Field trials of the Baby Check score card in general practice

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

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.

Health-care-seeking behaviour for childhood illnesses in a resource-poor setting

AIM

To determine health-care-seeking behaviour for childhood illnesses in a resource-poor setting.

METHOD

Cross-sectional survey was conducted in the children emergency room in a Nigerian tertiary hospital. Socio-demographic data and details of the place and type of care given to ill children before presentation in the tertiary hospital were obtained.

RESULTS

A total of 168 mother-child pairs were studied. The leading illnesses were characterised by fever (35.1%), cough (26.2%) and stooling (19.1%). Initial care was sought within homes (57.1%) and after 24 h of onset (61.9%). A significantly higher proportion of the mothers who sought care within 24 h did so within the homes (P < 0.001). Only 38.1% of the mothers felt that the illnesses were severe. Although 66.7% lived close to orthodox health facilities, only 50.6% utilized such orthodox health facilities. Care was mostly sought outside the homes from drug vendors (55.5%) and private clinics (25.0%). Overall, 72.2% of the mothers administered various drugs to their children before presentation. Home care mainly involved the use of drugs (52.1%) and herbal preparations (15.6%). Care was sought within 24 h of onset for children with fever compared with those with cough (P < 0.001) and stooling (P < 0.001). The leading reasons for not utilising orthodox health services at the onset of illnesses included non-recognition of the severe nature of the illness and poor finances.

CONCLUSION

Care-seeking for childhood illnesses was often delayed beyond 24 h, and most mothers sought care within homes. Health education is required to improve timely seeking of appropriate health care for childhood illnesses.

Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review

BACKGROUND

Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries.

METHODS

In this systematic review, we searched electronic databases (Medline, Embase, DARE, CINAHL), reference lists of relevant studies, and contacted experts to identify articles assessing clinical features of serious infection in children. 1939 potentially relevant studies were identified. Studies were selected on the basis of six criteria: design (studies of diagnostic accuracy or prediction rules), participants (otherwise healthy children aged 1 month to 18 years), setting (ambulatory care), outcome (serious infection), features assessed (assessable in ambulatory care setting), and sufficient data reported. Quality assessment was based on the Quality Assessment of Diagnostic Accuracy Studies criteria. We calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of each clinical feature and pre-test and post-test probabilities of the outcome. Clinical features with a positive likelihood ratio of more than 5.0 were deemed red flags (ie, warning signs for serious infection); features with a negative likelihood ratio of less than 0.2 were deemed rule-out signs.

FINDINGS

30 studies were included in the analysis. Cyanosis (positive likelihood ratio range 2.66-52.20), rapid breathing (1.26-9.78), poor peripheral perfusion (2.39-38.80), and petechial rash (6.18-83.70) were identified as red flags in several studies. Parental concern (positive likelihood ratio 14.40, 95% CI 9.30-22.10) and clinician instinct (positive likelihood ratio 23.50, 95 % CI 16.80-32.70) were identified as strong red flags in one primary care study. Temperature of 40 degrees C or more has value as a red flag in settings with a low prevalence of serious infection. No single clinical feature has rule-out value but some combinations can be used to exclude the possibility of serious infection-for example, pneumonia is very unlikely (negative likelihood ratio 0.07, 95% CI 0.01-0.46) if the child is not short of breath and there is no parental concern. The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10-6.70) or excluding (negative likelihood ratio range 0.16-0.97) the possibility of serious infection.

INTERPRETATION

The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken.

FUNDING

Health Technology Assessment and National Institute for Health Research National School for Primary Care Research.

Minor illness education for parents of young children

BACKGROUND

A number of previous studies on minor illness have concentrated on nurse-led clinics and the role of nurse practitioners. This study examines the effect of a minor illness education programme which aimed to increase parents' confidence and knowledge in managing childhood illnesses.

AIM

The primary aim of this study was to evaluate the effectiveness of a home visit and booklet in providing education to parents about minor infant illnesses.

DESIGN

A randomized controlled trial was conducted. The intervention involved a home visit to discuss parents' concerns and provide advice and information, and a booklet advising parents what to do and when to consult about infant illnesses.

METHOD

A total of 120 parents of 6 week old babies were identified over a 6 month period, using health visitors' caseloads, and randomized to an intervention group (60), that received a visit and a booklet, or a control group (60) that received standard care. Groups were compared on entry to the study and at 7 months, in terms of parental knowledge and confidence about childhood illnesses, the intended use of home care activities, intention to consult professionals and actual use of health services. Data were collected by self-completed questionnaire and case note review.

FINDINGS

The educational intervention resulted in a reduction in visits to the child health clinic but had little effect on use of other services. Parents in the intervention group showed a general trend towards greater certainty about the home care options they would choose, and a reduction in intention to consult a doctor. However, they also indicated a feeling of reduced confidence and knowledge.

CONCLUSION

The trial showed no effect on use of services but did demonstrate reduction in parents' intentions to consult a doctor, which appeared to be because of increased certainty about home care. However, it is of concern that they indicated feeling less confident and knowledgeable. It is not possible to clarify whether this represented anxiety that was constructive, enhancing decision-making or was destructive. Further work into the role of education in parental decision-making, anxiety levels and enhancement of confidence is required.

Field trials of the Baby Check score card in hospital

The Baby Check score card was used by junior paediatric doctors to assess 262 babies under 6 months old presenting to hospital. The duty registrar and two consultants independently graded the severity of each baby's illness without knowledge of the Baby Check score. The registrars assessed the babies at presentation while the consultants reviewed the notes. The consultants and registrars agreed about the need for hospital admission only about 75% of the time. The score's sensitivity and predictive values were similar to those of the registrars' grading. The score's specificity was 87%. Babies with serious diagnosis scored high, while minor illnesses scored low. The predictive value for requiring hospital admission increased with the score, rising to 100% for scores of 20 or more. The appropriate use of Baby Check should improve the detection of serious illness. It could also reduce the number of babies admitted with minor illness, without putting them at increased risk.

Field trials of the Baby Check score card: mothers scoring their babies at home

The Baby Check score card has been developed to help parents and health professionals grade the severity of acute illness in babies. This paper reports the results of two field trials in which mothers used Baby Check at home, 104 mothers scoring their babies daily for a week and 56 using it for six months. They all found Baby Check easy to use, between 68% and 81% found it useful, and 96% would recommended it to others. Over 70% of those using it daily used it very competently. Those using it infrequently did less well, suggesting that familiarity with the assessment is important. The scores obtained show that Baby Check's use would not increase the number of mothers seeking medical advice. With introduction and practice most mothers should be able to use Baby Check effectively. It should help them assess their babies' illnesses and make appropriate decisions about seeking medical advice.

Baby Check: a scoring system to grade the severity of acute systemic illness in babies under 6 months old

A scoring system has been developed to grade the severity of acute systemic illness in babies under 6 months of age. Data were collected on 28 symptoms and 47 signs from 1007 babies with a spectrum of illness ranging from well to seriously ill. Ordinal regression analysis identified 19 symptoms and signs which in combination graded the severity of the illness most accurately. The coefficients were converted to scores. The higher the score the more serious the illness. When applied to a theoretical cohort of 10,000 babies at home, a score less than 8 has a specificity of 98%, and a score of 13 or more a sensitivity of 92%. The positive predictive value for serious illness increases from zero at a score of zero to approaching 100% at scores over 30. The scoring system has been developed into score cards for parents and professionals.