PARTICIPANTS Parents of 22 children (12 with empyema, 8 with pneumonia, 1 with peritonsillar abscess and 1 with mastoiditis). RESULTS Parents' accounts revealed missed opportunities for timely treatment resulting from parental and health service associated factors. Themes relating to parental factors included problems assessing the severity of the illness (5 parents), beliefs about accessing health services (10 parents; including fear of appearing 'neurotic', belief that their concerns would not be taken seriously, and belief that their child would not be prescribed antibiotics or would be prescribed antibiotics too readily) and feeling powerless to challenge clinical authority (7 parents). Health service associated factors included perceived problems accessing healthcare services (13 parents; including inadequate primary care triage, barriers to accessing timely consultations and past experience of problems accessing healthcare leading to failure to consult) and perceived poor quality clinical encounters (11 parents; including inadequate assessment and communication). CONCLUSION Addressing, where appropriate, these parental (skills, fears and beliefs) and health service (access and consultation quality) associated factors may lead to more prompt care for seriously ill children.
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Affiliation(s)
- Nick A Francis
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff, UK.
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192
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Wood J, Butler CC, Hood K, Kelly MJ, Verheij T, Little P, Torres A, Blasi F, Schaberg T, Goossens H, Nuttall J, Coenen S. Antibiotic prescribing for adults with acute cough/lower respiratory tract infection: congruence with guidelines. Eur Respir J 2011; 38:112-8. [PMID: 21233267 DOI: 10.1183/09031936.00145810] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
European guidelines for treating acute cough/lower respiratory tract infection (LRTI) aim to reduce nonevidence-based variation in prescribing, and better target and increase the use of first-line antibiotics. However, their application in primary care is unknown. We explored congruence of both antibiotic prescribing and antibiotic choice with European Respiratory Society (ERS)/European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for managing LRTI. The present study was an analysis of prospective observational data from patients presenting to primary care with acute cough/LRTI. Clinicians recorded symptoms on presentation, and their examination and management. Patients were followed up with self-complete diaries. 1,776 (52.7%) patients were prescribed antibiotics. Given patients' clinical presentation, clinicians could have justified an antibiotic prescription for 1,915 (71.2%) patients according to the ERS/ESCMID guidelines. 761 (42.8%) of those who were prescribed antibiotics received a first-choice antibiotic (i.e. tetracycline or amoxicillin). Ciprofloxacin was prescribed for 37 (2.1%) and cephalosporins for 117 (6.6%). A lack of specificity in definitions in the ERS/ESCMID guidelines could have enabled clinicians to justify a higher rate of antibiotic prescription. More studies are needed to produce specific clinical definitions and indications for treatment. First-choice antibiotics were prescribed to the minority of patients who received an antibiotic prescription.
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Affiliation(s)
- J Wood
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
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193
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Wickremaratchi MM, Knipe MDW, Sastry BSD, Morgan E, Jones A, Salmon R, Weiser R, Moran M, Davies D, Ebenezer L, Raha S, Robertson NP, Butler CC, Ben-Shlomo Y, Morris HR. The motor phenotype of Parkinson's disease in relation to age at onset. Mov Disord 2011; 26:457-63. [PMID: 21229621 DOI: 10.1002/mds.23469] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 08/03/2010] [Accepted: 09/14/2010] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Parkinson's disease (PD) is heterogeneous and age at onset may define variation in clinical phenotype. Most previous studies have used various age cut-offs and have been based on clinical case series. METHODS We have studied the association between clinical features and age of onset in 358 community-based and regional patients with PD. RESULTS Tremor at presentation is twice as common in those with onset over 64 years as compared to those with onset under 45 (early onset PD - EOPD) and becomes more common with increasing age at onset (p values for trend ≤ 0.004). Dystonia affects 60% of those with EOPD, shows a curvilinear relationship with age at onset (cubic versus linear p=0.01) with highest risk in patients whose disease began before 48 years. In this study age at onset was a strong predictor of the development of dyskinesias, with younger age associated with a higher risk of dyskinesias. Following multivariable analysis, allowing for possibly confounding factors (disease duration, L-DOPA dosage, L-DOPA treatment duration) younger age at onset, (less than 55 years) predicted the development of L-DOPA induced dyskinesia (odds ratio <45 years 2.1, 95% CI 1.0, 4.8; odds ratio < 55 years 3.8, 95% CI 1.8, 8.0). Only 2/70 (2.9%) EOPD patients carried pathogenic parkin or PINK1 mutations and the clinical differences between early and late onset disease were not explained by the presence of mutations in these genes. DISCUSSION This study highlights the clinical differences between early and late onset PD, which have important implications for diagnosis and management.
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Jakobsen KA, Melbye H, Kelly MJ, Ceynowa C, Mölstad S, Hood K, Butler CC. Influence of CRP testing and clinical findings on antibiotic prescribing in adults presenting with acute cough in primary care. Scand J Prim Health Care 2010; 28:229-36. [PMID: 20704523 PMCID: PMC3444795 DOI: 10.3109/02813432.2010.506995] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The value of clinical findings in lower respiratory tract infection (LRTI) is known to be overrated. This study aimed to determine the independent influence of a point of care test (POCT) for C-reactive protein (CRP) on the prescription of antibiotics in patients with acute cough or symptoms suggestive of LRTI, and how symptoms and chest findings influence the decision to prescribe when the test is and is not used. DESIGN Prospective observational study of presentation and management of acute cough/LRTI in adults. SETTING Primary care research networks in Norway, Sweden, and Wales. SUBJECTS Adult patients contacting their GP with symptoms of acute cough/LRTI. MAIN OUTCOME MEASURES Predictors of antibiotic prescribing were evaluated in those tested and those not tested with a POCT for CRP using logistic regression and receiver operating characteristic (ROC) curve analysis. RESULTS A total of 803 patients were recruited in the three networks. Among the 372 patients tested with a POCT for CRP, the CRP value was the strongest independent predictor of antibiotic prescribing, with an odds ratio (OR) of CRP ≥ 50 mg/L of 98.1. Crackles on auscultation and a patient preference for antibiotics perceived by the GP were the strongest predictors of antibiotic prescribing when the CRP test was not used. CONCLUSIONS The CRP result is a major influence in the decision whether or not to prescribe antibiotics for acute cough. Clinicians attach less weight to discoloured sputum and abnormal lung sounds when a CRP value is available. CRP testing could prevent undue reliance on clinical features that poorly predict benefit from antibiotic treatment.
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Butler CC, Hood K, Kelly MJ, Goossens H, Verheij T, Little P, Melbye H, Torres A, Mölstad S, Godycki-Cwirko M, Almirall J, Blasi F, Schaberg T, Edwards P, Rautakorpi UM, Hupkova H, Wood J, Nuttall J, Coenen S. Treatment of acute cough/lower respiratory tract infection by antibiotic class and associated outcomes: a 13 European country observational study in primary care. J Antimicrob Chemother 2010; 65:2472-8. [PMID: 20852271 DOI: 10.1093/jac/dkq336] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Acute cough/lower respiratory tract infection (LRTI) is one of the commonest reasons for consulting and antibiotic prescribing. There are theoretical reasons why treatment with particular antibiotic classes may aid recovery more than others, but empirical, pragmatic evidence is lacking. We investigated whether treatment with a particular antibiotic class (amoxicillin) was more strongly associated with symptom score resolution and time to patients reporting recovery than each of eight other antibiotic classes or no antibiotic treatment for acute cough/LRTI. METHODS Clinicians recorded history, examination findings, symptom severity and antibiotic treatment for 3402 patients in a 13 country prospective observational study of adults presenting in 14 primary care research networks with acute cough/LRTI. 2714 patients completed a symptom score daily for up to 28 days and recorded the day on which they felt recovered. A three-level autoregressive moving average model (1,1) model investigated logged daily symptom scores to analyse symptom resolution. A two-level survival model analysed time to reported recovery. Clinical presentation was controlled for using clinician-recorded symptoms, sputum colour, temperature, age, co-morbidities, smoking status and duration of illness prior to consultation. RESULTS Compared with amoxicillin, no antibiotic class (and no antibiotic treatment) was associated with clinically relevant improved symptom resolution (all coefficients in the range -0.02 to 0.01 and all P values greater than 0.12). No antibiotic class (and no antibiotic treatment) was associated with faster time to recovery than amoxicillin. CONCLUSIONS Treatment by antibiotic class was not associated with symptom resolution or time to recovery in adults presenting to primary care with acute cough/LRTI.
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Affiliation(s)
- Christopher C Butler
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
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Bekkers MJ, Simpson SA, Dunstan F, Hood K, Hare M, Evans J, Butler CC. Enhancing the quality of antibiotic prescribing in primary care: qualitative evaluation of a blended learning intervention. BMC Fam Pract 2010; 11:34. [PMID: 20459655 PMCID: PMC2881907 DOI: 10.1186/1471-2296-11-34] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 05/07/2010] [Indexed: 11/26/2022]
Abstract
Background The Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial. Methods Semi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis. Results The majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data. Conclusion Participants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program. Trial registration Current Controlled Trials ISRCTN63355948
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Affiliation(s)
- Marie-Jet Bekkers
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK.
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198
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Affiliation(s)
- Stephen Rollnick
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4XN.
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199
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Cals JWL, Chappin FHF, Hopstaken RM, van Leeuwen ME, Hood K, Butler CC, Dinant GJ. C-reactive protein point-of-care testing for lower respiratory tract infections: a qualitative evaluation of experiences by GPs. Fam Pract 2010; 27:212-8. [PMID: 20022909 DOI: 10.1093/fampra/cmp088] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To explore GPs' attitudes to and experiences of introducing C-reactive protein (CRP) point-of-care testing (POCT) for lower respiratory tract infections (LRTI) in primary care. METHODS Semi-structured interview study with 20 GPs who participated in the IMPAC(3)T randomized trial evaluating the effect of GP use of CRP POCT on management of LRTI. Main outcomes were GPs' experiences and views about CRP POCT in general practice, including its role in guiding antibiotic prescribing decisions and applicability and implementation in daily practice. RESULTS GPs expressed mainly positive attitudes. Test results were rapidly available to support diagnostic and therapeutic processes for LRTI and other common infections, enhancing patient and GP confidence in prescribing decisions and empowering GPs to prescribe antibiotics less often. GPs were concerned about responding to ambiguous test results. They regarded financial reimbursement for using the test as essential for successful uptake. CONCLUSIONS GPs were generally positive about CRP POCT, and they felt that it empowered them to safely prescribe fewer antibiotics for LRTI without alienating their patients. Successful wider implementation should address reimbursement and updating management guidelines to include the place of CRP POCT.
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Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands.
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Stanton N, Hood K, Kelly MJ, Nuttall J, Gillespie D, Verheij T, Little P, Godycki-Cwirko M, Goossens H, Butler CC. Are smokers with acute cough in primary care prescribed antibiotics more often, and to what benefit? An observational study in 13 European countries. Eur Respir J 2009; 35:761-7. [PMID: 20032009 DOI: 10.1183/09031936.00168409] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Little is known about actual clinical practice regarding management of smokers compared with ex-smokers and nonsmokers presenting with acute cough in primary care, and whether a lower threshold for prescribing antibiotics benefits smokers. This was a multicentre 13-country European prospective observational study of primary care clinician management of acute cough in consecutive immunocompetent adults presenting with an acute cough of <or=28 days duration. There was complete smoking status data for 2,549 out of 3,402 participants. 28% were smokers, 24% ex-smokers and 48% nonsmokers. Smokers and ex-smokers had more chronic respiratory conditions (18.5% and 20.5% versus 12.5%). Median symptom severity scores were similar. Smokers were prescribed antibiotics more frequently (60%) than ex-smokers (51%) and nonsmokers (53%). After adjusting for clinical presentation and patient characteristics, the odds ratio of being prescribed antibiotics for smokers compared with nonsmokers was 1.44 (95% CI 1.12-1.86; p = 0.005). Patient recovery was not significantly different for smokers and nonsmokers, after adjusting for clinical presentation and patient characteristics. Smoking status was used as an independent factor to determine whether or not to prescribe an antibiotic. Being prescribed an antibiotic was not associated with recovery in smokers.
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Affiliation(s)
- N Stanton
- Dept of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK.
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