1
|
Christensen LD, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB, Huibers L. Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark. BMC PRIMARY CARE 2024; 25:31. [PMID: 38262975 PMCID: PMC10804570 DOI: 10.1186/s12875-024-02264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.
Collapse
Affiliation(s)
| | | | - Ellen Keizer
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| |
Collapse
|
2
|
Ellis J, Harnett J, Cameron G, Moss P, Gray A. Performance evaluation of the LumiraDx quantitative microfluidic point-of-care CRP test. Pract Lab Med 2024; 38:e00349. [PMID: 38188655 PMCID: PMC10770540 DOI: 10.1016/j.plabm.2023.e00349] [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: 11/14/2022] [Revised: 07/06/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
C-reactive protein (CRP) is an established acute-phase marker for infection, inflammation and tissue injury, used to guide clinical decision-making in primary and secondary care. This study compared the analytical performance of the quantitative microfluidic point-of-care LumiraDx CRP Test to a laboratory-based reference method (Siemens RCRP Flex assay on the Dimension® Xpand®) and evaluated equivalence of sample matrices (blood versus plasma) in point-of-care settings using samples from patients presenting with symptoms of infection or inflammation. The LumiraDx CRP Test demonstrated close agreement with the lab reference test (range, 5.1 to 245.2 mg/L, r = 0.992, slope = 0.998, intercept = -0.476; n = 205) and notable agreement between fingerstick and venous blood and plasma (r = 0.974-0.983; n = 44). Paired replicate precision had mean coefficients of variation of 6.4 % (plasma), 6.6 % (capillary direct) and 8.1 % (venous blood); overall error rates were 2.9 %. The quantitative LumiraDx CRP Test showed robust analytical performance across sample matrices and close agreement compared to the laboratory reference method when used at the point of care.
Collapse
Affiliation(s)
| | - James Harnett
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Gregor Cameron
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Phil Moss
- ED Clinical Research Unit, St George's Hospital, London, UK
| | - Alasdair Gray
- Emergency Medicine Research Group (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
3
|
de Sévaux JLH, Damoiseaux RAMJ, Hullegie S, Sanders EAM, de Wit GA, Zuithoff NPA, Yardley L, Anthierens S, Little P, Hay AD, Schilder AGM, Venekamp RP. Effectiveness of analgesic ear drops as add-on treatment to oral analgesics in children with acute otitis media: study protocol of the OPTIMA pragmatic randomised controlled trial. BMJ Open 2023; 13:e062071. [PMID: 36813504 PMCID: PMC9950909 DOI: 10.1136/bmjopen-2022-062071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Ear pain is the most prominent symptom of childhood acute otitis media (AOM). To control the pain and reduce reliance on antibiotics, evidence of effectiveness for alternative interventions is urgently needed. This trial aims to investigate whether analgesic ear drops added to usual care provide superior ear pain relief over usual care alone in children presenting to primary care with AOM. METHODS AND ANALYSIS This is a pragmatic, two-arm, individually randomised, open, superiority trial with cost-effectiveness analysis and nested mixed-methods process evaluation in general practices in the Netherlands. We aim to recruit 300 children aged 1-6 years with a general practitioner (GP) diagnosis of AOM and ear pain. Children will be randomly allocated (ratio 1:1) to either (1) lidocaine hydrochloride 5 mg/g ear drops (Otalgan) one to two drops up to six times daily for a maximum of 7 days in addition to usual care (oral analgesics, with/without antibiotics); or (2) usual care. Parents will complete a symptom diary for 4 weeks as well as generic and disease-specific quality of life questionnaires at baseline and 4 weeks. The primary outcome is the parent-reported ear pain score (0-10) over the first 3 days. Secondary outcomes include proportion of children consuming antibiotics, oral analgesic use and overall symptom burden in the first 7 days; number of days with ear pain, number of GP reconsultations and subsequent antibiotic prescribing, adverse events, complications of AOM and cost-effectiveness during 4-week follow-up; generic and disease-specific quality of life at 4 weeks; parents' and GPs' views and experiences with treatment acceptability, usability and satisfaction. ETHICS AND DISSEMINATION The Medical Research Ethics Committee Utrecht, the Netherlands, has approved the protocol (21-447/G-D). All parents/guardians of participants will provide written informed consent. Study results will be submitted for publication in peer-reviewed medical journals and presented at relevant (inter)national scientific meetings. TRIAL REGISTRATION The Netherlands Trial Register: NL9500; date of registration: 28 May 2021. At the time of publication of the study protocol paper, we were unable to make any amendments to the trial registration record in the Netherlands Trial Register. The addition of a data sharing plan was required to adhere to the International Committee of Medical Journal Editors guidelines. The trial was therefore reregistered in ClinicalTrials.gov (NCT05651633; date of registration: 15 December 2022). This second registration is for modification purposes only and the Netherlands Trial Register record (NL9500) should be regarded as the primary trial registration.
Collapse
Affiliation(s)
- Joline L H de Sévaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roger A M J Damoiseaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Saskia Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elisabeth A M Sanders
- Department of Paediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital University Medical Center, Utrecht, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIMV), Bilthoven, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Healthcare, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucy Yardley
- School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- School of Psychological Science, Faculty of Life Sciences, University of Bristol, Bristol, UK
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Anne G M Schilder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Biomedical Research Centre, NIHR University College London Hospitals, London, UK
- evidENT, Ear Institute, University College London, London, UK
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
4
|
Colliers A, Philips H, Bombeke K, Remmen R, Coenen S, Anthierens S. Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos. Eur J Gen Pract 2022; 28:87-94. [PMID: 35535690 PMCID: PMC9103350 DOI: 10.1080/13814788.2022.2064448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns. OBJECTIVES To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record. METHODS We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium. RESULTS Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic. CONCLUSION We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.
Collapse
Affiliation(s)
- Annelies Colliers
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Hilde Philips
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | | | - Roy Remmen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO) – Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| |
Collapse
|
5
|
Yardley L, Morton K, Greenwell K, Stuart B, Rice C, Bradbury K, Ainsworth B, Band R, Murray E, Mair F, May C, Michie S, Richards-Hall S, Smith P, Bruton A, Raftery J, Zhu S, Thomas M, McManus RJ, Little P. Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/bwfi7321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background
Digital interventions offer a potentially cost-effective means to support patient self-management in primary care, but evidence for the feasibility, acceptability and cost-effectiveness of digital interventions remains mixed. This programme focused on the potential for self-management digital interventions to improve outcomes in two common, contrasting conditions (i.e. hypertension and asthma) for which care is currently suboptimal, leading to excess deaths, illness, disability and costs for the NHS.
Objectives
The overall purpose was to address the question of how digital interventions can best provide cost-effective support for patient self-management in primary care. Our aims were to develop and trial digital interventions to support patient self-management of hypertension and asthma. Through the process of planning, developing and evaluating these interventions, we also aimed to generate a better understanding of what features and methods for implementing digital interventions could make digital interventions acceptable, feasible, effective and cost-effective to integrate into primary care.
Design
For the hypertension strand, we carried out systematic reviews of quantitative and qualitative evidence, intervention planning, development and optimisation, and an unmasked randomised controlled trial comparing digital intervention with usual care, with a health economic analysis and nested process evaluation. For the asthma strand, we carried out a systematic review of quantitative evidence, intervention planning, development and optimisation, and a feasibility randomised controlled trial comparing digital intervention with usual care, with nested process evaluation.
Setting
General practices (hypertension, n = 76; asthma, n = 7) across Wessex and Thames Valley regions in Southern England.
Participants
For the hypertension strand, people with uncontrolled hypertension taking one, two or three antihypertensive medications. For the asthma strand, adults with asthma and impaired asthma-related quality of life.
Interventions
Our hypertension intervention (i.e. HOME BP) was a digital intervention that included motivational training for patients to self-monitor blood pressure, as well as health-care professionals to support self-management; a digital interface to send monthly readings to the health-care professional and to prompt planned medication changes when patients’ readings exceeded recommended targets for 2 consecutive months; and support for optional patient healthy behaviour change (e.g. healthy diet/weight loss, increased physical activity and reduced alcohol and salt consumption). The control group were provided with a Blood Pressure UK (London, UK) leaflet for hypertension and received routine hypertension care. Our asthma intervention (i.e. My Breathing Matters) was a digital intervention to improve the functional quality of life of primary care patients with asthma by supporting illness self-management. Motivational content intended to facilitate use of pharmacological self-management strategies (e.g. medication adherence and appropriate health-care service use) and non-pharmacological self-management strategies (e.g. breathing retraining, stress reduction and healthy behaviour change). The control group were given an Asthma UK (London, UK) information booklet on asthma self-management and received routine asthma care.
Main outcome measures
The primary outcome for the hypertension randomised controlled trial was difference between intervention and usual-care groups in mean systolic blood pressure (mmHg) at 12 months, adjusted for baseline blood pressure, blood pressure target (i.e. standard, diabetic or aged > 80 years), age and general practice. The primary outcome for the asthma feasibility study was the feasibility of the trial design, including recruitment, adherence, intervention engagement and retention at follow-up. Health-care utilisation data were collected via notes review.
Review methods
The quantitative reviews included a meta-analysis. The qualitative review comprised a meta-ethnography.
Results
A total of 622 hypertensive patients were recruited to the randomised controlled trial, and 552 (89%) were followed up at 12 months. Systolic blood pressure was significantly lower in the intervention group at 12 months, with a difference of –3.4 mmHg (95% confidence interval –6.1 to –0.8 mmHg), and this gave an incremental cost per unit of systolic blood pressure reduction of £11 (95% confidence interval £5 to £29). Owing to a cost difference of £402 and a quality-adjusted life-year (QALY) difference of 0.044, long-term modelling puts the incremental cost per QALY at just over £9000. The probability of being cost-effective was 66% at willingness to pay £20,000 per quality-adjusted life-year, and this was higher at higher thresholds. A total of 88 patients were recruited to the asthma feasibility trial (target n = 80; n = 44 in each arm). At 3-month follow-up, two patients withdrew and six patients did not complete outcome measures. At 12 months, two patients withdrew and four patients did not complete outcome measures. A total of 36 out of 44 patients in the intervention group engaged with My Breathing Matters [with a median of four (range 0–25) logins].
Limitations
Although the interventions were designed to be as accessible as was feasible, most trial participants were white and participants of lower socioeconomic status were less likely to take part and complete follow-up measures. Challenges remain in terms of integrating digital interventions with clinical records.
Conclusions
A digital intervention using self-monitored blood pressure to inform medication titration led to significantly lower blood pressure in participants than usual care. The observed reduction in blood pressure would be expected to lead to a reduction of 10–15% in patients suffering a stroke. The feasibility trial of My Breathing Matters suggests that a fully powered randomised controlled trial of the intervention is warranted. The theory-, evidence- and person-based approaches to intervention development refined through this programme enabled us to identify and address important contextual barriers to and facilitators of engagement with the interventions.
Future work
This research justifies consideration of further implementation of the hypertension intervention, a fully powered randomised controlled trial of the asthma intervention and wide dissemination of our methods for intervention development. Our interventions can also be adapted for a range of other health conditions.
Trial and study registration
The trials are registered as ISRCTN13790648 (hypertension) and ISRCTN15698435 (asthma). The studies are registered as PROSPERO CRD42013004773 (hypertension review) and PROSPERO CRD42014013455 (asthma review).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 11. See the NIHR Journals Library website for further information.
Collapse
Affiliation(s)
- Lucy Yardley
- School of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Kate Morton
- School of Psychology, University of Southampton, Southampton, UK
| | - Kate Greenwell
- School of Psychology, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Cathy Rice
- Patient and public involvement contributor, UK
| | | | - Ben Ainsworth
- School of Psychology, University of Southampton, Southampton, UK
| | - Rebecca Band
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Elizabeth Murray
- Primary Care and Population Health, University College London, London, UK
| | - Frances Mair
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Carl May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Susan Michie
- Centre for Behaviour Change, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | | | - Peter Smith
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Anne Bruton
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - James Raftery
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Little
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| |
Collapse
|
6
|
Goggin K, Hurley EA, Lee BR, Bradley-Ewing A, Bickford C, Pina K, Donis de Miranda E, Yu D, Weltmer K, Linnemayr S, Butler CC, Newland JG, Myers AL. Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse. BMJ Open 2022; 12:e049258. [PMID: 36410835 PMCID: PMC9680140 DOI: 10.1136/bmjopen-2021-049258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING Academic and private practice outpatient clinics. PARTICIPANTS Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms. CONCLUSIONS AND RELEVANCE Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER NCT03037112.
Collapse
Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Brian R Lee
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Carey Bickford
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kimberly Pina
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Evelyn Donis de Miranda
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - David Yu
- Sunflower Medical Group, Kansas City, Kansas, USA
| | - Kirsten Weltmer
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- General Academic Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Angela L Myers
- Pediatric Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| |
Collapse
|
7
|
D’Hulster L, Abrams S, Bruyndonckx R, Anthierens S, Adriaenssens N, Butler CC, Verheij T, Goossens H, Little P, Coenen S. Nationwide implementation of online communication skills training to reduce overprescribing of antibiotics: a stepped-wedge cluster randomized trial in general practice. JAC Antimicrob Resist 2022; 4:dlac070. [PMID: 35774072 PMCID: PMC9240414 DOI: 10.1093/jacamr/dlac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives Primary care is responsible for a large proportion of unnecessary antibiotic use, which is one of the main drivers of antibiotic resistance. Randomized trials have found that online communication skills training for GPs reduces antibiotic prescribing for respiratory infections. This study assesses the real-world effect of implementing online communication skills training in general practice. Methods In a closed cohort stepped-wedge cluster randomized trial all Belgian GPs were invited to participate in online communication skills training courses (TRACE and INTRO) and provided with linked patient information booklets. The primary outcome was the antibiotic prescribing rate per 1000 patient contacts. Intention-to-treat and per protocol analyses were performed. Trial registration at ClinicalTrials.gov: NCT03265028. Results In total, 118 487 observations from 10 375 GPs were included in the analysis. Overall, 299 (2.88%) GPs completed TRACE and 93 (0.90%) completed INTRO, 30 of which completed both. There was no effect of the national implementation of TRACE and INTRO on the population-level antibiotic prescribing rate (prescribing rate ratio [PRR] = 0.99 [95% CI: 0.97–1.02]). GPs who actually completed TRACE prescribed fewer antibiotic prescriptions (PRR = 0.93 [95% CI: 0.90–0.95]). Conclusions Inviting GPs to complete an online communication skills training course and providing them with the linked patient information booklets did not reduce antibiotic prescribing. However, GPs who completed TRACE prescribed 7% fewer antibiotics, especially during winter. This suggests a significant decrease in population-wide antibiotic consumption could be achieved by focusing on increasing the uptake of this intervention by identifying and overcoming barriers to participation.
Collapse
Affiliation(s)
- Leon D’Hulster
- National Institute for Health and Disability Insurance , Galileelaan 5/01, 1210 Brussels , Belgium
| | - Steven Abrams
- Global Health Institute, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp , Antwerp , Belgium
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), UHasselt , Diepenbeek , Belgium
| | - Robin Bruyndonckx
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), UHasselt , Diepenbeek , Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp , Antwerp , Belgium
| | - Sibyl Anthierens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp , Antwerp , Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp , Antwerp , Belgium
| | - Niels Adriaenssens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp , Antwerp , Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp , Antwerp , Belgium
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford , Oxford , United Kingdom
| | - Theo Verheij
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp , Antwerp , Belgium
| | - Paul Little
- Primary Care Research Centre, Aldermoor Health Centre, Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton , Southampton , UK
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp , Antwerp , Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp , Antwerp , Belgium
| |
Collapse
|
8
|
Perceptions of primary health care physicians about the prescription of antibiotics in Saudi Arabia: Based on the model of Theory of planned behaviour. Saudi Pharm J 2022; 29:1416-1425. [PMID: 35002379 PMCID: PMC8720812 DOI: 10.1016/j.jsps.2021.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/30/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Knowledge of different factors that influence physician decision-making in general practice for prescribing antibiotics is vital for successfully implementing antimicrobial stewardship interventions. The Theory of planned behaviour (TPB) is an established model that describes how cognitions drive human behaviour. Objectives The present study was performed to identify the socio-cultural and behavioural determinants that affect antibiotics prescription behaviour among primary care physicians and estimate the awareness about antibiotic resistance of public health importance. Methodology The questionnaire was divided into three sections: Section-I, which contained demographic content. Section-II contained 21 question items measuring attitudes, subjective norms, perceived behavioural control, and behavioural intentions of the prescribers. Section III had 12 questions related to knowledge about antibiotic resistance. As determined by Cronbach's α for each set of measured constructs of questionnaire scale, the internal consistency was good (α ≥ 0.7). The participants' socio-cultural and behavioural determinants were graded in 3 categories depending upon the mean score, while frequencies were used to estimate antibiotic resistance awareness. The data was analyzed by calculating the one-way ANOVA and by post-hoc Tukey-Kramer HSD multiple comparison test. Results Four hundred thirty-four primary health care physicians responded to the questionnaire, and data was statistically investigated. Participants' knowledge of antibiotic-resistant bacteria was poor with greater behavioural intentions to prescribe antibiotics, but a positive attitude and acceptable perceived social pressure towards antibiotics. Conclusion Our study showed that awareness towards antibiotic-resistant bacteria among primary care physicians of Saudi Arabia stands insufficient but favourable attitude and satisfactory social pressure towards antibiotics with greater behavioural intentions to prescribe antibiotics. The continued medical education (CME) and frequent training interventions can increase these parameters of rational prescribing practice for antibiotics.
Collapse
|
9
|
Abstract
Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change ‘tools’: behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.
Collapse
Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail:
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Borek AJ, Campbell A, Dent E, Moore M, Butler CC, Holmes A, Walker AS, McLeod M, Tonkin-Crine S. Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. Implement Sci Commun 2021; 2:104. [PMID: 34526140 PMCID: PMC8441243 DOI: 10.1186/s43058-021-00209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022] Open
Abstract
Background Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. Methods We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified ‘guiding principles’ with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. Results Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an ‘implementation support’ website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). Conclusions We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00209-7.
Collapse
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
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, 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
| | - 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
| | | |
Collapse
|
11
|
McIntyre SA, Francis JJ, Gould NJ, Lorencatto F. The use of theory in process evaluations conducted alongside randomized trials of implementation interventions: A systematic review. Transl Behav Med 2021; 10:168-178. [PMID: 30476259 DOI: 10.1093/tbm/iby110] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Interventions to implement changes into health care practice (i.e., implementation interventions) are critical to improving care but their effects are poorly understood. Two strategies to better understand intervention effects are conducting process evaluations and using theoretical approaches (i.e., theories, models, frameworks). The extent to which theoretical approaches have been used in process evaluations conducted alongside trials of implementation interventions is unclear. In this study context, we reviewed (a) the proportion of process evaluations citing theoretical approaches, (b) which theoretical approaches were cited, and (c) whether and how theories were used. Systematic review (PROSPERO: CRD42016042789). MEDLINE, PsycINFO, Embase, CINAHL, and Cochrane CENTRAL were searched up to July 31, 2017. For all studies, data extraction included names and types of theoretical approaches cited. For studies citing a theory, data extraction included study characteristics and extent of theory use (i.e., "informed by," "applied," "tested," "built/created" theory). We identified 123 process evaluations. Key findings: (a) 77 (63%) process evaluations cited a theoretical approach; (b) the most cited theory was normalization process theory; (c) 32 (26%) process evaluations used theory: 7 (22%) were informed by, 18 (56%) applied, 7 (22%) tested, and none built/created theory. Although nearly two thirds of process evaluations cited a theoretical approach, only a quarter were informed by, applied, or tested a theory-despite the potential complementarity of these strategies. When theory was used, it was primarily applied. Using theory more substantively in process evaluations may accelerate our understanding of how implementation interventions operate.
Collapse
Affiliation(s)
- Stephen A McIntyre
- Centre for Health Services Research, School of Health Sciences, City, University of London, London, UK
| | - Jill J Francis
- Centre for Health Services Research, School of Health Sciences, City, University of London, London, UK
| | - Natalie J Gould
- Centre for Health Services Research, School of Health Sciences, City, University of London, London, UK
| | - Fabiana Lorencatto
- Centre for Health Services Research, School of Health Sciences, City, University of London, London, UK.,UCL Centre for Behaviour Change, University College London, London, UK
| |
Collapse
|
12
|
Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| |
Collapse
|
13
|
Powell PA, Roberts J, Gabbay M, Consedine NS. Care Starts at Home: Emotional State and Appeals to Altruism may Reduce Demand for Overused Health Services in the UK. Ann Behav Med 2021; 55:356-368. [PMID: 32964915 DOI: 10.1093/abm/kaaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Overuse of unnecessary services, screening tests, and treatments is an ongoing problem for national health care systems. Overuse is at least partly driven by patient demand. PURPOSE This study examined whether altering patients' emotional state and appealing to patient altruism would reduce demand for three commonly overused UK health services. METHODS In an online experiment, 1,267 UK volunteers were randomized to anxiety, compassion, or neutral conditions before viewing three overuse vignettes. In each vignette, use of the health service was recommended against by the doctor and participants were further randomized to one of three altruism frames, emphasizing the impact of overuse on the self, the self and others locally, or the self and others nationally. Participants rated the likelihood that they would pursue the health service and, assuming that they did not, how long they would be willing-to-wait for it. RESULTS Altruism frame had a small effect on intentions to use the health service. Those in the local or national (vs. self) frame were 4.7 and 6.1 percentage points, respectively, less likely to ask for the service. Emotion induction had no direct effect on outcomes. However, self-reporting higher levels of anxiety or compassion post-induction was associated with a small, greater likelihood in intentions to ask for the health service or willingness-to-wait, respectively. No interactions between frame and emotion were observed. CONCLUSIONS As a low-cost initiative, emphasizing the benefits to the self and local or national communities could be embedded in appeals designed to appropriately reduce health care overuse in the UK.
Collapse
Affiliation(s)
- Philip A Powell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Mark Gabbay
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Nathan S Consedine
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| |
Collapse
|
14
|
Mowbray F, Sivyer K, Santillo M, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience. Pilot Feasibility Stud 2020; 6:43. [PMID: 32280483 PMCID: PMC7126355 DOI: 10.1186/s40814-020-00590-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/24/2020] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background
We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals.
Methods
In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study.
Results
Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions.
Conclusions
This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received.
Trial registration
Current Controlled Trials ISRCTN12674243 (10 April 2017),
Collapse
|
15
|
Boiko O, Burgess C, Fox R, Ashworth M, Gulliford MC. Risks of use and non-use of antibiotics in primary care: qualitative study of prescribers' views. BMJ Open 2020; 10:e038851. [PMID: 33077568 PMCID: PMC7574941 DOI: 10.1136/bmjopen-2020-038851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing. METHODS Qualitative study using semistructured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted. RESULTS Thirty participants were recruited, including twenty-three general practitioners, five nurses and two pharmacists. Three main themes were identified: risk assessment, balancing treatment risks and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers' perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and Clostridium difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions and safety netting. CONCLUSIONS Attitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients' expectations.
Collapse
Affiliation(s)
- Olga Boiko
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, Oxfordshire, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK
| |
Collapse
|
16
|
Martínez-González NA, Keizer E, Plate A, Coenen S, Valeri F, Verbakel JYJ, Rosemann T, Neuner-Jehle S, Senn O. Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials. Antibiotics (Basel) 2020; 9:antibiotics9090610. [PMID: 32948060 PMCID: PMC7559694 DOI: 10.3390/antibiotics9090610] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/16/2022] Open
Abstract
C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).
Collapse
Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, PO Box 4466, CH-6002 Lucerne, Switzerland
- Correspondence:
| | - Ellen Keizer
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp-Campus Drie Eiken, Doornstraat 331, 2610 Antwerp (Wilrijk), Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp-Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp (Wilrijk), Belgium
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Jan Yvan Jos Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Kapucijnenvoer 33, 3000 Leuven, Belgium;
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| |
Collapse
|
17
|
Santillo M, Sivyer K, Krusche A, Mowbray F, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine. J Antimicrob Chemother 2020; 74:3362-3370. [PMID: 31430366 PMCID: PMC6798845 DOI: 10.1093/jac/dkz333] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/07/2019] [Accepted: 07/07/2019] [Indexed: 12/11/2022] Open
Abstract
Background Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors. Objectives To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics. Methods A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development. Results A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions. Conclusions The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.
Collapse
Affiliation(s)
- M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - A Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - N Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - L Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
| | | |
Collapse
|
18
|
Jiang TT, Yang YQ, Cao NX, Yin YP, Chen XS. Novel education-based intervention to reduce inappropriate antibiotic prescribing for treatment of gonorrhoea in China: protocol for a cluster randomised controlled trial. BMJ Open 2020; 10:e037549. [PMID: 32660953 PMCID: PMC7359379 DOI: 10.1136/bmjopen-2020-037549] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Inappropriate use of antibiotics to treat gonorrhoea can lead to antibiotic resistance. Education programmes may be helpful for improving physician prescribing behaviours in accordance with treatment guidelines. As traditional education based on printed materials may have limited effect on guideline-based treatment, innovative education strategies are needed. The current trial aims to assess the effectiveness of a novel education intervention to increase guideline-based treatment of gonorrhoea in China. METHODS AND ANALYSIS We will conduct a two-arm cluster randomised control trial at 144 hospitals (clusters) in eight Chinese provinces. The intervention will include an online training video developed on the WenJuanXing platform that covers workflows and requirements for managing a patient with uncomplicated gonorrhoea. Outpatient physicians in dermatology (dermatovenerology), urology, andrology and gynaecology will be given access to the video via a quick response code. In hospitals allocated to the control arm, physicians will continue to participate in their standard of care training programme. The primary outcome is the proportion of gonorrhoea antibiotic prescriptions adherent to Chinese national guidelines at the cluster level. In addition, to understand the reasons of physician's non-adherence to the intervention by conducting a questionnaire survey will be considered as the secondary outcome of the study. ETHICS AND DISSEMINATION Ethical approval was obtained from the Medical Ethics Committee of the Chinese Academy of Medical Sciences Institute of Dermatology (2020-LS-004). All physicians will provide an informed consent prior to participating in the study. Findings of the trial will be disseminated through conferences and peer-reviewed journals, and will be used to develop training programmes for physicians. TRIAL REGISTRATION NUMBER ChiCTR2000029591.
Collapse
Affiliation(s)
- Ting-Ting Jiang
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
| | - Yun-Qing Yang
- Department of prevention and health care, Guangzhou Institute of Dermatology, Guangzhou, China
| | - Ning-Xiao Cao
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
| | - Yue-Ping Yin
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
| | - Xiang-Sheng Chen
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
| |
Collapse
|
19
|
Whyte J, Winiecki S, Hoffman C, Patel K. FDA collaboration to improve safe use of fluoroquinolone antibiotics: an ex post facto matched control study of targeted short-form messaging and online education served to high prescribers. Pharm Pract (Granada) 2020; 18:1773. [PMID: 32377279 PMCID: PMC7194042 DOI: 10.18549/pharmpract.2020.2.1773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/05/2020] [Indexed: 11/18/2022] Open
Abstract
Objective: This ex post facto matched control study was conducted to
evaluate the effect of targeted short-form messages or continuing medical
education (CME) on fluoroquinolone prescribing among high prescribers. Methods: A total of 11,774 Medscape healthcare provider (HCP) members prescribing high
volumes of fluoroquinolones were randomized into three segments to receive
one of three unique targeted short-form messages, each delivered via email,
web alerts, and mobile alerts. Some HCPs receiving targeted short-form
messages also participated in CME on fluoroquinolone prescribing. A fourth
segment of HCPs participated in CME only. Test HCPs were matched to
third-party-provider prescriber data to identify control HCPs. We used
prescriber data to determine new prescription volume; percentage (%)
of HCPs with reduced prescribing; new prescription volume for acute
bacterial sinusitis (ABS), uncomplicated urinary tract infection (uUTI), and
acute bacterial exacerbations of chronic bronchitis in those with chronic
obstructive pulmonary disease (ABECB-COPD). Open rates for emailed targeted
short-form messages were also measured. Results: Targeted short-form messages and CME each resulted in significant new
prescription volume reduction versus control. Combining targeted short-form
messages with CME yielded the greatest percentage of test HCPs with reduced
prescribing (80.1%) versus controls (76.2%; p<0.0001).
New prescription volume decreased significantly for uUTI and ABS following
exposure to targeted short-form messages, CME, or both. Targeted short-form
messages containing comparative prescribing information with or without
clinical context were opened at slightly higher rates (10.8% and
10.6%, respectively) than targeted short-form messages containing
clinical context alone (9.1%). Conclusions: Targeted short-form messages and CME, alone and in combination, are
associated with reduced oral fluoroquinolone prescribing among high
prescribers.
Collapse
Affiliation(s)
- John Whyte
- MD, MPH. Chief Medical Officer, WebMD. New York, NY (United States).
| | - Scott Winiecki
- MD. Director. Safe Use Initiative, U.S. Food and Drug Administration. Silver Spring, MD (United States).
| | - Christina Hoffman
- MS. Group Vice President. Quality and Strategy, Medscape Education. New York, NY (United States).
| | - Kaushal Patel
- MBA. Group Vice President. Marketing Sciences, WebMD. New York, NY (United States).
| |
Collapse
|
20
|
Kyaw BM, Tudor Car L, van Galen LS, van Agtmael MA, Costelloe CE, Ajuebor O, Campbell J, Car J. Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. J Med Internet Res 2019; 21:e14984. [PMID: 31516125 PMCID: PMC6746065 DOI: 10.2196/14984] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/07/2019] [Accepted: 08/17/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescription is one of the key contributors to antibiotic resistance, which is managed with a range of interventions including education. OBJECTIVE We aimed to summarize evidence on the effectiveness of digital education of antibiotic management compared to traditional education for improving health care professionals' knowledge, skills, attitudes, and clinical practice. METHODS Seven electronic databases and two trial registries were searched for randomized controlled trials (RCTs) and cluster RCTs published between January 1, 1990, and September 20, 2018. There were no language restrictions. We also searched the International Clinical Trials Registry Platform Search Portal and metaRegister of Controlled Trials to identify unpublished trials and checked the reference lists of included studies and relevant systematic reviews for study eligibility. We followed Cochrane methods to select studies, extract data, and appraise and synthesize eligible studies. We used random-effect models for the pooled analysis and assessed statistical heterogeneity by visual inspection of a forest plot and calculation of the I2 statistic. RESULTS Six cluster RCTs and two RCTs with 655 primary care practices, 1392 primary care physicians, and 485,632 patients were included. The interventions included personal digital assistants; short text messages; online digital education including emails and websites; and online blended education, which used a combination of online digital education and traditional education materials. The control groups received traditional education. Six studies assessed postintervention change in clinical practice. The majority of the studies (4/6) reported greater reduction in antibiotic prescription or dispensing rate with digital education than with traditional education. Two studies showed significant differences in postintervention knowledge scores in favor of mobile education over traditional education (standardized mean difference=1.09, 95% CI 0.90-1.28; I2=0%; large effect size; 491 participants [2 studies]). The findings for health care professionals' attitudes and patient-related outcomes were mixed or inconclusive. Three studies found digital education to be more cost-effective than traditional education. None of the included studies reported on skills, satisfaction, or potential adverse effects. CONCLUSIONS Findings from studies deploying mobile or online modalities of digital education on antibiotic management were complementary and found to be more cost-effective than traditional education in improving clinical practice and postintervention knowledge, particularly in postregistration settings. There is a lack of evidence on the effectiveness of other digital education modalities such as virtual reality or serious games. Future studies should also include health care professionals working in settings other than primary care and low- and middle-income countries. CLINICAL TRIAL PROSPERO CRD42018109742; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=109742.
Collapse
Affiliation(s)
- Bhone Myint Kyaw
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Lorainne Tudor Car
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Louise Sandra van Galen
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Research & Expertise Center In Pharmacotherapy Education, Amsterdam, Netherlands
| | - Céire E Costelloe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Onyema Ajuebor
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - James Campbell
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| |
Collapse
|
21
|
Bakkum MJ, Tichelaar J, Wellink A, Richir MC, van Agtmael MA. Digital Learning to Improve Safe and Effective Prescribing: A Systematic Review. Clin Pharmacol Ther 2019; 106:1236-1245. [PMID: 31206612 PMCID: PMC6896235 DOI: 10.1002/cpt.1549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/27/2019] [Indexed: 12/12/2022]
Abstract
With the aim to modernize and harmonize prescribing education, the European Association for Clinical Pharmacology and Therapeutics (EACPT) Working Group on education recommended the extensive use and distribution of digital learning resources (DLRs). However, it is unclear whether the complex task of prescribing medicine can be taught digitally. Therefore, the aim of this review was to investigate the effect of diverse DLRs in clinical pharmacology and therapeutics education. Databases PubMed, EMBASE, CINAHL, ERIC, and CENTRAL were systematically searched. Sixty-five articles were included in the analyses. Direct effects on patients were studied, but not detected, in six articles. Skills and behavior were studied in 11 articles, 8 of which reported positive effects. Knowledge acquisition was investigated in 19 articles, all with positive effects. Qualitative analyses yielded 10 recommendations for the future development of DLRs. Digital learning is effective in teaching knowledge, attitudes, and skills associated with safe and effective prescribing.
Collapse
Affiliation(s)
- Michiel J Bakkum
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Jelle Tichelaar
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,European Association for Clinical Pharmacology and Therapeutics (EACPT) Education Working Group, Frankfurt, Germany
| | - Anne Wellink
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Milan C Richir
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,European Association for Clinical Pharmacology and Therapeutics (EACPT) Education Working Group, Frankfurt, Germany
| |
Collapse
|
22
|
Rowe TA, Linder JA. Novel approaches to decrease inappropriate ambulatory antibiotic use. Expert Rev Anti Infect Ther 2019; 17:511-521. [DOI: 10.1080/14787210.2019.1635455] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Theresa A. Rowe
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A. Linder
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
23
|
Dekker ARJ, Verheij TJM, Broekhuizen BDL, Butler CC, Cals JWL, Francis NA, Little P, Sanders EAM, Yardley L, Zuithoff NPA, van der Velden AW. Effectiveness of general practitioner online training and an information booklet for parents on antibiotic prescribing for children with respiratory tract infection in primary care: a cluster randomized controlled trial. J Antimicrob Chemother 2019; 73:1416-1422. [PMID: 29438547 DOI: 10.1093/jac/dkx542] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/25/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives Antibiotics are too often prescribed in childhood respiratory tract infection (RTI), despite limited effectiveness, potential side effects and bacterial resistance. We aimed to reduce antibiotic prescribing for children with RTI by online training for general practitioners (GPs) and information for parents. Methods A pragmatic cluster randomized controlled trial in primary care. The intervention consisted of online training for GPs and an information booklet for parents. The primary outcome was the antibiotic prescription rate for children presenting with RTI symptoms, as registered by GPs. Secondary outcomes were number of reconsultations within the same disease episode, consultations for new episodes, hospital referrals and pharmacy-dispensed antibiotic courses for children. This trial was registered at the Dutch Trial Register (NTR), registration number: NTR4240. Results After randomization, GPs from a total of 32 general practices registered 1009 consultations. An antibiotic was prescribed in 21% of consultations in the intervention group, compared with 33% in the usual care group, controlled for baseline prescribing (rate ratio 0.65, 95% CI 0.46-0.91). The probability of reconsulting during the same RTI episode did not differ significantly between the intervention and control groups, and nor did the numbers of consultations for new episodes and hospital referrals. In the intervention group antibiotic dispensing was 32 courses per 1000 children/year lower than the control group, adjusted for baseline prescribing (rate ratio 0.78, 95% CI 0.66-0.92). The numbers and proportion of second-choice antibiotics did not differ significantly. Conclusions Concise, feasible, online GP training, with an information booklet for parents, showed a relevant reduction in antibiotic prescribing for children with RTI.
Collapse
Affiliation(s)
- Anne R J Dekker
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Berna D L Broekhuizen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, 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
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care Medical Group, University of Southampton Medical School, Southampton, UK
| | - Elisabeth A M Sanders
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Lucy Yardley
- Academic Unit of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
24
|
Little P, Stuart B, Francis N, Douglas E, Tonkin-Crine S, Anthierens S, Cals JWL, Melbye H, Santer M, Moore M, Coenen S, Butler CC, Hood K, Kelson M, Godycki-Cwirko M, Mierzecki A, Torres A, Llor C, Davies M, Mullee M, O'Reilly G, van der Velden A, Geraghty AWA, Goossens H, Verheij T, Yardley L. Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial. Ann Fam Med 2019; 17:125-132. [PMID: 30858255 PMCID: PMC6411389 DOI: 10.1370/afm.2356] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial. METHODS A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months. RESULTS Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively). CONCLUSIONS Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.
Collapse
Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye).
| | - Beth Stuart
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Nick Francis
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Elaine Douglas
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Sarah Tonkin-Crine
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Sibyl Anthierens
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Jochen W L Cals
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Hasse Melbye
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Miriam Santer
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Samuel Coenen
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Chris C Butler
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Kerenza Hood
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Mark Kelson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Maciek Godycki-Cwirko
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Artur Mierzecki
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Antoni Torres
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Carl Llor
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Melanie Davies
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Gilly O'Reilly
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Alike van der Velden
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Adam W A Geraghty
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Herman Goossens
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Theo Verheij
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Lucy Yardley
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | | |
Collapse
|
25
|
George PP, Zhabenko O, Kyaw BM, Antoniou P, Posadzki P, Saxena N, Semwal M, Tudor Car L, Zary N, Lockwood C, Car J. Online Digital Education for Postregistration Training of Medical Doctors: Systematic Review by the Digital Health Education Collaboration. J Med Internet Res 2019; 21:e13269. [PMID: 30801252 PMCID: PMC6410118 DOI: 10.2196/13269] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/19/2022] Open
Abstract
Background Globally, online and local area network–based (LAN) digital education (ODE) has grown in popularity. Blended learning is used by ODE along with traditional learning. Studies have shown the increasing potential of these technologies in training medical doctors; however, the evidence for its effectiveness and cost-effectiveness is unclear. Objective This systematic review evaluated the effectiveness of online and LAN-based ODE in improving practicing medical doctors’ knowledge, skills, attitude, satisfaction (primary outcomes), practice or behavior change, patient outcomes, and cost-effectiveness (secondary outcomes). Methods We searched seven electronic databased for randomized controlled trials, cluster-randomized trials, and quasi-randomized trials from January 1990 to March 2017. Two review authors independently extracted data and assessed the risk of bias. We have presented the findings narratively. We mainly compared ODE with self-directed/face-to-face learning and blended learning with self-directed/face-to-face learning. Results A total of 93 studies (N=16,895) were included, of which 76 compared ODE (including blended) and self-directed/face-to-face learning. Overall, the effect of ODE (including blended) on postintervention knowledge, skills, attitude, satisfaction, practice or behavior change, and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher postintervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge scores (small to large effect size and very low quality) for the intervention, while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size and low quality), while 13 studies reported no difference in the skill scores between the groups. One study reported a higher attitude score for the intervention (very low quality), while four studies reported no difference in the attitude score between the groups. Four studies reported higher postintervention physician satisfaction with the intervention (large effect size and low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher postintervention practice or behavior change for the ODE group (small to moderate effect size and low quality), while five studies reported no difference in practice or behavior change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects or cost-effectiveness of the interventions. Conclusions Empiric evidence showed that ODE and blended learning may be equivalent to self-directed/face-to-face learning for training practicing physicians. Few other studies demonstrated that ODE and blended learning may significantly improve learning outcomes compared to self-directed/face-to-face learning. The quality of the evidence in these studies was found to be very low for knowledge. Further high-quality randomized controlled trials are required to confirm these findings.
Collapse
Affiliation(s)
- Pradeep Paul George
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore.,Joanna Briggs Institute, University of Adelaide, Adelaide, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Olena Zhabenko
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Bhone Myint Kyaw
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Panagiotis Antoniou
- Laboratory of Medical Physics, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Pawel Posadzki
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Nakul Saxena
- Ophthalmology Team, Novartis, Singapore, Singapore
| | - Monika Semwal
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Lorainne Tudor Car
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Nabil Zary
- Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Learning, Informative, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,10I Emerging Technologies Lab, Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Craig Lockwood
- Joanna Briggs Institute, University of Adelaide, Adelaide, Australia
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
26
|
The successful uptake and sustainability of rapid infectious disease and antimicrobial resistance point-of-care testing requires a complex 'mix-and-match' implementation package. Eur J Clin Microbiol Infect Dis 2019; 38:1015-1022. [PMID: 30710202 PMCID: PMC6520316 DOI: 10.1007/s10096-019-03492-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 11/03/2022]
Abstract
The emergence and spread of antimicrobial resistance is one of the major global issues currently threatening the health and wealth of nations, with effective guidelines and intervention strategies urgently required. Such guidelines and interventions should ideally be targeted at individuals, communities, and nations, requiring international coordination for maximum effect. In this respect, the European Joint Programming Initiative on Antimicrobial Resistance Transnational Working Group 'Antimicrobial Resistance - Rapid Diagnostic Tests' (JPIAMR AMR-RDT) is proposing to consider a 'mix-and-match' package for the implementation of point-of-care testing (PoCT), which is described in this publication. The working group was established with the remit of identifying barriers and solutions to the development and implementation of rapid infectious disease PoCT for combatting the global spread of antimicrobial resistance. It constitutes a multi-sectoral collaboration between medical, technological, and industrial opinion leaders involved in in vitro diagnostics development, medical microbiology, and clinical infectious diseases. The mix-and-match implementation package is designed to encourage the implementation of rapid infectious disease and antimicrobial resistance PoCT in transnational medical environments for use in the fight against increasing antimicrobial resistance.
Collapse
|
27
|
Liu C, Liu C, Wang D, Deng Z, Tang Y, Zhang X. Determinants of antibiotic prescribing behaviors of primary care physicians in Hubei of China: a structural equation model based on the theory of planned behavior. Antimicrob Resist Infect Control 2019; 8:23. [PMID: 30733857 PMCID: PMC6354420 DOI: 10.1186/s13756-019-0478-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/23/2019] [Indexed: 11/14/2022] Open
Abstract
Background Over-prescription of antibiotics is prevalent all over the world, contributing to the development of antibiotic resistance. The importance of understanding how physicians prescribe antibiotics is increasingly highlighted for the purpose of promoting good practice. This study aimed to identify factors that shape the antibiotic prescribing behaviors of physicians in primary care based on the theory of planned behavior (TPB). Methods Data were collected from 503 prescribers within 65 primary care facilities in Hubei, tapping into four behavioral aspects leading to antibiotic prescribing based on TPB, namely, attitudes (the degree to which a prescriber is in favor of the use of antibiotics), subjective norms (perceived social pressure to which a prescriber is subject in relation to antibiotic prescriptions), perceived control of behaviors (how easy a prescriber feels in making a rational decision on antibiotic prescriptions) and intentions (the degree to which a prescriber is willing to prescribe antibiotics). A total of 440,268 prescriptions were audited to assess physician antibiotic prescribing practices. The four behavioral constructs were further linked with physician's actual use of antibiotics using structural equation modelling (SEM) based on TPB. Results On average, 40.54% (SD = 20.82%) of the outpatient encounters resulted in a prescription for an antibiotic given by the participants and 9.81% (SD = 10.18%) of the patients were given two or more antibiotics. The participants showing a more favorable attitude toward antibiotics had a higher intention to prescribe antibiotics (β = 0.226, p < 0.001) and a lower intention to reduce antibiotic use (β = - 0.211, p < 0.001). Those who perceived lower social pressure (β = 0.113, p = 0.030) and higher control over prescribing behaviors (β = 0.113, p = 0.037) reported a higher intention to reduce the use of antibiotics. However, such intention did not translate into prescribing practice (p > 0.05), although stronger perceived behavioral control was directly linked with lower antibiotic prescriptions (β = - 0.110, p = 0.019). Weaker perceived behavioral control was evident in the participants who showed a less favorable attitude toward antibiotics (β = 0.128, p = 0.001). Conclusion Antibiotic prescribing practice is not under the volitional control of prescribers in primary care in China. Their rational prescribing practice is likely to be jeopardized by perceived weak control over prescribing behaviors.
Collapse
Affiliation(s)
- Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, Vic Australia
| | - Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Zhaohua Deng
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Yuqing Tang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| |
Collapse
|
28
|
Abstract
The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.
Collapse
Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| |
Collapse
|
29
|
Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review. J Am Board Fam Med 2018; 31:417-430. [PMID: 29743225 PMCID: PMC6013839 DOI: 10.3122/jabfm.2018.03.170225] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/28/2017] [Accepted: 01/04/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. METHODS We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. RESULTS Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. CONCLUSIONS A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS.
Collapse
|
30
|
Wang S, Han LZ, Ni YX, Zhang YB, Wang Q, Shi DK, Li WH, Wang YC, Mi CR. Changes in antimicrobial susceptibility of commonly clinically significant isolates before and after the interventions on surgical prophylactic antibiotics (SPAs) in Shanghai. Braz J Microbiol 2018; 49:552-558. [PMID: 29449171 PMCID: PMC6066744 DOI: 10.1016/j.bjm.2017.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/20/2017] [Accepted: 12/01/2017] [Indexed: 12/24/2022] Open
Abstract
Surveillances and interventions on antibiotics use have been suggested to improve serious drug-resistance worldwide. Since 2007, our hospital have proposed many measures for regulating surgical prophylactic antibiotics (carbapenems, third gen. cephalosporins, vancomycin, etc.) prescribing practices, like formulary restriction or replacement for surgical prophylactic antibiotics and timely feedback. To assess the impacts on drug-resistance after interventions, we enrolled infected patients in 2006 (pre-intervention period) and 2014 (post-intervention period) in a tertiary hospital in Shanghai. Proportions of targeted pathogens were analyzed: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), imipenem-resistant Escherichia coli (IREC), imipenem-resistant Klebsiella pneumoniae (IRKP), imipenem-resistant Acinetobacter baumannii (IRAB) and imipenem-resistant Pseudomonas aeruginosa (IRPA) isolates. Rates of them were estimated and compared between Surgical Department, ICU and Internal Department during two periods. The total proportions of targeted isolates in Surgical Department (62.44%, 2006; 64.09%, 2014) were more than those in ICU (46.13%, 2006; 50.99%, 2014) and in Internal Department (44.54%, 2006; 51.20%, 2014). Only MRSA has decreased significantly (80.48%, 2006; 55.97%, 2014) (p < 0.0001). The percentages of VRE and IREC in 3 departments were all <15%, and the slightest change were also both observed in Surgical Department (VRE: 0.76%, 2006; 2.03%, 2014) (IREC: 2.69%, 2006; 2.63%, 2014). The interventions on surgical prophylactic antibiotics can be effective for improving resistance; antimicrobial stewardship must be combined with infection control practices.
Collapse
Affiliation(s)
- Su Wang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Clinical Microbiology, Shanghai, China
| | - Li-Zhong Han
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Clinical Microbiology, Shanghai, China.
| | - Yu-Xing Ni
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Clinical Microbiology, Shanghai, China
| | - Yi-Bo Zhang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Qun Wang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Da-Ke Shi
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Wen-Hui Li
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Yi-Chen Wang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Chen-Rong Mi
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China.
| |
Collapse
|
31
|
Magin P, Tapley A, Morgan S, Davis JS, McElduff P, Yardley L, Henderson K, Dallas A, McArthur L, Mulquiney K, Davey A, Little P, Spike N, van Driel ML. Reducing early career general practitioners' antibiotic prescribing for respiratory tract infections: a pragmatic prospective non-randomised controlled trial. Fam Pract 2018; 35:53-60. [PMID: 28985369 DOI: 10.1093/fampra/cmx070] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescription and consequent antibacterial resistance is a major threat to healthcare. OBJECTIVES To evaluate the efficacy of a multifaceted intervention in reducing early career general practitioners' (GPs') antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis/bronchiolitis. METHODS A pragmatic non-randomized trial employing a non-equivalent control group design nested within an existing cohort study of GP registrars' (trainees') clinical practice. The intervention included access to online modules (covering the rationale of current clinical guidelines recommending non-prescription of antibiotics for URTI and bronchitis/bronchiolitis, and communication skills in management of acute bronchitis) followed by a face-to-face educational session. The intervention was delivered to registrars (and their supervisors) in two of Australia's seventeen regional GP training providers (RTPs). Three other RTPs were the control group. Outcomes were proportion of registrars' URTI consultations and bronchitis/bronchiolitis consultations prescribed antibiotics. Intention-to-treat analyses employed logistic regression within a Generalised Estimating Equation framework, adjusted for relevant independent variables. The predictors of interest were time; treatment group; and an interaction term for time-by-treatment group. The P value associated with an interaction term determined statistically significant differences in antibiotic prescribing. RESULTS Analyses include data of 217 intervention RTPs' and 311 control RTPs' registrars. There was no significant reduction in antibiotic prescribing for URTIs. For bronchitis/bronchiolitis, a significant reduction (interaction P value = 0.024) remained true for analysis adjusted for independent variables (P value = 0.040). The adjusted absolute reduction in prescribing was 15.8% (95% CI: 4.2%-27.5%). CONCLUSIONS A multifaceted intervention reduced antibiotic prescribing for bronchitis/bronchiolitis but not URTIs.
Collapse
Affiliation(s)
- Parker Magin
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Simon Morgan
- Elermore Vale General Practice, Elermore Vale, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Menzies School of Health Research, Royal Darwin Hospital Campus, Casuarina, Australia.,John Hunter Hospital, New Lambton Heights, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Lucy Yardley
- Centre for Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Kim Henderson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | | | - Lawrie McArthur
- Department of General Practice, University of Adelaide, Adelaide, Australia
| | - Katie Mulquiney
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Paul Little
- Primary Care & Population Sciences Academic Units, University of Southampton, Southampton, UK
| | - Neil Spike
- Department of General Practice, University of Melbourne, Melbourne, Australia.,Eastern Victoria General Practice Training, Melbourne, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
| |
Collapse
|
32
|
Deckx L, Anthierens S, Magin PJ, Morgan S, McArthur L, Yardley L, Dallas A, Little P, van Driel ML. Focus on early-career GPs: qualitative evaluation of a multi-faceted educational intervention to improve antibiotic prescribing. Fam Pract 2018; 35:99-104. [PMID: 28985300 DOI: 10.1093/fampra/cmx074] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. OBJECTIVES To explore the participants' experiences with the intervention. METHODS A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. RESULTS Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. CONCLUSION The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care.
Collapse
Affiliation(s)
- Laura Deckx
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sibyl Anthierens
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Parker J Magin
- GP Synergy NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Mayfield, New South Wales, Australia
| | - Simon Morgan
- Elermore Vale General Practice, Elermore Vale, New South Wales, Australia
| | - Lawrie McArthur
- Rural Clinical School, The University of Adelaide, Adelaide, Australia
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - Anthea Dallas
- School of Medicine, University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Paul Little
- Primary Care & Population Sciences Academic Units, University of Southampton, Southampton, UK
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
33
|
Douma KFL, Aalfs CM, Dekker E, Tanis PJ, Smets EM. An E-Learning Module to Improve Nongenetic Health Professionals' Assessment of Colorectal Cancer Genetic Risk: Feasibility Study. JMIR MEDICAL EDUCATION 2017; 3:e24. [PMID: 29254907 PMCID: PMC5748476 DOI: 10.2196/mededu.7173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/27/2017] [Accepted: 10/30/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Nongenetic health providers may lack the relevant knowledge, experience, and communication skills to adequately detect familial colorectal cancer (CRC), despite a positive attitude toward the assessment of history of cancer in a family. Specific training may enable them to more optimally refer patients to genetic counseling. OBJECTIVE The aim of this study was to develop an e-learning module for gastroenterologists and surgeons (in training) aimed at improving attitudes, knowledge, and comprehension of communication skills, and to assess the feasibility of the e-learning module for continued medical education of these specialists. METHODS A focus group helped to inform the development of a training framework. The e-learning module was then developed, followed by a feasibility test among a group of surgeons-in-training (3rd- and 4th-year residents) and then among gastroenterologists, using pre- and posttest questionnaires. RESULTS A total of 124 surgeons-in-training and 14 gastroenterologists participated. The e-learning was positively received (7.5 on a scale of 1 to 10). Between pre- and posttest, attitude increased significantly on 6 out of the 10 items. Mean test score showed that knowledge and comprehension of communication skills improved significantly from 49% to 72% correct at pretest to 67% to 87% correct at posttest. CONCLUSIONS This study shows the feasibility of a problem-based e-learning module to help surgeons-in-training and gastroenterologists in recognizing a hereditary predisposition in patients with CRC. The e-learning led to improvements in attitude toward the assessment of cancer family history, knowledge on criteria for referral to genetic counseling for CRC, and comprehension of communication skills.
Collapse
Affiliation(s)
- Kirsten Freya Lea Douma
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Cora M Aalfs
- Department of Clinical Genetics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Ellen M Smets
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
34
|
Internet and social media use for antibiotic-related information seeking: Findings from a survey among adult population in Italy. Int J Med Inform 2017; 111:131-139. [PMID: 29425624 DOI: 10.1016/j.ijmedinf.2017.12.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Internet represents an increasingly common source of health-related information. Internet and Social Media can be used to promote a prudent use of antibiotics. OBJECTIVE To establish the extent of Internet and Social Media use to search for antibiotic related information and the potential implications in health care among adult population in Italy. METHODS This cross-sectional study was conducted from March to May 2017, among a sample of parents of public school students. A 2-stage cluster sample design was planned. An informed consent form and a questionnaire were given to selected students to deliver to their parents. The questionnaire included questions on knowledge, attitudes, and behavior toward antibiotic use, and questions about Internet use to gather information about antibiotics. RESULTS A total of 913 parents completed the questionnaire, with a 67.4% response rate; 22.1% did not know when it was appropriate to use antibiotics. 32.3% of parents reported self-medication with antibiotics. 73.4% of respondents used the Internet to search for information about antibiotic use. Among social networks users, 46.5% reported the use of these media to get information about antibiotics and 45% of instant messaging app users share information about antibiotics. The results of the multiple logistic regression analysis showed that Internet use to search for antibiotic-related information was higher among females, younger subjects, with a higher level of education, in those who reported self-medication with antibiotics and in those who needed additional information on side effects of antibiotics from the GP compared with those who did not need any additional information. Internet use was significantly less likely in participants with cardiovascular diseases and cancer compared with those without chronic conditions, and in those who reported to strongly agree/agree, or were uncertain about antibiotic use without a GP prescription, compared with those who reported to be disagree/strongly disagree. CONCLUSIONS Internet and social media are widely used for antibiotic-related information seeking in the Italian population. Health organizations must consider social media within their communication strategy to promote the appropriate Web use for antibiotic-related information seeking in the general population, although more evidence is needed regarding the optimal mix of communication interventions.
Collapse
|
35
|
McDermott L, Leydon GM, Halls A, Kelly J, Nagle A, White J, Little P. Qualitative interview study of antibiotics and self-management strategies for respiratory infections in primary care. BMJ Open 2017; 7:e016903. [PMID: 29180593 PMCID: PMC5719297 DOI: 10.1136/bmjopen-2017-016903] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To explore perceptions of illness, the decisions to consult and the acceptability of delayed antibiotic prescriptions and self-help treatments for respiratory tract infections (RTIs). DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS 20 adult patients who had been participating in the 'PIPS' (Pragmatic Ibuprofen Paracetamol and Steam) trial in the South of England. METHOD Semistructured telephone interviews were conducted with participants to explore their experiences and views on various treatments for RTI. RESULTS Participants had concerns about symptoms that were not clinically serious and were mostly unaware of the natural history of RTIs, but were aware of the limitations of antibiotics and did not expect them with every consultation. Most viewed delayed prescriptions positively and had no strong preference over which technique is used to deliver the delayed antibiotic, but some patients received mixed messages, such as being told their infection was viral then being given an antibiotic, or were sceptical about the rationale. Participants disliked self-help treatments that involved taking medication and were particularly concerned about painkillers in combination. Steam inhalation was viewed as only moderately helpful for mild symptoms. CONCLUSION Delayed prescribing is acceptable no matter how the delay is operationalised, but explanation of the rationale is needed and care taken to minimise mixed messages about the severity of illnesses and causation by viruses or bacteria. Better access is needed to good natural history information, and the signs and symptoms requiring or not requiring general practitioner advice. Significant concerns about paracetamol, ibuprofen and steam inhalation are likely to need careful exploration in the consultation.
Collapse
Affiliation(s)
- Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Geraldine M Leydon
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amy Halls
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jo Kelly
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amanda Nagle
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jennifer White
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
36
|
Stein M, Lipman-Arens S, Oved K, Cohen A, Bamberger E, Navon R, Boico O, Friedman T, Etshtein L, Paz M, Gottlieb TM, Kriger O, Fonar Y, Pri-Or E, Yacobov R, Dotan Y, Hochberg A, Grupper M, Chistyakov I, Potasman I, Srugo I, Eden E, Klein A. A novel host-protein assay outperforms routine parameters for distinguishing between bacterial and viral lower respiratory tract infections. Diagn Microbiol Infect Dis 2017; 90:206-213. [PMID: 29273482 DOI: 10.1016/j.diagmicrobio.2017.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 01/12/2023]
Abstract
Bacterial and viral lower respiratory tract infections (LRTIs) are often clinically indistinguishable, leading to antibiotic overuse. We compared the diagnostic accuracy of a new assay that combines 3 host-biomarkers (TRAIL, IP-10, CRP) with parameters in routine use to distinguish bacterial from viral LRTIs. Study cohort included 184 potentially eligible pediatric and adult patients. Reference standard diagnosis was based on adjudication by an expert panel following comprehensive clinical and laboratory investigation (including respiratory PCRs). Experts were blinded to assay results and assay performers were blinded to reference standard outcomes. Evaluated cohort included 88 bacterial and 36 viral patients (23 did not fulfill inclusion criteria; 37 had indeterminate reference standard outcome). Assay distinguished bacterial from viral LRTI patients with sensitivity of 0.93±0.06 and specificity of 0.91±0.09, outperforming routine parameters, including WBC, CRP and chest x-ray signs. These findings support the assay's potential to help clinicians avoid missing bacterial LRTIs or overusing antibiotics.
Collapse
Affiliation(s)
- Michal Stein
- Infectious Diseases Unit, Hillel Yaffe Medical Center, Hadera, Israel.
| | | | - Kfir Oved
- MeMed Diagnostics, Tirat Carmel, Israel
| | - Asi Cohen
- MeMed Diagnostics, Tirat Carmel, Israel
| | - Ellen Bamberger
- MeMed Diagnostics, Tirat Carmel, Israel; Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Roy Navon
- MeMed Diagnostics, Tirat Carmel, Israel
| | | | - Tom Friedman
- MeMed Diagnostics, Tirat Carmel, Israel; Rambam Medical Center, Haifa, Israel
| | | | | | | | - Or Kriger
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yura Fonar
- Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Renata Yacobov
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yaniv Dotan
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Amit Hochberg
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Moti Grupper
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Irina Chistyakov
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Israel Potasman
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Isaac Srugo
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Eran Eden
- MeMed Diagnostics, Tirat Carmel, Israel
| | - Adi Klein
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| |
Collapse
|
37
|
Saliba-Gustafsson EA, Borg MA, Rosales-Klintz S, Nyberg A, StålsbyLundborg C. Maltese Antibiotic Stewardship Programme in the Community (MASPIC): protocol of a prospective quasiexperimental social marketing intervention. BMJ Open 2017; 7:e017992. [PMID: 28947463 PMCID: PMC5623537 DOI: 10.1136/bmjopen-2017-017992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Antibiotic misuse is a key driver of antibiotic resistance. In 2015/2016, Maltese respondents reported the highest proportions of antibiotic consumption in Europe. Since antibiotics are prescription-only medicines in Malta, research on effective strategies targeting general practitioners' (GPs) knowledge and behaviour is needed. Multifaceted behaviour change (BC) interventions are likely to be effective. Social marketing (SM) can provide the tools to promote sustained BC; however, its utilisation in Europe is limited. This paper aims to describe the design and methods of a multifaceted SM intervention aimed at changing Maltese GPs' antibiotic prescribing behaviour for patients with acute respiratory tract infections (aRTIs). METHODS AND ANALYSIS This 4-year quasiexperimental intervention study will be carried out in Malta and includes three phases: preintervention, intervention and postintervention. The preintervention phase intends to gain insight into the practices and attitudes of GPs, pharmacists and parents through interviews, focus group discussions and antibiotic prescribing surveillance. A 6-month intervention targeting GPs will be implemented following assessment of their prescribing intention and readiness for BC. The intervention will likely comprise: prescribing guidelines, patient educational materials, delayed antibiotic prescriptions and GP education. Outcomes will be evaluated in the postintervention phase through questionnaires based on the theory of planned behaviour and stages-of-change theory, as well as postintervention surveillance. The primary outcome will be the antibiotic prescribing rate for all patients with aRTIs. Secondary outcomes will include the proportion of diagnosis-specific antibiotic prescription and symptomatic relief medication prescribed, and the change in GPs stage-of-change and their intention to prescribe antibiotics. ETHICS AND DISSEMINATION The project received ethical approval from the University of Malta's Research Ethics Committee. Should this intervention successfully decrease antibiotic prescribing, it may be scaled up locally and transferred to similar settings. TRIAL REGISTRATION NUMBER NCT03218930; Pre-results.
Collapse
Affiliation(s)
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | | | - Anna Nyberg
- Department of Marketing and Strategy, Stockholm School of Economics, Stockholm, Sweden
| | | |
Collapse
|
38
|
Tonkin‐Crine SKG, Tan PS, van Hecke O, Wang K, Roberts NW, McCullough A, Hansen MP, Butler CC, Del Mar CB. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD012252. [PMID: 28881002 PMCID: PMC6483738 DOI: 10.1002/14651858.cd012252.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials. OBJECTIVES To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care. METHODS We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview. MAIN RESULTS We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications. AUTHORS' CONCLUSIONS We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.
Collapse
Affiliation(s)
- Sarah KG Tonkin‐Crine
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Pui San Tan
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Oliver van Hecke
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Kay Wang
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | | | - Christopher C Butler
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | | |
Collapse
|
39
|
Sikkens JJ, van Agtmael MA, Peters EJG, Lettinga KD, van der Kuip M, Vandenbroucke-Grauls CMJE, Wagner C, Kramer MHH. Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study. JAMA Intern Med 2017; 177:1130-1138. [PMID: 28459929 PMCID: PMC5818788 DOI: 10.1001/jamainternmed.2017.0946] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 02/26/2017] [Indexed: 01/23/2023]
Abstract
Importance Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs. Objective To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals. Design, Setting, and Participants The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study. Interventions We offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing. Main Outcomes and Measures Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time. Results A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found. Conclusions and Relevance Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.
Collapse
Affiliation(s)
- Jonne J. Sikkens
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
- EMGO+ Institute for Health and Care Research, Amsterdam, the Netherlands
- Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, the Netherlands
| | - Michiel A. van Agtmael
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
- Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, the Netherlands
| | - Edgar J. G. Peters
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Martijn van der Kuip
- Department of Pediatrics, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Cordula Wagner
- EMGO+ Institute for Health and Care Research, Amsterdam, the Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands
| | - Mark H. H. Kramer
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| |
Collapse
|
40
|
Chicoulaa B, Haas H, Viala J, Salvetat M, Olives JP. How French general practitioners manage and prevent recurrent respiratory tract infections in children: the SOURIRRE survey. Int J Gen Med 2017; 10:61-68. [PMID: 28293116 PMCID: PMC5345982 DOI: 10.2147/ijgm.s125806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recurrent respiratory tract infections (RRTIs) are the most common reason for children's visits to primary care physicians in France; however, little is known about general practitioners' (GPs) opinions and expectations concerning the management and prevention of these common and recurrent pathologies. PURPOSE To describe French GPs' daily practice in the management of respiratory infections and the prevention of their recurrence in children. METHODS A sample group of French GPs answered a structured questionnaire on risk factors, RRTI management, antibiotic use and prevention measures. RESULTS A total of 358 GPs participated in the survey. Rhinopharyngitis, the most frequent respiratory infection, was considered to be recurrent if six or more episodes occurred in a year. Four risk factors were acknowledged as substantial: living in communities, passive smoking, pollution and allergies. Around 63% of GPs said that RRTIs are too often treated with antibiotics. More than 85% thought that prevention of RRTIs is possible. Smoking cessation, vaccination, allergen avoidance and hygiene were identified as the main preventive measures. A large majority of GPs (84%) prescribed products for prevention and ~90% would prescribe a product stimulating immunity if the efficacy and tolerability of these agents was proven and confirmed in their daily practice. CONCLUSIONS French GPs are well aware of the health and socioeconomic burdens resulting from RRTIs, as well as the risk of antibiotic overuse. They have a prevention-oriented approach, implement preventive measures when possible and prescribe products for prevention.
Collapse
Affiliation(s)
| | - Hervé Haas
- Paediatric Emergency and Infectious Disease Departments, Lenval University Hospital, Nice
| | - Jérôme Viala
- Gastroenterology Department, Robert-Debré Hospital, Paris
| | | | - Jean-Pierre Olives
- Gastroenterology and Nutrition Department, Children's Hospital, University Hospital, Toulouse, France
| |
Collapse
|
41
|
del Río Carral M, Roux P, Bruchez C, Santiago-Delefosse M. Santé digitale : promesses, défis et craintes. Une revue de la littérature. PRAT PSYCHOL 2017. [DOI: 10.1016/j.prps.2016.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
42
|
Haldrup S, Thomsen RW, Bro F, Skov R, Bjerrum L, Søgaard M. Microbiological point of care testing before antibiotic prescribing in primary care: considerable variations between practices. BMC FAMILY PRACTICE 2017; 18:9. [PMID: 28125965 PMCID: PMC5270219 DOI: 10.1186/s12875-016-0576-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/16/2016] [Indexed: 11/10/2022]
Abstract
Background Point-of-care testing (POCT) in primary care may improve rational antibiotic prescribing. We examined use of POCT in Denmark, including patient- and general practitioner (GP)-related predictors. Methods We linked nationwide health care databases to assess POCT use (C-reactive protein (CRP), group A streptococcal (GAS) antigen swabs, bacteriological cultures, and urine test strips) per 1,000 overall GP consultations, 2004–2013. We computed odds ratios (OR) of POCT in patients prescribed antibiotics according to patient and GP age and sex, GP practice type, location, and workload. Results The overall use of POCT in Denmark increased by 45.8% during 2004–2013, from 147.2 per 1,000 overall consultations to 214.8. CRP tests increased by 132%, bacteriological cultures by 101.7% while GAS swabs decreased by 8.6%. POCT preceded 28% of antibiotic prescriptions in 2004 increasing to 44% in 2013. The use of POCT varied more than 5-fold among individual practices, from 54.9 to 394.7 per 1,000 consultations in 2013. POCT use varied substantially with patient age, and males were less likely to receive POCT than females (adjusted OR = 0.75, 95% CI 0.74-0.75) driven by usage of urine test strips among females (18% vs. 7%). Odds of POCT were higher among female GPs and decreased with higher GP age, with lowest usage among male GPs >60 years. GP urban/rural location and workload had little impact. Conclusion GPs use POCT increasingly with the highest use among young female GPs. In 2013, 44% of all antibiotic prescriptions were preceded by POCT but testing rates vary greatly across individual GPs.
Collapse
Affiliation(s)
- Steffen Haldrup
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark. .,Department of General Practice, Institute of Public Health, Aarhus University, Aarhus, Denmark.
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
| | - Flemming Bro
- Department of General Practice, Institute of Public Health, Aarhus University, Aarhus, Denmark
| | - Robert Skov
- Antimicrobial Resistance Reference Laboratory and Surveillance Unit, Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, Copenhagen University, Copenhagen, Denmark
| | - Mette Søgaard
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark.
| |
Collapse
|
43
|
Bustinduy AL, Chis Ster I, Shaw R, Irwin A, Thiagarajan J, Beynon R, Ladhani S, Sharland M. Predictors of fever-related admissions to a paediatric assessment unit, ward and reattendances in a South London emergency department: the CABIN 2 study. Arch Dis Child 2017; 102:22-28. [PMID: 27551062 DOI: 10.1136/archdischild-2016-310494] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the risk factors for ward and paediatric assessment unit (PAU) admissions from the emergency department (ED). DESIGN Prospective observational study. SETTING AND PATIENTS Febrile children attending a large tertiary care ED during the winter of 2014-2015. MAIN OUTCOME MEASURES Ward and PAU admissions, National Institute for Health and Care Excellence (NICE) guidelines classification, reattendance to the ED within 28 days and antibiotic use. RESULTS A total of 1097 children attending the children's ED with fever were analysed. Risk factors for PAU admission were tachycardia (RR=1.1, 95% CI (1 to 1.1)), ill-appearance (RR=2.2, 95% CI (1.2 to 4.2)), abnormal chest findings (RR=2.1, 95% CI (1.2 to 4.3)), categorised as NICE amber (RR 1.7 95% CI (1.2 to 2.5)). There was a 30% discordance between NICE categorisation at triage and statistical internal validation. Predictors of ward admission were a systemic (RR=6.9, 95% CI (2.4 to 19.8)) or gastrointestinal illness (RR=3.8, 95% (1.4 to 10.4)) and categorised as NICE Red (RR=5.9, 95% CI (2.2 to 15.3)). Only 51 children had probable bacterial pneumonia (4.6%), 52 children had a proven urinary tract infection (4.2%), with just 2 (0.2%) positive blood cultures out of 485 (44%) children who received an antibiotic. 15% of all children reattended by 28 days and were more likely to have been categorised as Amber and had investigations on initial visit. CONCLUSIONS Risk factors for PAU and ward admissions are different in this setting with high reattendance rates and very low proportion of confirmed/probable serious bacterial infections. Future studies need to focus on reducing avoidable admissions and antibiotic treatment.
Collapse
Affiliation(s)
- Amaya L Bustinduy
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | - Irina Chis Ster
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Rebecca Shaw
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK.,Children's Emergency Department, St George's NHS trust, London, UK
| | - Adam Irwin
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | | | - Rhys Beynon
- Children's Emergency Department, St George's NHS trust, London, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK.,Immunisation Department, Public Health England, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | | |
Collapse
|
44
|
Strumiło J, Chlabicz S, Pytel-Krolczuk B, Marcinowicz L, Rogowska-Szadkowska D, Milewska AJ. Combined assessment of clinical and patient factors on doctors' decisions to prescribe antibiotics. BMC FAMILY PRACTICE 2016; 17:63. [PMID: 27255505 PMCID: PMC4891944 DOI: 10.1186/s12875-016-0463-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 05/20/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Antibiotic overprescription is a worldwide problem. Decisions regarding antibiotic prescription for respiratory tract infections (RTIs) are influenced by medical and non-medical factors. METHODS In family medicine practices in Białystok, Poland, family medicine residents directly observed consultations with patients with RTI symptoms. The observing residents completed a questionnaire including patient data, clinical symptoms, diagnosis, any prescribed antibiotic, and assessment of ten patient pressure factors. RESULTS Of 1546 consultations of patients with RTIs, 54.26 % resulted in antibiotic prescription. Antibiotic prescription was strongly associated with rales (OR 26.90, 95 % CI 9.00-80.40), tonsillar exudates (OR 13.03, 95 % CI 7.10-23.80), and wheezing (OR 14.72, 95 % CI 7.70-28.10). The likelihood of antibiotic prescription was increased by a >7-day disease duration (OR 3.94, 95 % CI 2.80-5.50), purulent nasal discharge (OR 3.87, 95 % CI 2.40-6.10), starting self-medication with antibiotics (OR 4.11, 95 % CI 2.30-7.30), and direct request for antibiotics (OR 1.87, 95 % CI 1.30-2.80). Direct request not to prescribe antibiotics decreased the likelihood of receiving antibiotics (OR 0.34, 95 % CI 0.27-0.55). CONCLUSION While clinical signs and symptoms principally impact prescribing decisions, patient factors also contribute. The most influential patient pressure factors were starting self-medication with antibiotics, and directly requesting antibiotic prescription or no antibiotic prescription. Interventions aiming to improve clinical sign and symptom interpretation and to help doctors resist direct patient pressure could be beneficial for reducing unnecessary antibiotic prescribing.
Collapse
Affiliation(s)
- Julia Strumiło
- Department of Family Medicine and Community Nursing, Medical University of Białystok, Mieszka I 4B, 15-054, Białystok, Poland.
| | - Sławomir Chlabicz
- Department of Family Medicine and Community Nursing, Medical University of Białystok, Mieszka I 4B, 15-054, Białystok, Poland
| | - Barbara Pytel-Krolczuk
- Department of Family Medicine and Community Nursing, Medical University of Białystok, Mieszka I 4B, 15-054, Białystok, Poland
| | - Ludmiła Marcinowicz
- Department of Family Medicine and Community Nursing, Medical University of Białystok, Mieszka I 4B, 15-054, Białystok, Poland
| | - Dorota Rogowska-Szadkowska
- Department of Family Medicine and Community Nursing, Medical University of Białystok, Mieszka I 4B, 15-054, Białystok, Poland
| | - Anna Justyna Milewska
- Department of Statistics and Medical Informatics, Medical University of Białystok, Białystok, Poland
| |
Collapse
|
45
|
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.
Collapse
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
| |
Collapse
|
46
|
Provider Decisions to Treat Respiratory Illnesses with Antibiotics: Insights from a Randomized Controlled Trial. PLoS One 2016; 11:e0152986. [PMID: 27043012 PMCID: PMC4820114 DOI: 10.1371/journal.pone.0152986] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/22/2016] [Indexed: 12/28/2022] Open
Abstract
RATIONALE Lower respiratory tract illness (LRTI) frequently causes adult hospitalization and antibiotic overuse. Procalcitonin (PCT) treatment algorithms have been used successfully in Europe to safely reduce antibiotic use for LRTI but have not been adopted in the United States. We recently performed a feasibility study for a randomized clinical trial (RCT) of PCT and viral testing to guide therapy for non-pneumonic LRTI. OBJECTIVE The primary objective of the current study was to understand factors influencing PCT algorithm adherence during the RCT and evaluate factors influencing provider antibiotic prescribing practices for LRTI. STUDY DESIGN From October 2013-April 2014, 300 patients hospitalized at a community teaching hospital with non-pneumonic LRTI were randomized to standard or PCT-guided care with viral PCR testing. Algorithm adherence data was collected and multivariate stepwise logistic regression of clinical variables used to model algorithm compliance. 134 providers were surveyed anonymously before and after the trial to assess knowledge of biomarkers and viral testing and antibiotic prescribing practices. RESULTS Diagnosis of pneumonia on admission was the only variable significantly associated with non-adherence [7% (adherence) vs. 26% (nonadherence), p = 0.01]. Surveys confirmed possible infiltrate on chest radiograph as important for provider decisions, as were severity of illness, positive sputum culture, abnormal CBC and fever. However, age, patient expectations and medical-legal concerns were also at least somewhat important to prescribing practices. Physician agreement with the importance of viral and PCT testing increased from 42% to 64% (p = 0.007) and 49% to 74% (p = 0.001), respectively, after the study. CONCLUSIONS Optimal algorithm adherence will be important for definitive PCT intervention trials in the US to determine if PCT guided algorithms result in better outcomes than reliance on traditional clinical variables. Factors influencing treatment decisions such as patient age, presence of fever, patient expectations and medical legal concerns may be amenable to education to improve PCT algorithm compliance for LRTI.
Collapse
|
47
|
Dyar OJ, Beović B, Vlahović-Palčevski V, Verheij T, Pulcini C. How can we improve antibiotic prescribing in primary care? Expert Rev Anti Infect Ther 2016; 14:403-13. [PMID: 26853235 DOI: 10.1586/14787210.2016.1151353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals' behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.
Collapse
Affiliation(s)
- Oliver J Dyar
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Bojana Beović
- b Department of Infectious Diseases, University Medical Centre Ljubljana and Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
| | - Vera Vlahović-Palčevski
- c Department of Clinical Pharmacology, University Hospital Rijeka and Medical Faculty , University of Rijeka , Rijeka , Croatia
| | - Theo Verheij
- d Julius Center for Health Sciences and Primary Care , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Céline Pulcini
- e EA 4360 APEMAC , Université de Lorraine and Service de maladies infectieuses et tropicales, CHU de Nancy , Nancy , France
| | | |
Collapse
|
48
|
Magin PJ, Morgan S, Tapley A, Davis JS, McArthur L, Henderson KM, Mulquiney KJ, Dallas A, Davey AR, Scott J, van Driel ML. Reducing general practice trainees' antibiotic prescribing for respiratory tract infections: an evaluation of a combined face-to-face workshop and online educational intervention. EDUCATION FOR PRIMARY CARE 2015; 27:98-105. [PMID: 27005837 DOI: 10.1080/14739879.2015.1106085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Over-prescription of antibiotics for non-pneumonia respiratory tract infections (RTIs) is a major concern in general practice. Australian general practice registrars (trainees) have inappropriately high rates of prescription of antibiotics for RTIs. The 'apprenticeship' educational model and the trainee-trainer relationship are drivers of this inappropriate prescribing. We aimed to reduce registrars' non-pneumonia RTI antibiotic prescribing via an educational intervention (a 90-min face-to-face workshop supported by online modules), complemented by delivery of the same intervention, separately, to their trainers. We conducted a pre- and post-intervention comparison of the registrars' intention to prescribe antibiotics for common RTIs using McNemar's test. We similarly tested changes in supervisors' intended prescribing. Prescribing intentions were elicited by responses to six written clinical vignettes (upper respiratory tract infection, otitis media, sore throat and three acute bronchitis vignettes). We found that, for registrars, there were statistically significant reductions in antibiotic prescribing for the sore throat (24.0% absolute reduction), otitis media (17.5% absolute reduction) and two of the three acute bronchitis (12.0% and 18.0% absolute reduction) vignettes. There were significant reductions in supervisors' antibiotic prescribing intentions for the same four vignettes. We conclude that our intervention produced a significant change in registrars' intention to prescribe antibiotics for non-pneumonia RTIs.
Collapse
Affiliation(s)
- Parker J Magin
- a General Practice Training Valley to Coast , Newcastle , Australia.,b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia
| | - Simon Morgan
- a General Practice Training Valley to Coast , Newcastle , Australia
| | - Amanda Tapley
- a General Practice Training Valley to Coast , Newcastle , Australia
| | - Joshua S Davis
- b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia.,c Menzies School of Health Research , Darwin , Australia.,d Department of Immunology and Infectious Diseases , John Hunter Hospital , Newcastle , Australia
| | - Lawrie McArthur
- e Adelaide to Outback General Practice Training , Adelaide , Australia
| | - Kim M Henderson
- a General Practice Training Valley to Coast , Newcastle , Australia
| | | | - Anthea Dallas
- f Discipline of General Practice , University of Notre Dame , Sydney , Australia
| | - Andrew R Davey
- b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia
| | - John Scott
- a General Practice Training Valley to Coast , Newcastle , Australia
| | - Mieke L van Driel
- g Discipline of General Practice , University of Queensland , Brisbane , Australia
| |
Collapse
|
49
|
Cabral C, Lucas PJ, Ingram J, Hay AD, Horwood J. “It's safer to …” parent consulting and clinician antibiotic prescribing decisions for children with respiratory tract infections: An analysis across four qualitative studies. Soc Sci Med 2015; 136-137:156-64. [DOI: 10.1016/j.socscimed.2015.05.027] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
50
|
Hernandez-Santiago V, Marwick CA, Patton A, Davey PG, Donnan PT, Guthrie B. Time series analysis of the impact of an intervention in Tayside, Scotland to reduce primary care broad-spectrum antimicrobial use. J Antimicrob Chemother 2015; 70:2397-404. [PMID: 25953807 DOI: 10.1093/jac/dkv095] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/19/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Concern about Clostridium difficile infection (CDI) and resistance has driven interventions internationally to reduce broad-spectrum antimicrobial use. An intervention combining guidelines, education and feedback was implemented in Tayside, Scotland in 2009 aiming to reduce primary care prescribing of co-amoxiclav, cephalosporins, fluoroquinolones and clindamycin ('4C antimicrobials'). Our aim was to assess the impact of this real-world intervention on antimicrobial prescribing rates. METHODS We used interrupted time series with segmented regression analysis to examine associations between the intervention and changes in antimicrobial prescribing (quarterly rates of patients exposed to 4C antimicrobials, non-4C antimicrobials and any antimicrobial in 2005-12). RESULTS The intervention was associated with a highly significant and sustained decrease in 4C antimicrobial prescribing, by 33.5% (95% CI -26.1 to -40.9), 42.2% (95% CI -34.2 to -50.2) and 55.5% (95% CI -45.9 to -65.1) at 6, 12 and 24 months after intervention, respectively. The effect was seen across all age groups, with the largest reductions in people aged 65 years and over (58.4% reduction at 24 months, 95% CI -46.7 to -70.1) and care home residents (65.6% reduction at 24 months, 95% CI -51.8 to -79.4). There were balancing increases in doxycycline, nitrofurantoin and trimethoprim prescribing as well as a reduction in macrolide prescribing. Total antimicrobial exposure did not change. CONCLUSIONS A real-world intervention to reduce primary care prescribing of antimicrobials associated with CDI led to large, sustained reductions in the targeted prescribing, largely due to substitution with guideline-recommended antimicrobials rather than by avoiding antimicrobial use altogether. Further research is needed to examine the impact on antimicrobial resistance.
Collapse
Affiliation(s)
- Virginia Hernandez-Santiago
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Charis A Marwick
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Andrea Patton
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Peter G Davey
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Peter T Donnan
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Bruce Guthrie
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| |
Collapse
|