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Bisson JI, Ariti C, Cullen K, Kitchiner N, Lewis C, Roberts NP, Simon N, Smallman K, Addison K, Bell V, Brookes-Howell L, Cosgrove S, Ehlers A, Fitzsimmons D, Foscarini-Craggs P, Harris SRS, Kelson M, Lovell K, McKenna M, McNamara R, Nollett C, Pickles T, Williams-Thomas R. Pragmatic randomised controlled trial of guided self-help versus individual cognitive behavioural therapy with a trauma focus for post-traumatic stress disorder (RAPID). Health Technol Assess 2023; 27:1-141. [PMID: 37982902 PMCID: PMC11017158 DOI: 10.3310/ytqw8336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
Background Guided self-help has been shown to be effective for other mental conditions and, if effective for post-traumatic stress disorder, would offer a time-efficient and accessible treatment option, with the potential to reduce waiting times and costs. Objective To determine if trauma-focused guided self-help is non-inferior to individual, face-to-face cognitive-behavioural therapy with a trauma focus for mild to moderate post-traumatic stress disorder to a single traumatic event. Design Multicentre pragmatic randomised controlled non-inferiority trial with economic evaluation to determine cost-effectiveness and nested process evaluation to assess fidelity and adherence, dose and factors that influence outcome (including context, acceptability, facilitators and barriers, measured qualitatively). Participants were randomised in a 1 : 1 ratio. The primary analysis was intention to treat using multilevel analysis of covariance. Setting Primary and secondary mental health settings across the United Kingdom's National Health Service. Participants One hundred and ninety-six adults with a primary diagnosis of mild to moderate post-traumatic stress disorder were randomised with 82% retention at 16 weeks and 71% at 52 weeks. Nineteen participants and ten therapists were interviewed for the process evaluation. Interventions Up to 12 face-to-face, manualised, individual cognitive-behavioural therapy with a trauma focus sessions, each lasting 60-90 minutes, or to guided self-help using Spring, an eight-step online guided self-help programme based on cognitive-behavioural therapy with a trauma focus, with up to five face-to-face meetings of up to 3 hours in total and four brief telephone calls or e-mail contacts between sessions. Main outcome measures Primary outcome: the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, at 16 weeks post-randomisation. Secondary outcomes: included severity of post-traumatic stress disorder symptoms at 52 weeks, and functioning, symptoms of depression, symptoms of anxiety, alcohol use and perceived social support at both 16 and 52 weeks post-randomisation. Those assessing outcomes were blinded to group assignment. Results Non-inferiority was demonstrated at the primary end point of 16 weeks on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [mean difference 1.01 (one-sided 95% CI -∞ to 3.90, non-inferiority p = 0.012)]. Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, score improvements of over 60% in both groups were maintained at 52 weeks but the non-inferiority results were inconclusive in favour of cognitive-behavioural therapy with a trauma focus at this timepoint [mean difference 3.20 (one-sided 95% confidence interval -∞ to 6.00, non-inferiority p = 0.15)]. Guided self-help using Spring was not shown to be more cost-effective than face-to-face cognitive-behavioural therapy with a trauma focus although there was no significant difference in accruing quality-adjusted life-years, incremental quality-adjusted life-years -0.04 (95% confidence interval -0.10 to 0.01) and guided self-help using Spring was significantly cheaper to deliver [£277 (95% confidence interval £253 to £301) vs. £729 (95% CI £671 to £788)]. Guided self-help using Spring appeared to be acceptable and well tolerated by participants. No important adverse events or side effects were identified. Limitations The results are not generalisable to people with post-traumatic stress disorder to more than one traumatic event. Conclusions Guided self-help using Spring for mild to moderate post-traumatic stress disorder to a single traumatic event appears to be non-inferior to individual face-to-face cognitive-behavioural therapy with a trauma focus and the results suggest it should be considered a first-line treatment for people with this condition. Future work Work is now needed to determine how best to effectively disseminate and implement guided self-help using Spring at scale. Trial registration This trial is registered as ISRCTN13697710. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/97) and is published in full in Health Technology Assessment; Vol. 27, No. 26. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Katherine Cullen
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Neil Kitchiner
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
- Psychology & Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Catrin Lewis
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Neil P Roberts
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
- Psychology & Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Natalie Simon
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Kim Smallman
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Katy Addison
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Vicky Bell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Sarah Cosgrove
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Anke Ehlers
- University of Oxford and Oxford Health NHS Foundation Trust, Oxford, UK
| | | | | | - Shaun R S Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Mark Kelson
- Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | | | - Claire Nollett
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Tim Pickles
- Centre for Trials Research, Cardiff University, Cardiff, UK
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Shen X, Shen J, Pan Y, Cheng J, Chai J, Bowker K, MacGowan A, Oliver I, Lambert H, Wang D. Clinical diagnosis and treatment of common respiratory tract infections in relation to microbiological profiles in rural health facilities in China: implications for antibiotic stewardship. BMC FAMILY PRACTICE 2021; 22:87. [PMID: 33957884 PMCID: PMC8103749 DOI: 10.1186/s12875-021-01448-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 04/29/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND This paper tries to describe prevalence and patterns of antibiotics prescription and bacteria detection and sensitivity to antibiotics in rural China and implications for future antibiotic stewardship. METHODS The study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. It used mixed-methods comprising non-participative observations, exit-survey and microbiological study. Observations were conducted to record clinical diagnosis and antibiotic prescription. Semi-structured questionnaire survey was used to collect patient's sociodemographic information and symptoms. Sputum and throat swabs were collected for bacterial culture and susceptibility testing. RESULTS A total of 1068 (51.0% male vs 49.0% female) patients completed the study with diagnosis of respiratory tract infection (326,30.5%), bronchitis/tracheitis (249,23.3%), pharyngitis (119,11.1%) and others (374, 35.0%). They provided 683 sputum and 385 throat swab specimens. Antibiotics were prescribed for 88% of the RTI patients. Of all the specimens tested, 329 (31%) were isolated with bacteria. The most frequently detected bacteria were K. pneumonia (24% in all specimens), H. influenza (16%), H. parainfluenzae (15%), P. aeruginosa (6%), S.aureus (5%), M. catarrhalis (3%) and S. pneumoniae (2%). CONCLUSIONS The study establishes the feasibility of conducting microbiological testing outside Tier 2 and 3 hospitals in rural China. It reveals that prescription of antibiotics, especially broad-spectrum and combined antibiotics, is still very common and there is a clear need for stewardship programs aimed at both reducing the number of prescriptions and promoting single and narrow-spectrum antibiotics.
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Affiliation(s)
- Xingrong Shen
- School, of Public Health, Anhui Medical University, Hefei, Anhui China
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
| | - Jilu Shen
- Department of Clinical Laboratory, the Fourth Affiliated Hospital of Anhui Medical University, Hefei, Anhui China
| | - Yaping Pan
- Department of Clinical Laboratory, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui China
| | - Jing Cheng
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
| | - Jing Chai
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
| | - Karen Bowker
- Infection Sciences, Severn Pathology, North Bristol NHS Trust, Pathology Building, Southmead Hospital, Westbury-On-Trym, Bristol, BS10 5NB UK
| | - Alasdair MacGowan
- Infection Sciences, Severn Pathology, North Bristol NHS Trust, Pathology Building, Southmead Hospital, Westbury-On-Trym, Bristol, BS10 5NB UK
| | - Isabel Oliver
- Field Service, National Infection Service, Public Health England, 3rd floor, 2 Rivergate, Bristol, BS1 6EH UK
| | - Helen Lambert
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Debing Wang
- School, of Public Health, Anhui Medical University, Hefei, Anhui China
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
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Naurita M, Wibowo YI, Setiadi AP, Setiawan E, Halim SV, Sunderland B. Information on antibiotics in an Indonesian hospital outpatient setting: What is provided by pharmacy staff and recalled by patients? Pharm Pract (Granada) 2021; 19:2167. [PMID: 33520037 PMCID: PMC7819704 DOI: 10.18549/pharmpract.2021.1.2167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/10/2021] [Indexed: 11/14/2022] Open
Abstract
Background:
The provision of information by pharmacy staff is a key factor to ensure
patients’ understanding and quality use of medications, including
antibiotics. However, little is known regarding the transmission of
information between pharmacy staff and patients in Indonesia.
Objective:
This study aimed to identify information on antibiotics provided by pharmacy
staff and recalled by patients in an Indonesian outpatient setting.
Methods:
The study was conducted in a hospital outpatient clinic in Malang, Indonesia,
in 2019. A checklist was used to obtain the data on information provided by
pharmacy staff, while interviews were conducted to determine information
recalled by patients (only presenting patients were included); a total of 15
information items – i.e. 14 essential and one secondary – were
observed. Descriptive analysis was used to summarise data on the checklists
(‘given’ versus ‘not given’) as well as
responses from the interviews (‘recalled’ versus
‘missed’).
Results:
Eleven pharmacy staff (two pharmacists and nine pharmacy technicians) were
involved in providing information for patients obtaining oral antibiotics
during the study period. Of 14 essential information items, only about half
was given by pharmacy staff, with pharmacists significantly providing on
average more information items than pharmacy technicians (7.96 versus 7.67
respectively; p<0.001). The most frequently information items
provided (>90%) included “antibiotic
identification”, “indication”, administration
directions (i.e. “dosage”, “frequency”,
“hour of administration”, “administration before/after
meal”, “route of administration”), and “duration
of use”. A total of 230 patients consented to the study, giving
79.9% response rate. The average number of information items recalled
by patients was 7.09 (SD 1.45). Almost all patients could recall information
on administration directions [i.e. “route of administration”
(97.0%), “frequency” (95.2%),
“dosage” (92.6%), “hour of
administration” (85.7%), “administration before/after
meal” (89.1%)] and “duration of use”
(90.9%). Fewer patients were able to recall “antibiotic
identification” (76.5%) and “indication”
(77.0%).
Conclusions:
Pharmacy staff provided antibiotic information in a limited fashion, while
patients showed adequate ability to recall the information given to them.
Further study is needed to better understand the effective process of
information transmission between pharmacy staff and patients, especially if
more information was provided, to better optimise the use of antibiotics in
outpatient settings in Indonesia.
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Affiliation(s)
- Melani Naurita
- BSc. Pharm. Master Student, Faculty of Pharmacy, University of Surabaya . Surabaya ( Indonesia ).
| | - Yosi I Wibowo
- PhD. Senior Lecturer. Centre for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya . Surabaya ( Indonesia ).
| | - Adji P Setiadi
- Dr. Associate Professor. Centre for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya . Surabaya ( Indonesia ).
| | - Eko Setiawan
- M.Sc. in Clin. Pharm. Lecturer. Centre for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya . Surabaya ( Indonesia ).
| | - Steven V Halim
- MPharm. Lecturer. Centre for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya . Surabaya ( Indonesia ).
| | - Bruce Sunderland
- PhD. Professor. School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University . Perth, WA ( Australia ).
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Impact of antibiotics for children presenting to general practice with cough on adverse outcomes: secondary analysis from a multicentre prospective cohort study. Br J Gen Pract 2018; 68:e682-e693. [PMID: 30201827 PMCID: PMC6145994 DOI: 10.3399/bjgp18x698873] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/02/2018] [Indexed: 11/16/2022] Open
Abstract
Background Clinicians commonly prescribe antibiotics to prevent major adverse outcomes in children presenting in primary care with cough and respiratory symptoms, despite limited meaningful evidence of impact on these outcomes. Aim To estimate the effect of children’s antibiotic prescribing on adverse outcomes within 30 days of initial consultation. Design and setting Secondary analysis of 8320 children in a multicentre prospective cohort study, aged 3 months to <16 years, presenting in primary care across England with acute cough and other respiratory symptoms. Method Baseline clinical characteristics and antibiotic prescribing data were collected, and generalised linear models were used to estimate the effect of antibiotic prescribing on adverse outcomes within 30 days (subsequent hospitalisations and reconsultation for deterioration), controlling for clustering and clinicians’ propensity to prescribe antibiotics. Results Sixty-five (0.8%) children were hospitalised and 350 (4%) reconsulted for deterioration. Clinicians prescribed immediate and delayed antibiotics to 2313 (28%) and 771 (9%), respectively. Compared with no antibiotics, there was no clear evidence that antibiotics reduced hospitalisations (immediate antibiotic risk ratio [RR] 0.83, 95% confidence interval [CI] = 0.47 to 1.45; delayed RR 0.70, 95% CI = 0.26 to 1.90, overall P = 0.44). There was evidence that delayed (rather than immediate) antibiotics reduced reconsultations for deterioration (immediate RR 0.82, 95% CI = 0.65 to 1.07; delayed RR 0.55, 95% CI = 0.34 to 0.88, overall P = 0.024). Conclusion Most children presenting with acute cough and respiratory symptoms in primary care are not at risk of hospitalisation, and antibiotics may not reduce the risk. If an antibiotic is considered, a delayed antibiotic prescription may be preferable as it is likely to reduce reconsultation for deterioration.
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de Bont EGPM, Dinant GJ, Elshout G, van Well G, Francis NA, Winkens B, Cals JWL. Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial. Ann Fam Med 2018; 16:314-321. [PMID: 29987079 PMCID: PMC6037513 DOI: 10.1370/afm.2265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/27/2018] [Accepted: 04/30/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Fever is the most common reason for a child to be taken to a physician, yet the level of unwarranted antibiotic prescribing remains high. We aimed to determine the effect on antibiotic prescribing of providing an illness-focused interactive booklet on fever in children to out-of-hours primary care clinicians. METHODS We conducted a cluster-randomized controlled trial in 20 out-of-hours general practice centers in the Netherlands. Children aged younger than 12 years with fever were included. Family physicians at the 10 intervention sites had access to an illness-focused interactive booklet between November 2015 and June 2016. The primary outcome was antibiotic prescribing during the index consultation. Analysis was performed by fitting 2-level random intercept logistic regression models. RESULTS The trial took place among 3,518 family physicians and 25,355 children. The booklet was used in 28.5% of 11,945 consultations in the intervention group. Compared with usual care, access to the booklet did not significantly alter antibiotic prescribing during the index consultation (odds ratio = 0.90; 95% CI, 0.79-1.02; prescription rate, 23.5% vs 25.2%; intracluster correlation coefficient = 0.005). In contrast, use of the booklet significantly reduced antibiotic prescribing (odds ratio = 0.83; 95% CI, 0.74-0.94; prescription rate, 21.9% vs 25.2%; intracluster correlation coefficient = 0.002). Children managed by family physicians with access to the booklet were less likely to receive any drug prescription, and parents in the booklet group showed a reduced intention to consult again for similar illnesses. CONCLUSIONS Benefit of an illness-focused interactive booklet in improving outcomes of childhood fever in out-of-hours primary care was largely restricted to the cases in which family physicians actually used the booklet. Insight into reasons for use and nonuse may inform future interventions of this type.
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Affiliation(s)
- Eefje G P M de Bont
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Gijs Elshout
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gijs van Well
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Bjorn Winkens
- Department of Methodology and Statistics, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Wark P. Bronchitis (acute). BMJ CLINICAL EVIDENCE 2015; 2015:1508. [PMID: 26186368 PMCID: PMC4505629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Acute bronchitis affects more than 40 in 1000 adults per year in the UK. The causes are usually considered to be infective, but only around half of people have identifiable pathogens. The role of smoking or of environmental tobacco smoke inhalation in predisposing to acute bronchitis is unclear. One third of people may have longer-term symptoms or recurrence. METHODS AND OUTCOMES We conducted a systematic review, aiming to answer the following clinical question: What are the effects of treatments for acute bronchitis in people without chronic respiratory disease? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2015 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS At this update, searching of electronic databases retrieved 420 studies. After deduplication and removal of conference abstracts, 306 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 245 studies and the further review of 61 full publications. Of the 61 full articles evaluated, three updated systematic reviews and three RCTs were added at this update. We performed a GRADE evaluation for 12 PICO combinations. CONCLUSIONS In this systematic review we categorised the efficacy for six intervention-comparison combinations, based on information about the effectiveness and safety of the following interventions: antibiotics, antihistamines, antitussives, beta2 agonists (inhaled), and expectorants/mucolytics.
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Affiliation(s)
- Peter Wark
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia
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