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Tolley A, Bansal A, Murerwa R, Howard Dicks J. Cost-effectiveness of point-of-care diagnostics for AMR: a systematic review. J Antimicrob Chemother 2024; 79:1248-1269. [PMID: 38498622 PMCID: PMC11144491 DOI: 10.1093/jac/dkae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/19/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major threat to global health. By 2050, it is forecast that AMR will cause 10 million deaths and cost 100 trillion USD annually. Point-of-care tests (POCTs) may represent a cost-effective approach to reduce AMR. OBJECTIVES We systematically reviewed which POCTs addressing AMR have undergone economic evaluation in primary and secondary healthcare globally, how these POCTs have been economically evaluated, and which are cost-effective in reducing antimicrobial prescribing or the burden of AMR. Clinical cost-effectiveness was additionally addressed. METHODS This systematic review, accordant with PRISMA guidelines, was pre-registered on PROSPERO (CRD42022315192). MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar were searched from 2000 to 2023 for relevant publications. Quality assessment was performed using the Consensus of Health Economic Criteria. RESULTS The search strategy identified 1421 studies, of which 20 met the inclusion criteria. The most common POCTs assessed were for respiratory infections (n = 10), STIs (n = 3), and febrile patients in low- and middle-income countries (n = 3). All studies assessed costs from a healthcare provider perspective; five additionally considered the societal cost of AMR.Eighteen studies identified POCT strategies that reduced antimicrobial prescribing. Of these, 10 identified POCTs that would be considered cost-effective at a willingness-to-pay (WTP) threshold of £33.80 per antibiotic prescription avoided. Most POCT strategies improved clinical outcomes (n = 14); the remainder were clinically neutral. CONCLUSIONS There is evidence that some POCTs are cost-effective in reducing antimicrobial prescribing, with potential concomitant clinical benefits. Such interventions-especially CRP POCTs in both high- and low-income settings-merit further, large-scale clinical evaluation.
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Affiliation(s)
- Abraham Tolley
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Akhil Bansal
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Internal Medicine, St Vincent’s Hospital, Sydney, Australia
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Mills SE, Akbar SB, Hernandez-Santiago V. Barriers, enablers, benefits, and drawbacks to point-of-care testing: a survey of the general practice out-of-hours service in Scotland. BJGP Open 2024:BJGPO.2023.0094. [PMID: 38092440 DOI: 10.3399/bjgpo.2023.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/27/2023] [Accepted: 09/13/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND The general practice out-of-hours (GPOOH) service is under pressure to treat more patients in less time, while reducing referrals and minimising diagnostic errors. Point-of-care (POC) testing involves rapid clinical tests that can be used to generate results during the consultation, and has the potential to facilitate managing these competing demands safely. AIM To describe current availability of POC tests in GPOOH in Scotland, and identify barriers, enablers, benefits, and drawbacks to its use. DESIGN & SETTING Cross-sectional mixed-methods study, which surveyed opinions of clinicians working in the GPOOH service in NHS Scotland. METHOD An electronic questionnaire was developed, designed, piloted, and distributed to clinicians, which had closed questions and areas for free text. RESULTS In total, 142 responses were received. Urine dipstick testing (99.2%), pregnancy tests (98.5%), oxygen saturation (97.7%), and blood glucose testing (93.9%), were the only POC tests commonly available in GPOOH in NHS Scotland. There was strongest support for the provision of POC tests, particularly C-reactive protein (CRP; 79.4%), strep A (76.0%), and D-dimer (75.2%). Responders felt that POC tests would improve confidence (92.3%) and safety (89.8%) surrounding clinical decision making, improve patient satisfaction (80.6%), and reduce hospital and secondary care referrals (77.5%). Barriers to POC test use were availability of the test kits and machines (94.5%), training requirements on how to use the machine (71.1%) and interpret results (56.3%), and time to do the test (62.0%). CONCLUSION Few POC tests are in regular use in GPOOH in Scotland. GPOOH clinicians are supportive of using POC testing. They identified a number of benefits to its use, with very few drawbacks. Increased provision of POC testing in GPOOH in NHS Scotland should be considered urgently.
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Affiliation(s)
- Sarah Ee Mills
- University of St Andrews, School of Medicine, North Haugh, St Andrews, UK
| | - Sm Babar Akbar
- NHS Fife, General Practice Out of Hours Department, Victoria Hospital Kirkcaldy, Kirkcaldy, USA
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Elrobaa IH, Khan K, Mohamed E. The Role of Point-of-Care Testing to Improve Acute Care and Health Care Services. Cureus 2024; 16:e55315. [PMID: 38434607 PMCID: PMC10905651 DOI: 10.7759/cureus.55315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 03/05/2024] Open
Abstract
Health care is one of the most important services that need to be provided to any community. Many challenges exist in delivering proper and effective health services, including ensuring timely delivery, providing adequate care through effective management and achieving good outcomes. Point-of-care testing (POCT) plays a crucial role in delivering urgent and appropriate health services, especially in peripheral communities, emergency situations, disaster areas and overcrowded areas. We collected and reviewed secondary data about point-of-care testing from PubMed, Scopus and Google Scholar. Our findings emphasize that POCT provides fast care with minimal waiting time, avoids unnecessary investigations, aids in triage, and provides decision-makers with a clear understanding of the patient's condition to make informed decisions. We recommend point-of-care testing as a frontline investigation in emergency departments, intensive care units, peripheral hospitals, primary health care centers, disaster areas and field hospitals. Point-of-care testing can improve the quality of health services and ensure the provision of necessary health care.
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Affiliation(s)
- Islam H Elrobaa
- Emergency Medicine, College of Medicine, Qatar University, Doha, QAT
- Emergency Medicine, Hamad Medical Corporation (HMC), Doha, QAT
| | - Keebat Khan
- Emergency Medicine, Hamad Medical Corporation (HMC), Doha, QAT
| | - Eslam Mohamed
- Emergency Medicine, Hamad Medical Corporation (HMC), Doha, QAT
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Tenorio-Mucha J, Busta-Flores P, Lazo-Porras M, Vetter B, Safary E, Moran AE, Gupta R, Bernabé-Ortiz A. Facilitators and barriers of the implementation of point-of-care devices for cardiometabolic diseases: a scoping review. BMC Health Serv Res 2023; 23:412. [PMID: 37118750 PMCID: PMC10144879 DOI: 10.1186/s12913-023-09419-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Point-of-care testing (POCT) devices may facilitate the delivery of rapid and timely results, providing a clinically important advantage in patient management. The challenges and constraints in the implementation process, considering different levels of actors have not been much explored. This scoping review aimed to assess literature pertaining to implementation facilitators and barriers of POCT devices for the diagnosis or monitoring of cardiometabolic diseases. METHODS A scoping review of the literature was conducted. The inclusion criteria were studies on the inception, planning, or implementation of interventions with POCT devices for the diagnosis or monitoring of cardiometabolic diseases defined as dyslipidemia, cardiovascular diseases, type 2 diabetes, and chronic kidney disease. We searched MEDLINE, Embase, and Global Health databases using the OVID searching engine until May 2022. The Consolidated Framework of Implementation Research (CFIR) was used to classify implementation barriers and facilitators in five constructs. Also, patient, healthcare professional (HCP), and organization level was used. RESULTS Twenty studies met the eligibility criteria for data extraction. All studies except two were conducted in high-income countries. Some findings are: 1) Intervention: the most widely recognized facilitator was the quick turnaround time with which results are obtained. 2) Outer setting: at the organizational level, the lack of clear regulatory and accreditation mechanisms has hindered the adoption and sustainability of the use of POCT. 3) Inner setting: for HCP, performing POCT during the consultation was both a facilitator and a barrier in terms of time, personnel, and service delivery. 4) Individuals: the implementation of POCT may generate stress and discomfort in some HCP in terms of training and new responsibilities. 5) Process: for patients, it is highly appreciated that obtaining the sample was simple and more comfortable if venipuncture was not used. CONCLUSION This scoping review has described the facilitators and barriers of implementing a POCT device for cardiometabolic conditions using the CFIR. The information can be used to design better strategies to implement these devices and benefit more populations that have low access to cardiometabolic tests.
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Affiliation(s)
- Janeth Tenorio-Mucha
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445 - Miraflores, Lima, Peru
| | - Patricia Busta-Flores
- CONEVID - Unidad de Conocimiento y Evidencia, Facultad de Medicina "Alberto Hurtado", Universidad Peruana Cayetano Heredia, Lima, Peru
| | - María Lazo-Porras
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445 - Miraflores, Lima, Peru
| | | | | | | | - Reena Gupta
- Resolve to Save Lives, New York, NY, USA
- Department of Medicine of Medicine, University of California, San Francisco, USA
| | - Antonio Bernabé-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445 - Miraflores, Lima, Peru.
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Dewez JE, Nijman RG, Fitchett EJA, Lynch R, de Groot R, van der Flier M, Philipsen R, Vreugdenhil H, Ettelt S, Yeung S. Adoption of C-reactive protein point-of-care tests for the management of acute childhood infections in primary care in the Netherlands and England: a comparative health systems analysis. BMC Health Serv Res 2023; 23:191. [PMID: 36823597 PMCID: PMC9947887 DOI: 10.1186/s12913-023-09065-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The use of point of care (POC) tests varies across Europe, but research into what drives this variability is lacking. Focusing on CRP POC tests, we aimed to understand what factors contribute to high versus low adoption of the tests, and also to explore whether they are used in children. METHODS We used a comparative qualitative case study approach to explore the implementation of CRP POC tests in the Netherlands and England. These countries were selected because although they have similar primary healthcare systems, the availability of CRP POC tests in General Practices is very different, being very high in the former and rare in the latter. The study design and analysis were informed by the non-adoption, abandonment, spread, scale-up and sustainability (NASSS) framework. Data were collected through a review of documents and interviews with stakeholders. Documents were identified through a scoping literature review, search of websites, and stakeholder recommendation. Stakeholders were selected purposively initially, and then by snowballing. Data were analysed thematically. RESULTS Sixty-five documents were reviewed and 21 interviews were conducted. The difference in the availability of CRP POC tests is mainly because of differences at the wider national context level. In the two countries, early adopters of the tests advocated for their implementation through the generation of robust evidence and by engaging with all relevant stakeholders. This led to the inclusion of CRP POC tests in clinical guidelines in both countries. In the Netherlands, this mandated their reimbursement in accordance with Dutch regulations. Moreover, the prevailing better integration of health services enabled operational support from laboratories to GP practices. In England, the funding constraints of the National Health Service and the prioritization of alternative and less expensive antimicrobial stewardship interventions prevented the development of a reimbursement scheme. In addition, the lack of integration between health services limits the operational support to GP practices. In both countries, the availability of CRP POC tests for the management of children is a by-product of the test being available for adults. The tests are less used in children mainly because of concerns regarding their accuracy in this age-group. CONCLUSIONS The engagement of early adopters combined with a more favourable and receptive macro level environment, including the role of clinical guidelines and their developers in determining which interventions are reimbursed and the operational support from laboratories to GP practices, led to the greater adoption of the tests in the Netherlands. In both countries, CRP POC tests, when available, are less used less in children. Organisations considering introducing POC tests into primary care settings need to consider how their implementation fits into the wider health system context to ensure achievable plans.
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Affiliation(s)
- Juan Emmanuel Dewez
- grid.8991.90000 0004 0425 469XClinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruud G. Nijman
- grid.7445.20000 0001 2113 8111Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Elizabeth J. A. Fitchett
- grid.8991.90000 0004 0425 469XClinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca Lynch
- grid.8391.30000 0004 1936 8024Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, UK
| | - Ronald de Groot
- grid.10417.330000 0004 0444 9382Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Centre for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud UMC, Nijmegen, The Netherlands
| | - Michiel van der Flier
- grid.461578.9Paediatric Infectious diseases and Immunology, Amalia Children’s Hospital, Radboudumc, Nijmegen, The Netherlands ,grid.417100.30000 0004 0620 3132Paediatric Infectious Diseases and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ria Philipsen
- grid.10417.330000 0004 0444 9382Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Centre for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud UMC, Nijmegen, The Netherlands
| | - Harriet Vreugdenhil
- grid.7692.a0000000090126352Utrecht General Practice Training Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefanie Ettelt
- grid.8991.90000 0004 0425 469XDepartment of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK ,grid.506777.40000 0001 2295 4495Prognos AG, Basel, Switzerland
| | - Shunmay Yeung
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK. .,Department of Paediatrics, St Mary's Imperial College Hospital NHS Trust, London, UK.
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Smedemark SA, Aabenhus R, Llor C, Fournaise A, Olsen O, Jørgensen KJ. Biomarkers as point-of-care tests to guide prescription of antibiotics in people with acute respiratory infections in primary care. Cochrane Database Syst Rev 2022; 10:CD010130. [PMID: 36250577 PMCID: PMC9575154 DOI: 10.1002/14651858.cd010130.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. It follows that in many cases antibiotic use will not be beneficial to a patient's recovery but may expose them to potential side effects. Furthermore, limiting unnecessary antibiotic use is a key factor in controlling antibiotic resistance. One strategy to reduce antibiotic use in primary care is point-of-care biomarkers. A point-of-care biomarker (test) of inflammation identifies part of the acute phase response to tissue injury regardless of the aetiology (infection, trauma, or inflammation) and may be used as a surrogate marker of infection, potentially assisting the physician in the clinical decision whether to use an antibiotic to treat ARIs. Biomarkers may guide antibiotic prescription by ruling out a serious bacterial infection and help identify patients in whom no benefit from antibiotic treatment can be anticipated. This is an update of a Cochrane Review first published in 2014. OBJECTIVES To assess the benefits and harms of point-of-care biomarker tests of inflammation to guide antibiotic treatment in people presenting with symptoms of acute respiratory infections in primary care settings regardless of patient age. SEARCH METHODS We searched CENTRAL (2022, Issue 6), MEDLINE (1946 to 14 June 2022), Embase (1974 to 14 June 2022), CINAHL (1981 to 14 June 2022), Web of Science (1955 to 14 June 2022), and LILACS (1982 to 14 June 2022). We also searched three trial registries (10 December 2021) for completed and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared the use of point-of-care biomarkers with standard care. We included trials that randomised individual participants, as well as trials that randomised clusters of patients (cluster-RCTs). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the following primary outcomes: number of participants given an antibiotic prescription at index consultation and within 28 days follow-up; participant recovery within seven days follow-up; and total mortality within 28 days follow-up. We assessed risk of bias using the Cochrane risk of bias tool and the certainty of the evidence using GRADE. We used random-effects meta-analyses when feasible. We further analysed results with considerable heterogeneity in prespecified subgroups of individual and cluster-RCTs. MAIN RESULTS We included seven new trials in this update, for a total of 13 included trials. Twelve trials (10,218 participants in total, 2335 of which were children) evaluated a C-reactive protein point-of-care test, and one trial (317 adult participants) evaluated a procalcitonin point-of-care test. The studies were conducted in Europe, Russia, and Asia. Overall, the included trials had a low or unclear risk of bias. However all studies were open-labelled, thereby introducing high risk of bias due to lack of blinding. The use of C-reactive protein point-of-care tests to guide antibiotic prescription likely reduces the number of participants given an antibiotic prescription, from 516 prescriptions of antibiotics per 1000 participants in the control group to 397 prescriptions of antibiotics per 1000 participants in the intervention group (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69 to 0.86; 12 trials, 10,218 participants; I² = 79%; moderate-certainty evidence). Overall, use of C-reactive protein tests also reduce the number of participants given an antibiotic prescription within 28 days follow-up (664 prescriptions of antibiotics per 1000 participants in the control group versus 538 prescriptions of antibiotics per 1000 participants in the intervention group) (RR 0.81, 95% CI 0.76 to 0.86; 7 trials, 5091 participants; I² = 29; high-certainty evidence). The prescription of antibiotics as guided by C-reactive protein tests likely does not reduce the number of participants recovered, within seven or 28 days follow-up (567 participants recovered within seven days follow-up per 1000 participants in the control group versus 584 participants recovered within seven days follow-up per 1000 participants in the intervention group) (recovery within seven days follow-up: RR 1.03, 95% CI 0.96 to 1.12; I² = 0%; moderate-certainty evidence) (recovery within 28 days follow-up: RR 1.02, 95% CI 0.79 to 1.32; I² = 0%; moderate-certainty evidence). The use of C-reactive protein tests may not increase total mortality within 28 days follow-up, from 1 death per 1000 participants in the control group to 0 deaths per 1000 participants in the intervention group (RR 0.53, 95% CI 0.10 to 2.92; I² = 0%; low-certainty evidence). We are uncertain as to whether procalcitonin affects any of the primary or secondary outcomes because there were few participants, thereby limiting the certainty of evidence. We assessed the certainty of the evidence as moderate to high according to GRADE for the primary outcomes for C-reactive protein test, except for mortality, as there were very few deaths, thereby limiting the certainty of the evidence. AUTHORS' CONCLUSIONS The use of C-reactive protein point-of-care tests as an adjunct to standard care likely reduces the number of participants given an antibiotic prescription in primary care patients who present with symptoms of acute respiratory infection. The use of C-reactive protein point-of-care tests likely does not affect recovery rates. It is unlikely that further research will substantially change our conclusion regarding the reduction in number of participants given an antibiotic prescription, although the size of the estimated effect may change. The use of C-reactive protein point-of-care tests may not increase mortality within 28 days follow-up, but there were very few events. Studies that recorded deaths and hospital admissions were performed in children from low- and middle-income countries and older adults with comorbidities. Future studies should focus on children, immunocompromised individuals, and people aged 80 years and above with comorbidities. More studies evaluating procalcitonin and potential new biomarkers as point-of-care tests used in primary care to guide antibiotic prescription are needed. Furthermore, studies are needed to validate C-reactive protein decision algorithms, with a specific focus on potential age group differences.
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Affiliation(s)
- Siri Aas Smedemark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit of General Practice, Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| | - Anders Fournaise
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Vejle, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ole Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Holzinger F, Gehrke-Beck S, Krüger K. [Acute and chronic cough - differential diagnosis and treatment]. Dtsch Med Wochenschr 2022; 147:989-1001. [PMID: 35915885 DOI: 10.1055/a-1716-8101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Cough is a frequent reason for consultation in the general practitioner's office. Most of the time, the symptom is harmless and self-limiting, as in the case of a banal cold cough, for example - however, serious diseases such as malignancies can also be the cause. Evaluation is therefore not always easy. This article presents a targeted and appropriate approach and discusses which treatments are recommended and effective.Acute and chronic cough are differentiated according to the duration of symptoms (up to 8 weeks/longer than 8 weeks). The most common cause of acute cough is a self-limiting viral infection of the upper respiratory tract; the most important differential diagnosis is community-acquired pneumonia. If there are no defined warning signs (red flags), the history and clinical examination are sufficient to establish the diagnosis in the case of an acute cough; medication is not necessary. In the case of a chronic cough, a chest X-ray is usually ordered and then further investigations are carried out in accordance with the most probable suspected diagnosis; probationary therapies are an important part of the workup. Coughs that are refractory to treatment or unexplained require individualised treatment (pharmacological, including off-label, non-pharmacological) and regular re-evaluation.
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Martínez-González NA, Plate A, Jäger L, Senn O, Neuner-Jehle S. The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners. Antibiotics (Basel) 2022; 11:antibiotics11050543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023] Open
Abstract
Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92–98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65–87%). Faced with intermediate CRP results, GPs preferred 3–5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland
- Correspondence: or
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Levy Jäger
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
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Matthes A, Wolf F, Bleidorn J, Markwart R. "It Was Very Comforting to Find Out Right Away." - Patient Perspectives on Point-of-Care Molecular SARS-CoV-2 Testing in Primary Care. Patient Prefer Adherence 2022; 16:2031-2039. [PMID: 35975172 PMCID: PMC9375998 DOI: 10.2147/ppa.s372366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The use of point-of-care tests (POCTs) has been a central strategy to cope with the COVID-19 pandemic. Yet, evidence on the application and consequences of POCTs within medical settings is rare. PURPOSE To assess and understand patient perspectives on molecular point-of-care SARS-CoV-2 testing conducted in primary care. METHODS We conducted a cross-sectional survey study among patients who were tested with a molecular SARS-CoV-2 rapid test (ID NOWTM COVID-19 rapid test, Abbott) in 13 primary care practices in the state of Thuringia (Germany) from February to April 2021. The following aspects were covered in the questionnaire through rating scales and open text formats: test characteristics, trust in test result, consequences of immediate result, cost amount willing to pay and expectations in the future. Open text answers were categorized; quantitative data were analyzed using descriptive statistics and a Mann-Whitney U-test to reveal differences in cost contribution depending on the test result. RESULTS A total of 215 patients from nine family practices and one pediatric practice participated. The immediate availability of the test result was important to the majority of patients (94.3%). 95.7% of patients trusted in their test result. Personal consequences of the immediate test result referred to pandemic measures, certainty of action and reassurance. For further tests, patients were willing to pay between 0€ and 100€ (interquartile range = 10-25€) for the molecular SARS-CoV-2 POCT, regardless of the test result. Expectations of being offered the test again in case of renewed cold symptoms were reported by 96.2%. CONCLUSION Patients highly appreciated molecular SARS-CoV-2 rapid testing conducted in primary care practices. The immediate availability of the test result led to adjustments in patients' behavior and emotional wellbeing. However, potentially challenging for the implementation of POCTs in primary care practices may be the reimbursement of test costs and patients' expectations in future situation.
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Affiliation(s)
- Anni Matthes
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Thuringia, Germany
- InfectoGnostics Research Campus Jena, Jena, Thuringia, Germany
- Correspondence: Anni Matthes, Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Bachstr. 18, Jena, Thuringia, 07743, Germany, Tel +49 3641 939 5824, Fax +49 3641 939 5802, Email
| | - Florian Wolf
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Thuringia, Germany
| | - Jutta Bleidorn
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Thuringia, Germany
| | - Robby Markwart
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Thuringia, Germany
- InfectoGnostics Research Campus Jena, Jena, Thuringia, Germany
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10
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Rasti R, Brännström J, Mårtensson A, Zenk I, Gantelius J, Gaudenzi G, Alvesson HM, Alfvén T. Point-of-care testing in a high-income country paediatric emergency department: a qualitative study in Sweden. BMJ Open 2021; 11:e054234. [PMID: 34824122 PMCID: PMC8627407 DOI: 10.1136/bmjopen-2021-054234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/05/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES In many resource-limited health systems, point-of-care tests (POCTs) are the only means for clinical patient sample analyses. However, the speed and simplicity of POCTs also makes their use appealing to clinicians in high-income countries (HICs), despite greater laboratory accessibility. Although also part of the clinical routine in HICs, clinician perceptions of the utility of POCTs are relatively unknown in such settings as compared with others. In a Swedish paediatric emergency department (PED) where POCT use is routine, we aimed to characterise healthcare providers' perspectives on the clinical utility of POCTs and explore their implementation in the local setting; to discuss and compare such perspectives, to those reported in other settings; and finally, to gather requests for ideal novel POCTs. DESIGN Qualitative focus group discussions study. A data-driven content analysis approach was used for analysis. SETTING The PED of a secondary paediatric hospital in Stockholm, Sweden. PARTICIPANTS Twenty-four healthcare providers clinically active at the PED were enrolled in six focus groups. RESULTS A range of POCTs was routinely used. The emerging theme Utility of our POCT use is double-edged illustrated the perceived utility of POCTs. While POCT services were considered to have clinical and social value, the local routine for their use was named to distract clinicians from the care for patients. Requests were made for ideal POCTs and their implementation. CONCLUSION Despite their clinical integration, deficient implementation routines limit the benefits of POCT services to this well-resourced paediatric clinic. As such deficiencies are shared with other settings, it is suggested that some characteristics of POCTs and of their utility are less related to resource level and more to policy deficiency. To address this, we propose the appointment of skilled laboratory personnel as ambassadors to hospital clinics offering POCT services, to ensure higher utility of such services.
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Affiliation(s)
- Reza Rasti
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Paediatric Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
- Paediatric Immuno-psychiatry Unit, CAP Research Centre, Stockholm Healthcare Services, Stockholm, Sweden
| | - Johanna Brännström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Mårtensson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Ingela Zenk
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden
| | - Jesper Gantelius
- Division of Nanobiotechnology, Department of Protein Science, KTH Royal Institute of Technology, Science for Life Laboratory, Stockholm, Sweden
| | - Giulia Gaudenzi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Division of Nanobiotechnology, Department of Protein Science, KTH Royal Institute of Technology, Science for Life Laboratory, Stockholm, Sweden
| | | | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden
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11
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Li E, Dewez JE, Luu Q, Emonts M, Maconochie I, Nijman R, Yeung S. Role of point-of-care tests in the management of febrile children: a qualitative study of hospital-based doctors and nurses in England. BMJ Open 2021; 11:e044510. [PMID: 33972339 PMCID: PMC8112413 DOI: 10.1136/bmjopen-2020-044510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The use of rapid point-of-care tests (POCTs) has been advocated for improving patient management and outcomes and for optimising antibiotic prescribing. However, few studies have explored healthcare workers' views about their use in febrile children. The aim of this study was to explore the perceptions of hospital-based doctors and nurses regarding the use of POCTs in England. STUDY DESIGN Qualitative in-depth interviews with purposively selected hospital doctors and nurses. Data were analysed thematically. SETTING Two university teaching hospitals in London and Newcastle. PARTICIPANTS 24 participants (paediatricians, emergency department doctors, trainee paediatricians and nurses). RESULTS There were diverse views about the use of POCTs in febrile children. The reported advantages included their ease of use and the rapid availability of results. They were seen to contribute to faster clinical decision-making; the targeting of antibiotic use; improvements in patient care, flow and monitoring; cohorting (ie, the physical clustering of hospitalised patients with the same infection to limit spread) and enhancing communication with parents. These advantages were less evident when the turnaround for results of laboratory tests was 1-2 hours. Factors such as clinical experience and specialty, as well as the availability of guidelines recommending POCT use, were also perceived as influential. However, in addition to their perceived inaccuracy, participants were concerned about POCTs not resolving diagnostic uncertainty or altering clinical management, leading to a commonly expressed preference for relying on clinical skills rather than test results solely. CONCLUSION In this study conducted at two university teaching hospitals in England, participants expressed mixed opinions about the utility of current POCTs in the management of febrile children. Understanding the current clinical decision-making process and the specific needs and preferences of clinicians in different settings will be critical in ensuring the optimal design and deployment of current and future tests.
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Affiliation(s)
- Edmond Li
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Department of Surgery & Cancer, Imperial College, London, UK
| | - Juan Emmanuel Dewez
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Queena Luu
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Marieke Emonts
- Department of Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Paediatric Emergency Department, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Ruud Nijman
- Section of Paediatric Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Shunmay Yeung
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Department of Paediatric Infectious Disease, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
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12
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Borek AJ, Campbell A, Dent E, Butler CC, Holmes A, Moore M, Walker AS, McLeod M, Tonkin-Crine S. Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices. BMC FAMILY PRACTICE 2021; 22:25. [PMID: 33485324 PMCID: PMC7825381 DOI: 10.1186/s12875-021-01371-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. METHODS This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. RESULTS Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience - participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' - participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities - participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context - various other situational and practical issues were raised with implementing the strategies. CONCLUSIONS High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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13
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Eley CV, Sharma A, Lee H, Charlett A, Owens R, McNulty CAM. Effects of primary care C-reactive protein point-of-care testing on antibiotic prescribing by general practice staff: pragmatic randomised controlled trial, England, 2016 and 2017. ACTA ACUST UNITED AC 2020; 25. [PMID: 33153517 PMCID: PMC7645970 DOI: 10.2807/1560-7917.es.2020.25.44.1900408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background C-reactive protein (CRP) testing can be used as a point-of-care test (POCT) to guide antibiotic use for acute cough. Aim We wanted to determine feasibility and effect of introducing CRP POCT in general practices in an area with high antibiotic prescribing for patients with acute cough and to evaluate patients’ views of the test. Methods We used a McNulty–Zelen cluster pragmatic randomised controlled trial design in general practices in Northern England. Eight intervention practices accepted CRP testing and eight control practices maintained usual practice. Data collection included process evaluation, patient questionnaires, practice audit and antibiotic prescribing data. Results Eight practices with over 47,000 patient population undertook 268 CRP tests over 6 months: 78% of patients had a CRP < 20 mg/L, 20% CRP 20–100 mg/L and 2% CRP > 100 mg/L, where 90%, 22% and 100%, respectively, followed National Institute for Health and Care Excellence (NICE) antibiotic prescribing guidance. Patients reported that CRP testing was comfortable (88%), convenient (84%), useful (92%) and explained well (85%). Patients believed CRP POCT aided clinical diagnosis, provided quick results and reduced unnecessary antibiotic use. Intervention practices had an estimated 21% reduction (95% confidence interval: 0.46–1.35) in the odds of prescribing for cough compared with the controls, a non-significant but clinically relevant reduction. Conclusions In routine general practice, CRP POCT use was variable. Non-significant reductions in antibiotic prescribing may reflect small sample size due to non-use of tests. While CRP POCT may be useful, primary care staff need clearer CRP guidance and action planning according to NICE guidance.
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Affiliation(s)
| | - Anita Sharma
- An NHS Clinical Commissioning Group, Greater Manchester, United Kingdom
| | - Hazel Lee
- An NHS Clinical Commissioning Group, Greater Manchester, United Kingdom
| | - Andre Charlett
- Statistics Unit, Public Health England, London, United Kingdom
| | - Rebecca Owens
- Primary Care Unit, Public Health England, Gloucester, United Kingdom
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14
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Kuil SD, Schneeberger C, van Leth F, de Jong MD, Harting J. "A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: a qualitative study. BMC Geriatr 2020; 20:450. [PMID: 33148189 PMCID: PMC7643302 DOI: 10.1186/s12877-020-01853-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent non-specific symptomatology and asymptomatic bacteriuria. The objective of this study was to explore health care professionals' perceptions of the proposed use of inflammatory marker Point-Of-Care Testing (POCT) in this respect. METHODS We conducted a qualitative inquiry (2018-2019) alongside the multicenter PROGRESS study (NL6293), which assessed the sensitivity of C-reactive protein and procalcitonin POCT in UTI. We used semi-structured face-to-face interviews. The participants were physicians (n = 12) and nurses (n = 6) from 13 nursing homes in the Netherlands. Most respondents were not familiar with inflammatory marker POCT, while some used POCT for respiratory tract infections. Both the interview guide and the analysis of the interview transcripts were based on the Consolidated Framework for Implementation Research. RESULTS All respondents acknowledged that sufficiently sensitive POCT could decrease diagnostic uncertainty to some extent in residents presenting with non-specific symptoms. They primarily thought that negative test results would rule out UTI and justify withholding antibiotic treatment. Secondly, they described how positive test results could rule in UTI and justify antimicrobial treatment. However, most respondents also expected new diagnostic uncertainties to arise. Firstly, in case of negative test results, they were not sure how to deal with residents' persisting non-specific symptoms. Secondly, in case of positive test results, they feared overlooking infections other than UTI. These new uncertainties could lead to inappropriate antibiotics use. Therefore, POCT was thought to create a false sense of confidence. CONCLUSIONS Our study suggests that inflammatory marker POCT will only improve UTI management in nursing homes to some extent. To realize the expected added value, any implementation of POCT requires thorough guidance to ensure appropriate use. Developing UTI markers with high negative and positive predictive values may offer greater potential to improve UTI management in nursing homes.
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Affiliation(s)
- S D Kuil
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - C Schneeberger
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - F van Leth
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - M D de Jong
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J Harting
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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15
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C-reactive protein-guided antibiotic prescribing for COPD exacerbations: a qualitative evaluation. Br J Gen Pract 2020; 70:e505-e513. [PMID: 32424045 PMCID: PMC7239040 DOI: 10.3399/bjgp20x709865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background Antibiotics are prescribed to >70% of patients presenting in primary care with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The PACE randomised controlled trial found that a C-reactive protein point-of-care test (CRP-POCT) management strategy for AECOPD in primary care resulted in a 20% reduction in patient-reported antibiotic consumption over 4 weeks. Aim To understand perceptions of the value of CRP-POCT for guiding antibiotic prescribing for AECOPD; explore possible mechanisms, mediators, and pathways to effects; and identify potential barriers and facilitators to implementation from the perspectives of patients and clinicians. Design and setting Qualitative process evaluation in UK general practices. Method Semi-structured telephone interviews with 20 patients presenting with an AECOPD and 20 primary care staff, purposively sampled from the PACE study. Interviews were audio-recorded, transcribed, and analysed using framework analysis. Results Patients and clinicians felt that CRP-POCT was useful in guiding clinicians’ antibiotic prescribing decisions for AECOPD, and were positive about introduction of the test in routine care. The CRP-POCT enhanced clinician confidence in antibiotic prescribing decisions, reduced decisional ambiguity, and facilitated communication with patients. Some clinicians thought the CRP-POCT should be routinely used in consultations for AECOPD; others favoured use only when there was decisional uncertainty. CRP-POCT cartridge preparation time and cost were potential barriers to implementation. Conclusion CRP-POCT-guided antibiotic prescribing for AECOPD had high acceptability, but commissioning arrangements and further simplification of the CRP-POCT need attention to facilitate implementation in routine practice.
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16
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Burrowes SAB, Rader A, Ni P, Drainoni ML, Barlam TF. Low Uptake of Rapid Diagnostic Tests for Respiratory Tract Infections in an Urban Safety Net Hospital. Open Forum Infect Dis 2020; 7:ofaa057. [PMID: 32166096 PMCID: PMC7060900 DOI: 10.1093/ofid/ofaa057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/13/2020] [Indexed: 01/21/2023] Open
Abstract
Background Rapid diagnostic tests (RDTs) have been developed with the aim of providing accurate results in a timely manner. Despite this, studies report that provider uptake remains low. Methods We conducted a retrospective analysis of ambulatory, urgent care, and emergency department (ED) encounters at an urban safety net hospital with a primary diagnosis of an upper or lower respiratory tract infection (eg, bronchitis, pharyngitis, acute sinusitis) from January 1, 2016, to December 31, 2018. We collected RDT type and results, antibiotics prescribed, demographic and clinical patient information, and provider demographics. Results RDT use was low; a test was performed at 29.5% of the 33 494 visits. The RDT most often ordered was the rapid Group A Streptococcus (GAS) test (n = 7352), predominantly for visits with a discharge diagnosis of pharyngitis (n = 5818). Though antibiotic prescription was more likely if the test was positive (relative risk [RR], 1.68; 95% confidence interval [CI], 1.58–1.8), 92.46% of streptococcal pharyngitis cases with a negative test were prescribed an antibiotic. The Comprehensive Respiratory Panel (CRP) was ordered in 2498 visits; influenza was the most commonly detected pathogen. Physicians in the ED were most likely to order a CRP. Antibiotic prescription was lower if the CRP was not ordered compared with a negative CRP result (RR, 0.77; 95% CI, 0.7–0.84). There was no difference in prescribing by CRP result (negative vs positive). Conclusions RDTs are used infrequently in the outpatient setting, and impact on prescribing was inconsistent. Further work is needed to determine barriers to RDT use and to address potential solutions.
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Affiliation(s)
- Shana A B Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alec Rader
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Pengsheng Ni
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Evans Center for Implementation and Improvement Sciences (CIIS), Boston University School of Medicine, Boston, Massachusetts, USA.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts, USA
| | - Tamar F Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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17
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Francis NA, Gillespie D, White P, Bates J, Lowe R, Sewell B, Phillips R, Stanton H, Kirby N, Wootton M, Thomas-Jones E, Hood K, Llor C, Cals J, Melbye H, Naik G, Gal M, Fitzsimmons D, Alam MF, Riga E, Cochrane A, Butler CC. C-reactive protein point-of-care testing for safely reducing antibiotics for acute exacerbations of chronic obstructive pulmonary disease: the PACE RCT. Health Technol Assess 2020; 24:1-108. [PMID: 32202490 PMCID: PMC7132534 DOI: 10.3310/hta24150] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed antibiotics, but these may not be beneficial, and they can cause side effects and increase the risk of subsequent resistant infections. Point-of-care tests (POCTs) could safely reduce inappropriate antibiotic prescribing and antimicrobial resistance. OBJECTIVE To determine whether or not the use of a C-reactive protein (CRP) POCT to guide prescribing decisions for AECOPD reduces antibiotic consumption without having a negative impact on chronic obstructive pulmonary disease (COPD) health status and is cost-effective. DESIGN A multicentre, parallel-arm, randomised controlled open trial with an embedded process, and a health economic evaluation. SETTING General practices in Wales and England. A UK NHS perspective was used for the economic analysis. PARTICIPANTS Adults (aged ≥ 40 years) with a primary care diagnosis of COPD, presenting with an AECOPD (with at least one of increased dyspnoea, increased sputum volume and increased sputum purulence) of between 24 hours' and 21 days' duration. INTERVENTION CRP POCTs to guide antibiotic prescribing decisions for AECOPD, compared with usual care (no CRP POCT), using remote online randomisation. MAIN OUTCOME MEASURES Patient-reported antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status as measured with the Clinical COPD Questionnaire (CCQ) at 2 weeks. For the economic evaluation, patient-reported resource use and the EuroQol-5 Dimensions were included. RESULTS In total, 653 participants were randomised from 86 general practices. Three withdrew consent and one was randomised in error, leaving 324 participants in the usual-care arm and 325 participants in the CRP POCT arm. Antibiotics were consumed for AECOPD by 212 out of 274 participants (77.4%) and 150 out of 263 participants (57.0%) in the usual-care and CRP POCT arm, respectively [adjusted odds ratio 0.31, 95% confidence interval (CI) 0.20 to 0.47]. The CCQ analysis comprised 282 and 281 participants in the usual-care and CRP POCT arms, respectively, and the adjusted mean CCQ score difference at 2 weeks was 0.19 points (two-sided 90% CI -0.33 to -0.05 points). The upper limit of the CI did not contain the prespecified non-inferiority margin of 0.3. The total cost from a NHS perspective at 4 weeks was £17.59 per patient higher in the CRP POCT arm (95% CI -£34.80 to £69.98; p = 0.408). The mean incremental cost-effectiveness ratios were £222 per 1% reduction in antibiotic consumption compared with usual care at 4 weeks and £15,251 per quality-adjusted life-year gained at 6 months with no significant changes in sensitivity analyses. Patients and clinicians were generally supportive of including CRP POCT in the assessment of AECOPD. CONCLUSIONS A CRP POCT diagnostic strategy achieved meaningful reductions in patient-reported antibiotic consumption without impairing COPD health status or increasing costs. There were no associated harms and both patients and clinicians valued the diagnostic strategy. FUTURE WORK Implementation studies that also build on our qualitative findings could help determine the effect of this intervention over the longer term. TRIAL REGISTRATION Current Controlled Trials ISRCTN24346473. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - David Gillespie
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Patrick White
- Department of Primary Care & Public Health Sciences, King's College London, London, UK
| | - Janine Bates
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Rachel Lowe
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Bernadette Sewell
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Rhiannon Phillips
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Helen Stanton
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Nigel Kirby
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, University Hospital of Wales, Cardiff, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Jochen Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Gurudutt Naik
- Department of Wound Healing, University Hospital Wales, Cardiff, UK
| | - Micaela Gal
- Wales Primary and Emergency Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Mohammed Fasihul Alam
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Evgenia Riga
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Cochrane
- Department of Primary Care & Public Health Sciences, King's College London, London, UK
| | - Christopher C Butler
- Primary Care and Vaccines Collaborative Clinical Trials Unit, University of Oxford, John Radcliffe Hospital, Oxford, UK
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18
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van Hecke O, Butler C, Mendelson M, Tonkin-Crine S. Introducing new point-of-care tests for common infections in publicly funded clinics in South Africa: a qualitative study with primary care clinicians. BMJ Open 2019; 9:e029260. [PMID: 31772084 PMCID: PMC6887073 DOI: 10.1136/bmjopen-2019-029260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
UNLABELLED Broad-spectrum antibiotics are routinely prescribed empirically in the resource-poor settings for suspected acute common infections, which drive antimicrobial resistance. Point-of-care testing (POCT) might increase the appropriateness of decisions about whether and which antibiotic to prescribe, but implementation will be most effective if clinician's perspectives are taken into account. OBJECTIVES To explore the perceptions of South African primary care clinicians working in publicly funded clinics about: making antibiotic prescribing decisions for two common infection syndromes (acute cough, urinary tract infection); their experiences of existing POCTs; their perceptions of the barriers and opportunities for introducing (hypothetical) new POCTs. DESIGN, METHOD, PARTICIPANTS, SETTING Qualitative semistructured interviews with 23 primary care clinicians (nurses and doctors) at publicly funded clinics in the Western Cape Metro district, South Africa. Data were analysed using thematic analysis. RESULTS Clinicians reported that their antibiotic prescribing decisions were influenced by their clinical assessment, patient comorbidities, social factors (eg, access to care) and perceived patient expectations. Their experiences with currently available POCTs were largely positive, and they were optimistic about the potential for new POCTs to: support evidence-based prescribing decisions that might reduce unnecessary antibiotic prescriptions; reduce the need for further investigations; support effective communication with patients, especially when antibiotics were unlikely to be of benefit. Resources and workflow disruption were seen as the main barriers to uptake into routine care. CONCLUSIONS Clinicians working in publicly funded clinics in the Western Cape Metro of South Africa saw POCTs as potentially useful for positively addressing both clinical and social drivers of the overprescribing of broad-spectrum antibiotics, but were concerned about the resource implications and disruption of existing patient workflows.
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Affiliation(s)
- Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Brookes-Howell L, Thomas-Jones E, Bates J, Bekkers MJ, Brugman C, Coulman E, Francis N, Hashmi K, Hood K, Kirby N, Llor C, Little P, Moore M, Moragas A, Rumsby K, Verheij T, Butler C. Challenges in managing urinary tract infection and the potential of a point-of-care test guided care in primary care: an international qualitative study. BJGP Open 2019; 3:bjgpopen18X101630. [PMID: 31366667 PMCID: PMC6662873 DOI: 10.3399/bjgpopen18x101630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 10/26/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Little is known about clinicians' experiences of using a point-of-care test (POCT) to inform management of urinary tract infection (UTI) in general practice. AIM To explore experiences of using the Flexicult test to inform management of UTI and views on requirements for an optimal POCT to inform successful implementation. DESIGN & SETTING Telephone interviews with 35 primary care clinicians and healthcare professionals in Wales, England, Spain, and the Netherlands, who had participated in a trial of the Flexicult POCT for UTI based on urine culture. METHOD Thematic analysis of semi-structured interviews. RESULTS Most primary care clinicians interviewed agreed on the need for a POCT in UTI management, and that the Flexicult POCT delivered quicker results than laboratory results used in usual care, reassured patients, boosted their confidence in decision-making, and reminded them about antibiotic stewardship. However, clinicians also reported difficulties in interpreting results, limitations on when the Flexicult could be used, and concerns that testing all patients would strain care delivery and prolong patient discomfort when delaying decisions until a non-rapid POCT result was available. An optimal POCT would produce more rapid results, and be reliable and easy to use. Uptake into routine care would be enhanced by: clear guidance on which patients should be tested; training for interpreting 'grey area' results; reiterating that even 'straightforward' cases might be better managed with a test; clear messages about stopping unnecessary antibiotics versus completing a course; and better self-management strategies to accompany implementation of delayed, or non-prescription of, antibiotics. CONCLUSION Primary care clinicians believe that POCT tests could play a useful role in the management of UTI and gave clear recommendations for successful implementation.
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Affiliation(s)
- Lucy Brookes-Howell
- Research Fellow (Qualitative), Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Emma Thomas-Jones
- Research Fellow, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Janine Bates
- Research Associate, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Marie-Jet Bekkers
- Research Associate, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Curt Brugman
- Project Manager, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Elinor Coulman
- Research Associate, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Nick Francis
- Professor, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Khurram Hashmi
- GP Academic Fellow, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Professor, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Nigel Kirby
- Senior Data Manager, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Carl Llor
- GP and Researcher, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Little
- Professor, Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - Michael Moore
- Professor, Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - Anna Moragas
- Project Manager, University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- GP and Associate Professor, University Rovira i Virgili. Primary Healthcare Centre Jaume I, Tarragona, Spain
| | - Kate Rumsby
- Study Manager, Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - Theo Verheij
- Professor, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Christopher Butler
- Professor of Primary Care, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Recent advances in immunodiagnostics based on biosensor technologies-from central laboratory to the point of care. Anal Bioanal Chem 2019; 411:7607-7621. [PMID: 31152226 DOI: 10.1007/s00216-019-01915-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022]
Abstract
Immunological methods are widely applied in medical diagnostics for the detection and quantification of a plethora of analytes. Associated analytical challenges usually require these assays to be performed in a central laboratory. During the last several years, however, the clinical demand for rapid immunodiagnostics to be performed in the immediate proximity of the patient has been constantly increasing. Biosensors constitute one of the key technologies enabling the necessary, yet challenging transition of immunodiagnostic tests from the central laboratory to the point of care. This review is intended to provide insights into the current state of this transition process with a focus on the role of biosensor-based systems. To begin with, an overview on standard immunodiagnostic tests presently employed in the central laboratory and at the point of care is given. The review then moves on to demonstrate how biosensor technologies are reshaping this landscape. Single analyte as well as multiplexed immunosensors applicable to point of care scenarios are presented. A section on the areas of clinical application then creates the bridge to day-to-day diagnostic practice. Finally, the depicted developments are critically weighed and future perspectives discussed in order to give the reader a firm idea on the forthcoming trends to be expected in this diagnostic field.
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O'Connor R, O'Doherty J, O'Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci 2018; 187:969-986. [PMID: 29532292 PMCID: PMC6209023 DOI: 10.1007/s11845-018-1774-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections. AIMS To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions. METHODS Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review. RESULTS Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education. CONCLUSION There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.
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Affiliation(s)
- Ray O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland.
| | - Jane O'Doherty
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Andrew O'Regan
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
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Eley CV, Sharma A, Lecky DM, Lee H, McNulty CAM. Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England. BMJ Open 2018; 8:e023925. [PMID: 30361406 PMCID: PMC6224729 DOI: 10.1136/bmjopen-2018-023925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To explore the knowledge, skills, attitudes and beliefs of general practice staff about C reactive protein (CRP) point-of-care tests (POCTs) in routine general practice and associated barriers and facilitators to implementing it to improve the management of acute cough. DESIGN A qualitative methodology including interviews and focus groups using the Com-B framework to understand individuals' behaviour to implement CRP POCT in routine general practice. Data were analysed inductively and then aligned to the Com-B framework. SETTING A service evaluation of CRP POCT over a 6-month period was previously conducted in randomly selected GP practices from a high prescribing National Health Service Clinicial Commissioning Groups in England. All 11 intervention practices (eight accepting CRPs; three declining CRPs) and the eight control practices, which were not offered CRP POCT, were also invited to interview. A further randomly selected practice not allocated to intervention or control was also invited to participate. PARTICIPANTS Seven of eight accepting CRP, one of three declining CRP and four of nine control practices consented to participate. 12 practices and 26 general practice staff participated; 11 interviews, 3 focus groups and 1 hand-written response. RESULTS Participants reported that CRP POCT can increase diagnostic certainty for acute cough, inform appropriate management, manage patient expectations for antibiotics, support patient education and improve appropriate antibiotic prescribing. Reported barriers to implementing CRP POCT included: CRP cost, time, easy access to the POCT machine and effects on clinical workflow. Participants with greater CRP use usually had a dedicated staff member with the machine located in their consultation room. CONCLUSIONS CRP POCT can help general practice staff improve patient care and education if incorporated into routine care, but this will need enthusiasts with dedicated POCT instruments or smaller, cheaper, more portable machines. In addition, funding will be needed to support test costs and staff time.
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Affiliation(s)
| | - Anita Sharma
- NHS Oldham Clinical Commissioning Group, Oldham, UK
| | | | - Hazel Lee
- NHS Oldham Clinical Commissioning Group, Oldham, UK
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23
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Gal M, Francis NA, Hood K, Villacian J, Goossens H, Watkins A, Butler CC. Matching diagnostics development to clinical need: Target product profile development for a point of care test for community-acquired lower respiratory tract infection. PLoS One 2018; 13:e0200531. [PMID: 30067760 PMCID: PMC6070214 DOI: 10.1371/journal.pone.0200531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 06/28/2018] [Indexed: 11/23/2022] Open
Abstract
Background Point of care tests (POCTs) are increasingly being promoted for guiding the primary medical care of community acquired lower respiratory tract infections (CA-LRTI). POCT development has seldom been guided by explicitly identified clinical need and requirements of the intended users. Approaches for identifying POCT priorities and developing target product profiles (TPPs) for POCTs in primary medical care are not well developed, and there is no published TPP for a CA-LRTI POCT aimed at developed countries. Methods We conducted workshops with expert stakeholders and a survey with primary care clinicians to produce a target product profile (TPP) to guide the development of a clinically relevant and technologically feasible POCT for CA-LRTI. Results Participants with clinical, academic, industrial, technological and basic scientific backgrounds contributed to four expert workshops, and 45 practicing primary care clinicians responded to an online survey and prioritised community-acquired pneumonia (CAP) as the CA-LRTI where a new POCT was most urgently needed. Consensus was reached on a TPP document that included information on the intended niche in the clinical pathway in primary medical care; diagnostic product specification (intended use statement and test concept), and minimum and ideal user specifications. Clinicians minimum requirements of a CA-LRTI POCT included the use of minimally invasive samples, a result in less than 30 minutes, no more than a single preparation step, minimum operational requirements, and detection of common respiratory pathogens and their resistance to commonly prescribed antibiotics. Conclusions This multidisciplinary, multistage partnership approach generated a clinically-driven TPP for guiding the development of a new POCT, and this approach as well as the TPP itself may be useful to others developing a new POCT.
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Affiliation(s)
- Micaela Gal
- Division of Population Medicine, Medical School, Cardiff University, Cardiff, United Kingdom
- * E-mail:
| | - Nicholas A. Francis
- Division of Population Medicine, Medical School, Cardiff University, Cardiff, United Kingdom
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | | | - Herman Goossens
- Department of Clinical Pathology, University of Antwerp, Wilrijk, Belgium
| | - Angela Watkins
- Division of Population Medicine, Medical School, Cardiff University, Cardiff, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Hayhoe B, Butler CC, Majeed A, Saxena S. Telling the truth about antibiotics: benefits, harms and moral duty in prescribing for children in primary care. J Antimicrob Chemother 2018; 73:2298-2304. [DOI: 10.1093/jac/dky223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Benedict Hayhoe
- Child Health Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Reynolds Building, St Dunstan’s Road, London, UK
| | - Christopher C Butler
- Nuffield Department of Primary Health Sciences, Medical Sciences Division, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, Reynolds Building, St Dunstan’s Road, London, UK
| | - Sonia Saxena
- Child Health Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Reynolds Building, St Dunstan’s Road, London, UK
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25
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Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography. Br J Gen Pract 2018; 68:e633-e645. [PMID: 29914880 DOI: 10.3399/bjgp18x697889] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/15/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections. AIM The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists). DESIGN AND SETTING Systematic review and meta-ethnography of qualitative studies. METHOD A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed. RESULTS In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary). CONCLUSION Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities.
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26
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Veinot TC, Senteio CR, Hanauer D, Lowery JC. Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis. J Am Med Inform Assoc 2018; 25:746-758. [PMID: 29025114 PMCID: PMC7646963 DOI: 10.1093/jamia/ocx085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/18/2017] [Accepted: 08/01/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. Materials and Methods We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. Results The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. Discussion The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. Conclusion The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.
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Affiliation(s)
- Tiffany C Veinot
- School of Information and School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Charles R Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - David Hanauer
- Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Julie C Lowery
- Center for Clinical Management, Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA
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Khine Zaw Y, Charoenboon N, Haenssgen MJ, Lubell Y. A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon. Am J Trop Med Hyg 2018; 98:1661-1670. [PMID: 29633689 PMCID: PMC6086164 DOI: 10.4269/ajtmh.17-0906] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients' treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to 1) compare local conceptions of illness and medicines in relation to health-care seeking and antibiotic demand; and to 2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients' preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients' self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test. Although we expected that local conceptions of illness diverge from inbuilt assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and nonusers. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes.
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Affiliation(s)
- Yuzana Khine Zaw
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marco J Haenssgen
- CABDyN Complexity Centre, Saïd Business School, University of Oxford, Oxford, United Kingdom.,Green Templeton College, United Kingdom.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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28
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C-reactive protein point-of-care testing in children with cough: qualitative study of GPs' perceptions. BJGP Open 2017; 1:bjgpopen17X101193. [PMID: 30564689 PMCID: PMC6181107 DOI: 10.3399/bjgpopen17x101193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/18/2017] [Indexed: 11/18/2022] Open
Abstract
Background Point-of-care C-reactive protein (CRP) testing is widely accepted in Dutch general practice for adult patients with acute cough, but GPs’ perceptions of its use in children with suspected lower respiratory tract infection (LRTI) are unknown. Knowledge of these perceptions is important when considering broadening its indication to use in children. Aim To explore the perceptions of Dutch GPs of the addition of point-of-care CRP testing to the diagnostic evaluation of children, and compare these to their perceptions of use in adults. Design & setting A qualitative study in general practice in the Netherlands. Method Semi-structured interviews were held with 11 GPs. Interviews were analysed using open coding and a thematic approach. Results GPs’ perceptions of the addition of point-of-care CRP testing to diagnostic process in children with suspected LRTI differ from their perceptions of this in adults. Five themes were identified: patient characteristics; vulnerability of the child; clinical presentation; availability of evidence; the impact of the procedure; and use of point-of-care CRP testing as a communication tool. Conclusion Differences between the perceptions of using point-of-care CRP testing in children and adults need to be addressed when considering the possible implementation of this diagnostic instrument.
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Patient Willingness to Have Tests to Guide Antibiotic Use for Respiratory Tract Infections: From the WWAMI Region Practice and Research Network (WPRN). J Am Board Fam Med 2017; 30:645-656. [PMID: 28923817 PMCID: PMC6836869 DOI: 10.3122/jabfm.2017.05.170087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/01/2017] [Accepted: 05/02/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The majority of consultations for acute respiratory tract infections (RTIs) lead to prescriptions for antibiotics, which have limited clinical benefit. We explored patients' willingness to have blood tests as part of the diagnostic work-up for RTIs, and patient knowledge about antibiotics. METHODS Patients at 6 family medicine clinics were surveyed. Regression modeling was used to determine independent predictors of willingness to have venous and point-of-care (POC) blood tests, and knowledge of the value of antibiotics for RTIs. RESULTS Data were collected from 737 respondents (response rate 83.8%), of whom 65.7% were women, 60.1% were white, and 25.1% were current smokers; patients' mean age was 46.9 years. Sex (female), race (white), and a preference to avoid antibiotics were independent predictors of greater level of antibiotic knowledge. A total of 63.1% were willing to have a venous draw and 79% a POC blood test, to help guide antibiotic decision-making. Non-American Indian/Alaskan Native race, current smoking, and greater knowledge of antibiotics were independent predictors of willingness to have a POC test. CONCLUSION A large majority of patients seemed willing to have POC tests to facilitate antibiotic prescribing decisions for RTIs. Poor knowledge about antibiotics suggests better education regarding antibiotic use might influence patient attitudes towards use of antibiotics for RTIs.
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Bruning AHL, de Kruijf WB, van Weert HCPM, Willems WLM, de Jong MD, Pajkrt D, Wolthers KC. Diagnostic performance and clinical feasibility of a point-of-care test for respiratory viral infections in primary health care. Fam Pract 2017; 34:558-563. [PMID: 28369370 PMCID: PMC7108454 DOI: 10.1093/fampra/cmx019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Inappropriately high levels of antibiotics are still prescribed in primary health care for respiratory tract infections (RTIs). Access to diagnostic point-of-care tests (POCTs) for RTIs might reduce this over-prescription. OBJECTIVE The purpose of our study was to determine the diagnostic performance and clinical feasibility of a recently developed diagnostic POCT for respiratory viruses, the mariPOC®, in a Dutch primary healthcare setting. METHODS In patients with RTI symptoms presenting to a family practice during the 2015-2016 winter season, we determined the test's sensitivity and specificity relative to polymerase chain reaction (PCR) testing performed in a laboratory. The clinical feasibility of the POCT was evaluated by interviewing general practitioners (GPs). RESULTS One or more respiratory viruses were detected in 54.9% of the patients (n = 204). For influenza A virus (n = 24), sensitivity of the POCT was 54.2% and specificity was 98.9%; for influenza B virus (n = 18), sensitivity was 72.2% and specificity 99.5%; and for respiratory syncytial virus (RSV) (n = 12), sensitivity was 50.0% and specificity 100%. In samples with higher viral load, sensitivity was 85.7% for influenza A, 78.6% for influenza B and 85.7% for RSV. The availability of a diagnostic test for respiratory viruses was appreciated by both patients and GPs. CONCLUSIONS Our study shows that diagnostic POCTs for respiratory viruses might contribute to a precise and evidence-based diagnosis of RTIs and could positively influence prescription of antibiotics by GPs. However, before implementation in primary healthcare, diagnostic accuracy of the POCT needs improvement and it is impact on clinical decision making should be further assessed.
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Affiliation(s)
- Andrea H L Bruning
- Department of Pediatric Infectious Diseases and Immunology, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Wilhelmina B de Kruijf
- Department of Pediatric Infectious Diseases and Immunology, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | | | | | - Menno D de Jong
- Department of Medical Microbiology, AMC, Amsterdam, The Netherlands
| | - Dasja Pajkrt
- Department of Pediatric Infectious Diseases and Immunology, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Katja C Wolthers
- Department of Medical Microbiology, AMC, Amsterdam, The Netherlands
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Chambers D, Booth A, Baxter SK, Johnson M, Dickinson KC, Goyder EC. Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BackgroundCurrent NHS policy favours the expansion of diagnostic testing services in community and primary care settings.ObjectivesOur objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.Review methodsWe performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.ResultsWe identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.ConclusionsIn the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.LimitationsWe have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.Future workThere is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan K Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine C Dickinson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth C Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Jones CHD, Glogowska M, Locock L, Lasserson DS. Embedding new technologies in practice - a normalization process theory study of point of care testing. BMC Health Serv Res 2016; 16:591. [PMID: 27756282 PMCID: PMC5070078 DOI: 10.1186/s12913-016-1834-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 10/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Many point of care diagnostic technologies are available which produce results within minutes, and offer the opportunity to deliver acute care out of hospital settings. Increasing access to diagnostics at the point of care could increase the volume and scope of acute ambulatory care. Yet these technologies are not routinely used in many settings. We aimed to explore how point of care testing is used in a setting where it has become ‘normalized’ (embedded in everyday practice), in order to inform future adoption and implementation in other settings. We used normalization process theory to guide our case study approach. Methods We used a single case study design, choosing a community based ambulatory care unit where point of care testing is used routinely. A focused ethnographic approach was taken, including non-participant observation of all activities related to point of care testing, and semi-structured interviews, with all clinical staff involved in point of care testing at the unit. Data were analysed thematically, guided by normalization process theory. Results Fourteen days of observation and six interviews were completed. Staff had a shared understanding of the purpose, value and benefits of point of care testing, believing it to be integral to the running of the unit. They organised themselves as a team to ensure that point of care testing worked effectively; and one key individual led a change in practice to ensure more consistency and trust in procedures. Staff assessed point of care testing as worthwhile for the unit, their patients, and themselves in terms of job satisfaction and knowledge. Potential barriers to adoption of point of care testing were evident (including lack of trust in the accuracy of some results compared to laboratory testing; and lack of ease of use of some aspects of the equipment); but these did not prevent point of care testing from becoming embedded, because the importance and value attributed to it were so strong. Conclusions This case study offers insights into successful adoption of new diagnostic technologies into every day practice. Such analyses may be critical to realising their potential to change processes of care. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1834-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Caroline H D Jones
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - Louise Locock
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Daniel S Lasserson
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headley Way, Oxford, OX3 9DU, UK
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Abstract
Respiratory tract infections (RTI) are among the most common acute conditions leading to GP consultations and to antibiotic prescribing in primary care, even though 70% are viral, and many others are minor self-limiting bacterial infections.1-4 Between 0.5% and 1.1% of adults have community-acquired pneumonia every year in the UK, most of whom are managed in primary care.4,5 The decision to prescribe antibiotics for an acute RTI in primary care is often based on clinical symptoms, which have low sensitivity and specificity, and high inter-observer variability.2,4 In primary care, it is very difficult to differentiate between diagnoses without additional tests.6 Unnecessary antibiotic prescribing may not aid recovery, exposes patients to potential adverse effects, may encourage repeat attendance and contributes to antibiotic resistance.2,7 One strategy aiming to reduce antibiotic prescribing in primary care is the use of biomarkers (e.g. C-reactive protein [CRP]).2 In the correct clinical context (e.g. in previously healthy people, not those with chronic lung disease) and as an adjunct to clinical assessment, a biomarker may help in the management of an RTI.2 In order to be used during the consultation, the results of a biomarker test must be rapidly available (e.g. 'point-of-care' [POC] testing).4 POC testing for CRP has recently been recommended as part of a national clinical guideline on the diagnosis and management of pneumonia.4 Here, we review the rationale for POC CRP testing and its advantages and disadvantages.
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Tonkin-Crine S, Anthierens S, Hood K, Yardley L, Cals JWL, Francis NA, Coenen S, van der Velden AW, Godycki-Cwirko M, Llor C, Butler CC, Verheij TJM, Goossens H, Little P. Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: achieving clarity through mixed methods triangulation. Implement Sci 2016; 11:66. [PMID: 27175799 PMCID: PMC4866290 DOI: 10.1186/s13012-016-0436-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 05/06/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Mixed methods are commonly used in health services research; however, data are not often integrated to explore complementarity of findings. A triangulation protocol is one approach to integrating such data. A retrospective triangulation protocol was carried out on mixed methods data collected as part of a process evaluation of a trial. The multi-country randomised controlled trial found that a web-based training in communication skills (including use of a patient booklet) and the use of a C-reactive protein (CRP) point-of-care test decreased antibiotic prescribing by general practitioners (GPs) for acute cough. The process evaluation investigated GPs' and patients' experiences of taking part in the trial. METHODS Three analysts independently compared findings across four data sets: qualitative data collected view semi-structured interviews with (1) 62 patients and (2) 66 GPs and quantitative data collected via questionnaires with (3) 2886 patients and (4) 346 GPs. Pairwise comparisons were made between data sets and were categorised as agreement, partial agreement, dissonance or silence. RESULTS Three instances of dissonance occurred in 39 independent findings. GPs and patients reported different views on the use of a CRP test. GPs felt that the test was useful in convincing patients to accept a no-antibiotic decision, but patient data suggested that this was unnecessary if a full explanation was given. Whilst qualitative data indicated all patients were generally satisfied with their consultation, quantitative data indicated highest levels of satisfaction for those receiving a detailed explanation from their GP with a booklet giving advice on self-care. Both qualitative and quantitative data sets indicated higher patient enablement for those in the communication groups who had received a booklet. CONCLUSIONS Use of CRP tests does not appear to engage patients or influence illness perceptions and its effect is more centred on changing clinician behaviour. Communication skills and the patient booklet were relevant and useful for all patients and associated with increased patient satisfaction. A triangulation protocol to integrate qualitative and quantitative data can reveal findings that need further interpretation and also highlight areas of dissonance that lead to a deeper insight than separate analyses.
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Affiliation(s)
- Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Sibyl Anthierens
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Wilrijk, Antwerp, Belgium
| | - Kerenza Hood
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Samuel Coenen
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Wilrijk, Antwerp, Belgium
- Vaccine and Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerp, Belgium
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Carl Llor
- Primary Healthcare Centre Via Roma, Barcelona, Spain
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Vaccine and Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Huddy JR, Ni MZ, Barlow J, Majeed A, Hanna GB. Point-of-care C reactive protein for the diagnosis of lower respiratory tract infection in NHS primary care: a qualitative study of barriers and facilitators to adoption. BMJ Open 2016; 6:e009959. [PMID: 26940107 PMCID: PMC4785316 DOI: 10.1136/bmjopen-2015-009959] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Point-of-care (POC) C reactive protein (CRP) is incorporated in National Institute of Health and Care Excellence (NICE) guidelines for the diagnosis of pneumonia, reduces antibiotic prescribing and is cost effective. AIM To determine the barriers and facilitators to adoption of POC CRP testing in National Health Service (NHS) primary care for the diagnosis of lower respiratory tract infection. DESIGN The study followed a qualitative methodology based on grounded theory. The study was undertaken in 2 stages. Stage 1 consisted of semistructured interviews with 8 clinicians from Europe and the UK who use the test in routine practice, and focused on their subjective experience in the challenges of implementing POC CRP testing. Stage 2 was a multidisciplinary-facilitated workshop with NHS stakeholders to discuss barriers to adoption, impact of adoption and potential adoption scenarios. Emergent theme analysis was undertaken. PARTICIPANTS Participants included general practitioners (including those with commissioning experience), biochemists, pharmacists, clinical laboratory scientists and industry representatives from the UK and abroad. RESULTS Barriers to the implementation of POC CRP exist, but successful adoption has been demonstrated abroad. Analysis highlighted 7 themes: reimbursement and incentivisation, quality control and training, laboratory services, practitioner attitudes and experiences, effects on clinic flow and workload, use in pharmacy and gaps in evidence. CONCLUSIONS Successful adoption models from the UK and abroad demonstrate a distinctive pattern and involve collaboration with central laboratory services. Incorporating antimicrobial stewardship into quality improvement frameworks may incentivise adoption. Further research is needed to develop scaling-up strategies to address the resourcing, clinical governance and economic impact of widespread NHS implementation.
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Affiliation(s)
- Jeremy R Huddy
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Melody Z Ni
- Department of Surgery and Cancer, Imperial College, London, UK
| | - James Barlow
- Imperial College Business School, South Kensington Campus, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
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Borsci S, Buckle P, Hanna GB. Why you need to include human factors in clinical and empirical studies ofin vitropoint of care devices? Review and future perspectives. Expert Rev Med Devices 2016; 13:405-16. [DOI: 10.1586/17434440.2016.1154277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Anticona Huaynate CF, Pajuelo Travezaño MJ, Correa M, Mayta Malpartida H, Oberhelman R, Murphy LL, Paz-Soldan VA. Diagnostics barriers and innovations in rural areas: insights from junior medical doctors on the frontlines of rural care in Peru. BMC Health Serv Res 2015; 15:454. [PMID: 26438342 PMCID: PMC4595324 DOI: 10.1186/s12913-015-1114-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/24/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Worldwide, rural communities face barriers when accessing health services. In response, numerous initiatives have focused on fostering technological innovations, new management approaches and health policies. Research suggests that the most successful innovations are those involving stakeholders at all levels. However, there is little evidence exploring the opinions of local health providers that could contribute with further innovation development and research. The aims of this study were to explore the perspectives of medical doctors (MDs) working in rural areas of Peru, regarding the barriers impacting the diagnostic process, and ideas for diagnostic innovations that could assist them. METHODS Data gathered through three focus group discussions (FGG) and 18 individual semi-structured interviews (SSI) with MDs who had completed their medical service in rural areas of Peru in the last two years were analyzed using thematic analysis. RESULTS Three types of barriers emerged. The first barrier was the limited access to point of care (POC) diagnostic tools. Tests were needed for: i) the differential diagnosis of malaria vs. pneumonia, ii) dengue vs. leptospirosis, iii) tuberculosis, iv) vaginal infections and cervical cancer, v) neurocysticercosis, and vi) heavy metal toxicity. Ultrasound was needed for the diagnosis of obstetric and intra-abdominal conditions. There were also health system-related barriers such as limited funding for diagnostic services, shortage of specialists, limited laboratory services and access to telecommunications, and lack of institutional support. Finally, the third type of barriers included patient related-barriers to follow through with diagnostic referrals. Ideas for innovations proposed included POC equipment and tests, and telemedicine. CONCLUSIONS MDs at primary health facilities in rural Peru face diagnostic challenges that are difficult to overcome due to a limited access to diagnostic tools. Referrals to specialized facilities are constrained by deficiencies in the organization of health services and by barriers that impede the patients' travel to distant health facilities. Technological innovations suggested by the participants such as POC diagnostic tools and mobile-health (m-health) applications could help address part of the problem. However, other types of innovation to address social, adaptation and policy issues should not be dismissed.
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Affiliation(s)
- Cynthia Fiorella Anticona Huaynate
- Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado, 430. SMP., Lima, Peru.
- Department of Global Community Health & Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2301, New Orleans, LA, 70112, USA.
| | - Monica Jehnny Pajuelo Travezaño
- Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado, 430. SMP., Lima, Peru.
- Department of Global Community Health & Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2301, New Orleans, LA, 70112, USA.
| | - Malena Correa
- Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado, 430. SMP., Lima, Peru.
- Department of Global Community Health & Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2301, New Orleans, LA, 70112, USA.
| | - Holger Mayta Malpartida
- Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado, 430. SMP., Lima, Peru.
- Department of Global Community Health & Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2301, New Orleans, LA, 70112, USA.
| | - Richard Oberhelman
- Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado, 430. SMP., Lima, Peru.
| | - Laura L Murphy
- Department of Global Health Systems & Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 1900, New Orleans, LA, 70112, USA.
| | - Valerie A Paz-Soldan
- Department of Global Health Systems & Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 1900, New Orleans, LA, 70112, USA.
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Cooke J, Butler C, Hopstaken R, Dryden MS, McNulty C, Hurding S, Moore M, Livermore DM. Narrative review of primary care point-of-care testing (POCT) and antibacterial use in respiratory tract infection (RTI). BMJ Open Respir Res 2015; 2:e000086. [PMID: 25973210 PMCID: PMC4426285 DOI: 10.1136/bmjresp-2015-000086] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance is a global problem and is being addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) and procalcitonin, measurements to guide antibacterial prescribing in adult patients presenting to GP practices with symptoms of respiratory tract infection (RTI). Studies that were included were randomised controlled trials, controlled before and after studies, cohort studies and economic evaluations. Many studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces antibiotic prescribing by 23.3% to 36.16%. Procalcitonin is not currently available as a point-of-care testing (POCT), but has shown value for patients with RTI admitted to hospital. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. CRP POCT can better target antibacterial prescribing by GPs and contribute to national antimicrobial resistance strategies. Health services need to develop ways to ensure funding is transferred in order for POCT to be implemented.
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Affiliation(s)
- Jonathan Cooke
- Division of Infectious Diseases, Department of Medicine, The Centre for Infection Prevention and Management, Imperial College London, London, UK
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Christopher Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Rogier Hopstaken
- Saltro Diagnostic Centre for Primary Care, Utrecht, The Netherlands
| | - Matthew Scott Dryden
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Simon Hurding
- Scottish Government, Clinical Lead Therapeutics Branch, Edinburgh, UK
- Medicines Management Adviser NHS Lothian, Edinburgh, UK
| | - Michael Moore
- Primary Care and Population Sciences, University of Southampton Aldermoor Health Centre, Aldermoor Close, UK
| | - David Martin Livermore
- Norwich Medical School, University of East Anglia, Norwich, UK
- Antimicrobial Resistance & Healthcare Associated Infections Reference Unit, Public Health England, London, UK
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Wang S, Pulcini C, Rabaud C, Boivin JM, Birgé J. Inventory of antibiotic stewardship programs in general practice in France and abroad. Med Mal Infect 2015; 45:111-23. [DOI: 10.1016/j.medmal.2015.01.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/18/2014] [Accepted: 01/28/2015] [Indexed: 12/18/2022]
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Clinicians' views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections. J Gen Intern Med 2015; 30:408-16. [PMID: 25373834 PMCID: PMC4370987 DOI: 10.1007/s11606-014-3076-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/01/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority. OBJECTIVE We aimed to explore clinicians' experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs). DESIGN We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions. PARTICIPANTS General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study. APPROACH Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis. KEY RESULTS Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician's own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics. CONCLUSION Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.
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Dempsey PP, Businger AC, Whaley LE, Gagne JJ, Linder JA. Primary care clinicians' perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC FAMILY PRACTICE 2014; 15:194. [PMID: 25495918 PMCID: PMC4275949 DOI: 10.1186/s12875-014-0194-5] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Abstract
Background Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated. Methods To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis. Results All the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians’ misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits. Conclusions Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients’ expectations. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0194-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick P Dempsey
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | - Alexandra C Businger
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | - Lauren E Whaley
- Bureau of Infectious Diseases, Massachusetts Department of Public Health, Boston, MA, USA.
| | - Joshua J Gagne
- Survey and Data Management Core, Dana Farber Cancer Institute, Boston, MA, USA.
| | - Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA.
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Aabenhus R, Jensen JUS, Jørgensen KJ, Hróbjartsson A, Bjerrum L. Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care. Cochrane Database Syst Rev 2014:CD010130. [PMID: 25374293 DOI: 10.1002/14651858.cd010130.pub2] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. Unnecessary antibiotic use will, in many cases, not be beneficial to the patients' recovery and expose them to potential side effects. Furthermore, as a causal link exists between antibiotic use and antibiotic resistance, reducing unnecessary antibiotic use is a key factor in controlling this important problem. Antibiotic resistance puts increasing burdens on healthcare services and renders patients at risk of future ineffective treatments, in turn increasing morbidity and mortality from infectious diseases. One strategy aiming to reduce antibiotic use in primary care is the guidance of antibiotic treatment by use of a point-of-care biomarker. A point-of-care biomarker of infection forms part of the acute phase response to acute tissue injury regardless of the aetiology (infection, trauma and inflammation) and may in the correct clinical context be used as a surrogate marker of infection,possibly assisting the doctor in the clinical management of ARIs.Objectives To assess the benefits and harms of point-of-care biomarker tests of infection to guide antibiotic treatment in patients presenting with symptoms of acute respiratory infections in primary care settings regardless of age.Search methods We searched CENTRAL (2013, Issue 12), MEDLINE (1946 to January 2014), EMBASE (2010 to January 2014), CINAHL (1981 to January 2014), Web of Science (1955 to January 2014) and LILACS (1982 to January 2014).Selection criteria We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared use of point-of-care biomarkers with standard of care. We included trials that randomised individual patients as well as trials that randomised clusters of patients(cluster-RCTs).Two review authors independently extracted data on the following outcomes: i) impact on antibiotic use; ii) duration of and recovery from infection; iii) complications including the number of re-consultations, hospitalisations and mortality; iv) patient satisfaction. We assessed the risk of bias of all included trials and applied GRADE. We used random-effects meta-analyses when feasible. We further analysed results with a high level of heterogeneity in pre-specified subgroups of individually and cluster-RCTs.Main results The only point-of-care biomarker of infection currently available to primary care identified in this review was C-reactive protein. We included six trials (3284 participants; 139 children) that evaluated a C-reactive protein point-of-care test. The available information was from trials with a low to moderate risk of bias that address the main objectives of this review.Overall a reduction in the use of antibiotic treatments was found in the C-reactive protein group (631/1685) versus standard of care(785/1599). However, the high level of heterogeneity and the statistically significant test for subgroup differences between the three RCTs and three cluster-RCTs suggest that the results of the meta-analysis on antibiotic use should be interpreted with caution and the pooled effect estimate (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92; I2 statistic = 68%) may not be meaningful.The observed heterogeneity disappeared in our pre planned subgroup analysis based on study design: RR 0.90, 95% CI 0.80 to 1.02; I2 statistic = 5% for RCTs and RR 0.68, 95% CI 0.61 to 0.75; I2 statistic = 0% for cluster-RCTs, suggesting that this was the cause of the observed heterogeneity.There was no difference between using a C-reactive protein point-of-care test and standard care in clinical recovery (defined as at least substantial improvement at day 7 and 28 or need for re-consultations day 28). However, we noted an increase in hospitalisations in the C-reactive protein group in one study, but this was based on few events and may be a chance finding. No deaths were reported in any of the included studies.We classified the quality of the evidence as moderate according to GRADE due to imprecision of the main effect estimate.Authors' conclusions A point-of-care biomarker (e.g. C-reactive protein) to guide antibiotic treatment of ARIs in primary care can reduce antibiotic use,although the degree of reduction remains uncertain. Used as an adjunct to a doctor's clinical examination this reduction in antibiotic use did not affect patient-reported outcomes, including recovery from and duration of illness.However, a possible increase in hospitalisations is of concern. A more precise effect estimate is needed to assess the costs of the intervention and compare the use of a point-of-care biomarker to other antibiotic-saving strategies.
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Affiliation(s)
- Rune Aabenhus
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark. . ;
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Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, Lasseter G, Cheng MYE, Leydon G, McDermott L, Turner D, Pinedo-Villanueva R, Raftery J, Glasziou P, Mullee M. PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess 2014; 18:vii-xxv, 1-101. [PMID: 24467988 DOI: 10.3310/hta18060] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. OBJECTIVE This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. DESIGN The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. SETTING The setting was UK primary care general practices. PARTICIPANTS Participants were patients aged ≥ 3 years with acute sore throat. INTERVENTIONS An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. MAIN OUTCOME MEASURES The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). RESULTS The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. CONCLUSIONS Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN32027234. SOURCE OF FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - F D Richard Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian Williamson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - Gemma Lasseter
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - M Y Edith Cheng
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lisa McDermott
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Turner
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | | | - James Raftery
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Paul Glasziou
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
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Tonkin-Crine S, Anthierens S, Francis NA, Brugman C, Fernandez-Vandellos P, Krawczyk J, Llor C, Yardley L, Coenen S, Godycki-Cwirko M, Butler CC, Verheij TJM, Goossens H, Little P, Cals JW. Exploring patients' views of primary care consultations with contrasting interventions for acute cough: a six-country European qualitative study. NPJ Prim Care Respir Med 2014; 24:14026. [PMID: 25030621 PMCID: PMC4373386 DOI: 10.1038/npjpcrm.2014.26] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/07/2014] [Accepted: 05/26/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In a pan-European randomised controlled trial (GRACE INTRO) of two interventions, (i) a point-of-care C-reactive protein test and/or (ii) training in communication skills and use of an interactive patient booklet, both interventions resulted in large reductions in antibiotic prescribing for acute cough. AIMS This process evaluation explored patients' views of primary care consultations using the two interventions in six European countries. METHODS Sixty-two interviews were conducted with patients who had participated in the GRACE INTRO trial. Interviews were transcribed verbatim and translated into English where necessary. Analysis used techniques from thematic and framework analysis. RESULTS Most patients were satisfied with their consultation despite many not receiving an antibiotic. Patients appeared to accept the use of both intervention approaches. A minority, but particularly in the trial arm with both interventions, reported that they would wait longer before consulting for cough in future. CONCLUSIONS Patients perceived that both interventions supported the general practitioner's (GP's) prescribing decisions by helping them understand when an antibiotic was, and was not, needed. Patients consulting with acute cough had largely positive views about the GP's enhanced communication skills, which included understanding their concerns, and the use of a near-patient test as an additional investigation.
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Affiliation(s)
- Sarah Tonkin-Crine
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sibyl Anthierens
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Curt Brugman
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jaroslaw Krawczyk
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Carl Llor
- Primary Care Centre Jaume I, University Rovira i Virgili, Tarragona, Spain
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Christopher C Butler
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Theo JM Verheij
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Jochen W Cals
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
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45
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Affiliation(s)
- Carl Llor
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University
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46
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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] [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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Yardley L, Douglas E, Anthierens S, Tonkin-Crine S, O’Reilly G, Stuart B, Geraghty AWA, Arden-Close E, van der Velden AW, Goosens H, Verheij TJM, Butler CC, Francis NA, Little P. Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial. Implement Sci 2013; 8:134. [PMID: 24238118 PMCID: PMC3922910 DOI: 10.1186/1748-5908-8-134] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/12/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners' (GPs') and patients' attitudes. METHODS GPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics. RESULTS GPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful. CONCLUSIONS Our findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.
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Affiliation(s)
- Lucy Yardley
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton SO17 1BG, UK
| | - Elaine Douglas
- Department of Epidemiology & Public Health, Health Behaviour Research Centre, UCL, Gower Street, London WC1E 6BT, UK
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care, University of Antwerp, Universiteitsplein 1 Wilrijk, Antwerp BE-2610, Belgium
| | - Sarah Tonkin-Crine
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Gilly O’Reilly
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Beth Stuart
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Adam W A Geraghty
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Emily Arden-Close
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton SO17 1BG, UK
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands
| | - Herman Goosens
- Laboratory of Medical Microbiology, VAXINFECTIO, University of Antwerp, Antwerp, Belgium
| | - Theo JM Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands
| | - Chris C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4YS, UK
| | - Nick A Francis
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4YS, UK
| | - Paul Little
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
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Jones CHD, Howick J, Roberts NW, Price CP, Heneghan C, Plüddemann A, Thompson M. Primary care clinicians' attitudes towards point-of-care blood testing: a systematic review of qualitative studies. BMC FAMILY PRACTICE 2013; 14:117. [PMID: 23945264 PMCID: PMC3751354 DOI: 10.1186/1471-2296-14-117] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 07/29/2013] [Indexed: 11/16/2022]
Abstract
Background Point-of-care blood tests are becoming increasingly available and could replace current venipuncture and laboratory testing for many commonly used tests. However, at present very few have been implemented in most primary care settings. Understanding the attitudes of primary care clinicians towards these tests may help to identify the barriers and facilitators to their wider adoption. We aimed to systematically review qualitative studies of primary care clinicians’ attitudes to point-of-care blood tests. Methods We systematically searched Medline, Embase, ISI Web of Knowledge, PsycINFO and CINAHL for qualitative studies of primary care clinicians’ attitudes towards point-of-care blood tests in high income countries. We conducted a thematic synthesis of included studies. Results Our search identified seven studies, including around two hundred participants from Europe and Australia. The synthesis generated three main themes: the impact of point-of-care testing on decision-making, diagnosis and treatment; impact on clinical practice more broadly; and impact on patient-clinician relationships and perceived patient experience. Primary care clinicians believed point-of-care testing improved diagnostic certainty, targeting of treatment, self-management of chronic conditions, and clinician-patient communication and relationships. There were concerns about test accuracy, over-reliance on tests, undermining of clinical skills, cost, and limited usefulness. Conclusions We identified several perceived benefits and barriers regarding point-of-care tests in primary care. These imply that if point-of-care tests are to become more widely adopted, primary care clinicians require evidence of their accuracy, rigorous testing of the impact of introduction on patient pathways and clinical practice, and consideration of test funding.
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Kaman WE, Andrinopoulou ER, Hays JP. Perceptions of point-of-care infectious disease testing among European medical personnel, point-of-care test kit manufacturers, and the general public. Patient Prefer Adherence 2013; 7:559-77. [PMID: 23814465 PMCID: PMC3693915 DOI: 10.2147/ppa.s44889] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The proper development and implementation of point-of-care (POC) diagnostics requires knowledge of the perceived requirements and barriers to their implementation. To determine the current requirements and perceived barriers to the introduction of POC diagnostics in the field of medical microbiology (MM)-POC a prospective online survey (TEMPOtest-QC) was established. METHODS AND RESULTS The TEMPOtest-QC survey was online between February 2011 and July 2012 and targeted the medical community, POC test diagnostic manufacturers, general practitioners, and the general public. In total, 293 individuals responded to the survey, including 91 (31%) medical microbiologists, 39 (13%) nonmedical microbiologists, 25 (9%) employees of POC test manufacturers, and 138 (47%) members of the general public. Responses were received from 18 different European countries, with the largest percentage of these living in The Netherlands (52%). The majority (>50%) of medical specialists regarded the development of MM-POC for blood culture and hospital acquired infections as "absolutely necessary", but were much less favorable towards their use in the home environment. Significant differences in perceptions between medical specialists and the general public included the: (1) Effect on quality of patient care; (2) Ability to better monitor patients; (3) Home testing and the doctor-patient relationship; and (4) MM-POC interpretation. Only 34.7% of the general public is willing to pay more than a€10 ($13) for a single MM-POC test, with 85.5% preferring to purchase their MM-POC test from a pharmacy. CONCLUSION The requirements for the proper implementation of MM-POC were found to be generally similar between medical specialists and POC test kit manufacturers. The general public was much more favorable with respect to a perceived improvement in the quality of healthcare that these tests would bring to the hospital and home environment.
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Affiliation(s)
- Wendy E Kaman
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - John P Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
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Leydon GM, McDermott L, Moore M, Williamson I, Hobbs FDR, Lambton T, Cooper R, Henderson H, Little P. A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: 'swamped with sore throats?'. BMJ Open 2013; 3:e002460. [PMID: 23558734 PMCID: PMC3641470 DOI: 10.1136/bmjopen-2012-002460] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 02/05/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore patient and healthcare professionals' (HCP) views of clinical scores and rapid streptococcal antigen detection tests (RADTs) for acute sore throat. DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS General practitioners (GPs), nurse practitioners (NPs) and patients from general practices across Hampshire, Oxfordshire and the West Midlands who were participating in the Primary Care Streptococcal Management (PRISM) study. METHOD Semistructured, face-to-face and phone interviews were conducted with GPs, NPs and patients from general practices across Hampshire, Oxfordshire and the West Midlands. RESULTS 51 participants took part in the study. Of these, 42 were HCPs (29 GPs and 13 NPs) and 9 were patients. HCPs could see a positive role for RADTs in terms of reassurance, as an educational tool for patients, and for aiding inexperienced practitioners, but also had major concerns about RADT use in clinical practice. Particular concerns included the validity of the tests (the role of other bacteria, and carrier states), the tension and possible disconnect with clinical assessment and intuition, the issues of time and resource use and the potential for medicalisation of self-limiting illness. In contrast, however, experience of using RADTs over time seemed to make some participants more positive about using the tests. Moreover, patients were much more positive about the place of RADTs in providing reassurance and in limiting their antibiotic use. CONCLUSIONS It is unlikely that RADTs will have a (comfortable) place in clinical practice in the near future until health professionals' concerns are met, and they have direct experience of using them. The routine use of clinical scoring systems for acute upper respiratory illness also face important barriers related to clinicians' perceptions of their utility in the face of clinician experience and intuition.
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Affiliation(s)
- Gerry M Leydon
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
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