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Clement C, Ingram J, Cabral C, Blair PS, Hay AD, Seume P, Horwood J. Implementation of the CHIldren with acute COugh (CHICO) intervention to improve antibiotics management: a qualitative study in primary care. Br J Gen Pract 2024:BJGP.2023.0330. [PMID: 38296358 PMCID: PMC11080639 DOI: 10.3399/bjgp.2023.0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/08/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Childhood respiratory tract infections (RTIs) are common and can lead to unnecessary antibiotic use and antimicrobial resistance. The CHIldren with COugh (CHICO) intervention incorporates a clinician-focused algorithm (STARWAVe) to predict future hospitalisation risk, elicitation of carer concerns, and a carer-focused personalised leaflet recording treatment decisions and safety-netting information. AIM To examine the implementation of the CHICO intervention by primary care clinicians. DESIGN AND SETTING A qualitative study with primary care clinicians in England taking part in the CHICO randomised controlled trial. METHOD Interviews explored the CHICO intervention's acceptability and use. Clinicians from a range of practices with high and low antibiotic dispensing rates were recruited. Normalisation process theory underpinned data collection and thematic analysis. RESULTS Most clinicians liked the intervention because it was quick and easy to use, it helped elicit carer concerns, and reassured clinicians and carers of the appropriateness of treatment decisions. However, clinicians used it as a supportive aid for treatment decisions rather than as a tool for behaviour change. The accompanying advice leaflet helped explain treatment decisions and support self-care. The intervention did not always align with clinicians' usual processes, which could affect use. Increased familiarisation with the algorithm led to reduced intervention use, which was further reduced during the COVID-19 pandemic as a result of changes to practice and remote consultations. CONCLUSION Clinicians found the CHICO intervention useful to support decision making around antibiotic prescribing and it helped discussions with carers about concerns and treatment decisions. The intervention may need to be adapted to align more with clinicians' consultation flow and remote consultations.
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Affiliation(s)
- Clare Clement
- Centre for Appearance Research, University of the West of England (UWE Bristol), Bristol
| | - Jenny Ingram
- Centre for Academic Child Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol
| | - Christie Cabral
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol
| | - Peter S Blair
- Centre for Academic Child Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol
| | - Penny Seume
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol
| | - Jeremy Horwood
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol
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Blair PS, Young GJ, Clement C, Dixon P, Seume P, Ingram J, Taylor J, Horwood J, Lucas PJ, Cabral C, Francis NA, Beech E, Gulliford M, Creavin S, Lane JA, Bevan S, Hay AD. A multifaceted intervention to reduce antibiotic prescribing among CHIldren with acute COugh and respiratory tract infection: the CHICO cluster RCT. Health Technol Assess 2023; 27:1-110. [PMID: 38204218 PMCID: PMC11017154 DOI: 10.3310/ucth3411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background Clinical uncertainty in primary care regarding the prognosis of children with respiratory tract infections contributes to the unnecessary use of antibiotics. Improved identification of children at low risk of future hospitalisation might reduce clinical uncertainty. A National Institute for Health and Care Research-funded 5-year programme (RP-PG-0608-10018) was used to develop and feasibility test an intervention. Objectives The aim of the children with acute cough randomised controlled trial was to reduce antibiotic prescribing among children presenting with acute cough and respiratory tract infection without increasing hospital admission. Design An efficient, pragmatic open-label, two-arm trial (with embedded qualitative and health economic analyses) using practice-level randomisation using routinely collected data as the primary outcome. Setting General practitioner practices in England. Participants General practitioner practices using the Egton Medical Information Systems® patient-record system for children aged 0-9 years presenting with a cough or upper respiratory tract infection. Recruited by Clinical Research Networks and Clinical Commissioning Groups. Intervention Comprised: (1) elicitation of parental concerns during consultation; (2) a clinician-focused prognostic algorithm to identify children with acute cough and respiratory tract infection at low, average or elevated risk of hospitalisation in the next 30 days accompanied by prescribing guidance, (3) provision of a printout for carers including safety-netting advice. Main outcome measures Co-primaries using the practice list-size for children aged 0-9 years as the denominator: rate of dispensed amoxicillin and macrolide items at each practice (superiority comparison) from NHS Business Services Authority ePACT2 and rate of hospital admission for respiratory tract infection (non-inferiority comparison) from Clinical Commissioning Groups, both routinely collected over 12 months. Results Of the 310 practices required, 294 (95%) were recruited (144 intervention and 150 controls) with 336,496 registered 0-9-year-olds (5% of all 0-9-year-old children in England) from 47 Clinical Commissioning Groups. Included practices were slightly larger than those not included, had slightly lower baseline dispensing rates and were located in more deprived areas (reflecting the distribution for practice postcodes nationally). Twelve practices (4%) subsequently withdrew (six related to the pandemic). The median number of times the intervention was used was 70 per practice (by a median of 9 clinicians) over 12 months. There was no evidence that the antibiotic dispensing rate in the intervention practices [0.155 (95% confidence interval 0.135 to 0.179)] differed to controls [0.154 (95% confidence interval 0.130 to 0.182), relative risk= 1.011 (95% confidence interval 0.992 to 1.029); p = 0.253]. There was, overall, a reduction in dispensing levels and intervention usage during the pandemic. The rate of hospitalisation for respiratory tract infection in the intervention practices [0.019 (95% confidence interval 0.014 to 0.026)] compared to the controls [0.021 (95% confidence interval 0.014 to 0.029)] was non-inferior [relative risk = 0.952 (95% confidence interval 0.905 to 1.003)]. The qualitative evaluation found the clinicians liked the intervention, used it as a supportive aid, especially with borderline cases but that it, did not always integrate well within the consultation flow and was used less over time. The economic evaluation found no evidence of a difference in mean National Health Service costs between arms; mean difference -£1999 (95% confidence interval -£6627 to 2630). Conclusions The intervention was feasible and subjectively useful to practitioners, with no evidence of harm in terms of hospitalisations, but did not impact on antibiotic prescribing rates. Future work and limitations Although the intervention does not appear to change prescribing behaviour, elements of the approach may be used in the design of future interventions. Trial registration This trial is registered as ISRCTN11405239 (date assigned 20 April 2018) at www.controlled-trials.com (accessed 5 September 2022). Version 4.0 of the protocol is available at: https://www.journalslibrary.nihr.ac.uk/ (accessed 5 September 2022). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (NIHR award ref: 16/31/98) programme and is published in full in Health Technology Assessment; Vol. 27, No. 32. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Peter S Blair
- Centre for Academic Child Health, University of Bristol, Bristol Medical School, Bristol, UK
| | - Grace J Young
- Bristol Trials Centre (Bristol Randomised Trials Collaboration), Bristol Medical School, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Trials Centre (Bristol Randomised Trials Collaboration), Bristol Medical School, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Padraig Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Oxford, UK
| | - Penny Seume
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Jenny Ingram
- Centre for Academic Child Health, University of Bristol, Bristol Medical School, Bristol, UK
| | - Jodi Taylor
- Bristol Trials Centre (Bristol Randomised Trials Collaboration), Bristol Medical School, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Christie Cabral
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Nick A Francis
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | | | - Martin Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Sam Creavin
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Janet A Lane
- Bristol Trials Centre (Bristol Randomised Trials Collaboration), Bristol Medical School, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Scott Bevan
- Bristol Trials Centre (Bristol Randomised Trials Collaboration), Bristol Medical School, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
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3
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Gillard S, Anderson K, Clarke G, Crowe C, Goldsmith L, Jarman H, Johnson S, Lomani J, McDaid D, Pariza P, Park AL, Smith J, Turner K, Yoeli H. Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-221. [PMID: 38149657 DOI: 10.3310/pbsm2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Background People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. Objectives The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. Design This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. Setting The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Outcomes Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Results Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. Limitations The availability and quality of data imposed limitations on the reliability of some analyses. Future work Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. Study registration The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Steve Gillard
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - Katie Anderson
- School of Health and Psychological Sciences, City, University of London, London, UK
| | | | - Chloe Crowe
- Adult Acute Mental Health Services, North East London NHS Foundation Trust, London, UK
| | - Lucy Goldsmith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Jarman
- Emergency Department Clinical Research Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Jo Lomani
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Paris Pariza
- Improvement Analytics Unit, Health Foundation, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jared Smith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kati Turner
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Yoeli
- School of Health and Psychological Sciences, City, University of London, London, UK
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4
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Hay AD. Twenty five years in the making: new evidence impacted by covid. BMJ 2023; 381:1033. [PMID: 37146990 DOI: 10.1136/bmj.p1033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol
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Blair PS, Young G, Clement C, Dixon P, Seume P, Ingram J, Taylor J, Cabral C, Lucas PJ, Beech E, Horwood J, Gulliford M, Francis NA, Creavin S, Lane JA, Bevan S, Hay AD. Multi-faceted intervention to improve management of antibiotics for children presenting to primary care with acute cough and respiratory tract infection (CHICO): efficient cluster randomised controlled trial. BMJ 2023; 381:e072488. [PMID: 37100446 PMCID: PMC10131137 DOI: 10.1136/bmj-2022-072488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To assess whether an easy-to-use multifaceted intervention for children presenting to primary care with respiratory tract infections would reduce antibiotic dispensing, without increasing hospital admissions for respiratory tract infection. DESIGN Two arm randomised controlled trial clustered by general practice, using routine outcome data, with qualitative and economic evaluations. SETTING English primary care practices using the EMIS electronic medical record system. PARTICIPANTS Children aged 0-9 years presenting with respiratory tract infection at 294 general practices, before and during the covid-19 pandemic. INTERVENTION Elicitation of parental concerns during consultation; a clinician focused prognostic algorithm to identify children at very low, normal, or elevated 30 day risk of hospital admission accompanied by antibiotic prescribing guidance; and a leaflet for carers including safety netting advice. MAIN OUTCOME MEASURES Rate of dispensed amoxicillin and macrolide antibiotics (superiority comparison) and hospital admissions for respiratory tract infection (non-inferiority comparison) for children aged 0-9 years over 12 months (same age practice list size as denominator). RESULTS Of 310 practices needed, 294 (95%) were randomised (144 intervention and 150 controls) representing 5% of all registered 0-9 year olds in England. Of these, 12 (4%) subsequently withdrew (six owing to the pandemic). Median intervention use per practice was 70 (by a median of 9 clinicians). No evidence was found that antibiotic dispensing differed between intervention practices (155 (95% confidence interval 138 to 174) items/year/1000 children) and control practices (157 (140 to 176) items/year/1000 children) (rate ratio 1.011, 95% confidence interval 0.992 to 1.029; P=0.25). Pre-specified subgroup analyses suggested reduced dispensing in intervention practices with fewer prescribing nurses, in single site (compared with multisite) practices, and in practices located in areas of lower socioeconomic deprivation, which may warrant future investigation. Pre-specified sensitivity analysis suggested reduced dispensing among older children in the intervention arm (P=0.03). A post hoc sensitivity analysis suggested less dispensing in intervention practices before the pandemic (rate ratio 0.967, 0.946 to 0.989; P=0.003). The rate of hospital admission for respiratory tract infections in the intervention practices (13 (95% confidence interval 10 to 18) admissions/1000 children) was non-inferior compared with control practices (15 (12 to 20) admissions/1000 children) (rate ratio 0.952, 0.905 to 1.003). CONCLUSIONS This multifaceted antibiotic stewardship intervention for children with respiratory tract infections did not reduce overall antibiotic dispensing or increase respiratory tract infection related hospital admissions. Evidence suggested that in some subgroups and situations (for example, under non-pandemic conditions) the intervention slightly reduced prescribing rates but not in a clinically relevant way. TRIAL REGISTRATION ISRCTN11405239ISRCTN registry ISRCTN11405239.
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Affiliation(s)
- Peter S Blair
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Grace Young
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - P Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Penny Seume
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jenny Ingram
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jodi Taylor
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christie Cabral
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Jeremy Horwood
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Martin Gulliford
- King's College London, School of Population and Life Course Sciences London, UKPrimary Care Research Centre, School of Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | | | - Sam Creavin
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Janet A Lane
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Scott Bevan
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alistair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Blair PS, Ingram J, Clement C, Young G, Seume P, Taylor J, Cabral C, Lucas PJ, Beech E, Horwood J, Dixon P, Gulliford MC, Francis N, Creavin ST, Lane A, Bevan S, Hay AD. Can primary care research be conducted more efficiently using routinely reported practice-level data: a cluster randomised controlled trial conducted in England? BMJ Open 2022; 12:e061574. [PMID: 35777876 PMCID: PMC9252201 DOI: 10.1136/bmjopen-2022-061574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Conducting randomised controlled trials (RCTs) in primary care is challenging; recruiting patients during time-limited or remote consultations can increase selection bias and physical access to patients' notes is costly and time-consuming. We investigated barriers and facilitators to running a more efficient design. DESIGN An RCT aiming to reduce antibiotic prescribing among children presenting with acute cough and a respiratory tract infection (RTI) with a clinician-focused intervention, embedded at the practice level. By using aggregate level, routinely collected data for the coprimary outcomes, we removed the need to recruit individual participants. SETTING Primary care. PARTICIPANTS Baseline data from general practitioner practices and interviews with individuals from Clinical Research Networks (CRNs) in England who helped recruit practices and Clinical Commission Groups (CCGs) who collected outcome data. INTERVENTION The intervention included: (1) explicit elicitation of parental concerns, (2) a prognostic algorithm to identify children at low risk of hospitalisation and (3) provision of a printout for carers including safety-netting advice. COPRIMARY OUTCOMES For 0-9 years old-(1) Dispensing data for amoxicillin and macrolide antibiotics and (2) hospital admission rate for RTI. RESULTS We recruited 294 of the intended 310 practices (95%) representing 336 496 registered 0-9 years old (5% of all 0-9 years old children). Included practices were slightly larger, had slightly lower baseline prescribing rates and were located in more deprived areas reflecting the national distribution. Engagement with CCGs and their understanding of their role in this research was variable. Engagement with CRNs and installation of the intervention was straight-forward although the impact of updates to practice IT systems and lack of familiarity required extended support in some practices. Data on the coprimary outcomes were almost 100%. CONCLUSIONS The infrastructure for trials at the practice level using routinely collected data for primary outcomes is viable in England and should be promoted for primary care research where appropriate. TRIAL REGISTRATION NUMBER ISRCTN11405239.
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Affiliation(s)
- Peter S Blair
- Centre for Academic Child Health, University of Bristol, Bristol, UK
| | - Jenny Ingram
- Centre for Academic Child Health, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Grace Young
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Penny Seume
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Jodi Taylor
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Christie Cabral
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | | | - Jeremy Horwood
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | | | - Nick Francis
- School of Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Sam T Creavin
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Athene Lane
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Scott Bevan
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Gillard S, Foster R, White S, Barlow S, Bhattacharya R, Binfield P, Eborall R, Faulkner A, Gibson S, Goldsmith LP, Simpson A, Lucock M, Marks J, Morshead R, Patel S, Priebe S, Repper J, Rinaldi M, Ussher M, Worner J. The impact of working as a peer worker in mental health services: a longitudinal mixed methods study. BMC Psychiatry 2022; 22:373. [PMID: 35650562 PMCID: PMC9158348 DOI: 10.1186/s12888-022-03999-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Peer workers are increasingly employed in mental health services to use their own experiences of mental distress in supporting others with similar experiences. While evidence is emerging of the benefits of peer support for people using services, the impact on peer workers is less clear. There is a lack of research that takes a longitudinal approach to exploring impact on both employment outcomes for peer workers, and their experiences of working in the peer worker role. METHODS In a longitudinal mixed methods study, 32 peer workers providing peer support for discharge from inpatient to community mental health care - as part of a randomised controlled trial - undertook in-depth qualitative interviews conducted by service user researchers, and completed measures of wellbeing, burnout, job satisfaction and multi-disciplinary team working after completing training, and four and 12 months into the role. Questionnaire data were summarised and compared to outcomes for relevant population norms, and changes in outcomes were analysed using paired t-tests. Thematic analysis and interpretive workshops involving service user researchers were used to analysis interview transcripts. A critical interpretive synthesis approach was used to synthesise analyses of both datasets. RESULTS For the duration of the study, all questionnaire outcomes were comparable with population norms for health professionals or for the general population. There were small-to-medium decreases in wellbeing and aspects of job satisfaction, and increase in burnout after 4 months, but these changes were largely not maintained at 12 months. Peer workers felt valued, empowered and connected in the role, but could find it challenging to adjust to the demands of the job after initial optimism. Supervision and being part of a standalone peer worker team was supportive, although communication with clinical teams could be improved. CONCLUSIONS Peer workers seem no more likely to experience negative impacts of working than other healthcare professionals but should be well supported as they settle into post, provided with in-work training and support around job insecurity. Research is needed to optimise working arrangements for peer workers alongside clinical teams.
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Affiliation(s)
| | - Rhiannon Foster
- grid.28577.3f0000 0004 1936 8497City, University of London, London, UK
| | - Sarah White
- grid.264200.20000 0000 8546 682XSt George’s, University of London, London, UK
| | - Sally Barlow
- grid.28577.3f0000 0004 1936 8497City, University of London, London, UK
| | - Rahul Bhattacharya
- grid.450709.f0000 0004 0426 7183East London NHS Foundation Trust, London, UK
| | - Paul Binfield
- grid.450709.f0000 0004 0426 7183East London NHS Foundation Trust, London, UK
| | - Rachel Eborall
- grid.37640.360000 0000 9439 0839South London & Maudsley NHS Foundation Trust, London, UK
| | | | - Sarah Gibson
- grid.264200.20000 0000 8546 682XSt George’s, University of London, London, UK
| | - Lucy P. Goldsmith
- grid.264200.20000 0000 8546 682XSt George’s, University of London, London, UK
| | - Alan Simpson
- grid.13097.3c0000 0001 2322 6764King’s College London, London, UK
| | - Mike Lucock
- grid.15751.370000 0001 0719 6059University of Huddersfield, Huddersfield, UK
| | - Jacqui Marks
- grid.264200.20000 0000 8546 682XSt George’s, University of London, London, UK
| | - Rosaleen Morshead
- grid.264200.20000 0000 8546 682XSt George’s, University of London, London, UK
| | - Shalini Patel
- grid.439450.f0000 0001 0507 6811South West London & St George’s Mental Health NHS Trust, London, UK
| | - Stefan Priebe
- grid.4868.20000 0001 2171 1133Queen Mary, University of London, London, UK
| | - Julie Repper
- Implementing Recovery through Organisational Change, Nottingham, UK
| | - Miles Rinaldi
- grid.439450.f0000 0001 0507 6811South West London & St George’s Mental Health NHS Trust, London, UK
| | - Michael Ussher
- grid.264200.20000 0000 8546 682XSt George’s, University of London, London, UK ,grid.11918.300000 0001 2248 4331University of Stirling, Stirling, UK
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8
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Hardefeldt LY, Hur B, Richards S, Scarborough R, Browning GF, Billman-Jacobe H, Gilkerson JR, Ierardo J, Awad M, Chay R, Bailey KE. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac015. [PMID: 35233530 PMCID: PMC8874133 DOI: 10.1093/jacamr/dlac015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/02/2022] [Indexed: 11/28/2022] Open
Abstract
Background Antimicrobial stewardship programmes (ASPs) have been widely implemented in medical practice to improve antimicrobial prescribing and reduce selection for multidrug-resistant pathogens. Objectives To implement different antimicrobial stewardship intervention packages in 135 veterinary practices and assess their impact on antimicrobial prescribing. Methods In October 2018, general veterinary clinics were assigned to one of three levels of ASP, education only (CON), intermediate (AMS1) or intensive (AMS2). De-identified prescribing data (1 October 2016 to 31 October 2020), sourced from VetCompass Australia, were analysed and a Poisson regression model fitted to identify the effect of the interventions on the incidence rates of antimicrobial prescribing. Results The overall incidence rate (IR) of antimicrobial prescribing for dogs and cats prior to the intervention was 3.7/100 consultations, which declined by 36% (2.4/100) in the implementation period, and by 50% (1.9/100) during the post-implementation period. Compared with CON, in AMS2 there was a 4% and 6% reduction in the overall IR of antimicrobial prescribing, and a 24% and 24% reduction in IR of high importance antimicrobial prescribing, attributable to the intervention in the implementation and post-implementation periods, respectively. A greater mean difference in the IR of antimicrobial prescribing was seen in high-prescribing clinics. Conclusions These AMS interventions had a positive impact in a large group of general veterinary practices, resulting in a decline in overall antimicrobial use and a shift towards use of antimicrobials rated as low importance, with the greatest impact in high-prescribing clinics.
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Affiliation(s)
- L. Y. Hardefeldt
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
- Corresponding author. E-mail:
| | - B. Hur
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - S. Richards
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - R. Scarborough
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - G. F. Browning
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - H. Billman-Jacobe
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - J. R. Gilkerson
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - J. Ierardo
- Greencross Vets Pty Ltd, Brisbane, Queensland, Australia
| | - M. Awad
- Greencross Vets Pty Ltd, Brisbane, Queensland, Australia
| | - R. Chay
- Greencross Vets Pty Ltd, Brisbane, Queensland, Australia
| | - K. E. Bailey
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
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9
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Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother 2021; 75:2394-2410. [PMID: 32356877 DOI: 10.1093/jac/dkaa154] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/06/2020] [Accepted: 03/27/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES This systematic review (SR) reviews the evidence on use of theory in developing and evaluating behaviour change interventions (BCIs) to improve clinicians' antimicrobial prescribing (AP). METHODS The SR protocol was registered with PROSPERO. Eleven databases were searched from inception to October 2018 for peer-reviewed, English-language, primary literature in any healthcare setting and for any medical condition. This included research on changing behavioural intentions (e.g. in simulated scenarios) and research measuring actual AP. All study designs/methodologies were included. Excluded were: grey literature and/or those which did not state a theory. Two reviewers independently extracted and quality assessed the data. The Theory Coding Scheme (TCS) evaluated the extent of the use of theory. RESULTS Searches found 4227 potentially relevant papers after removal of duplicates. Screening of titles/abstracts led to dual assessment of 38 full-text papers. Ten (five quantitative, three qualitative and two mixed-methods) met the inclusion criteria. Studies were conducted in the UK (n = 8), Canada (n = 1) and Sweden (n = 1), most in primary care settings (n = 9), targeting respiratory tract infections (n = 8), and medical doctors (n = 10). The most common theories used were Theory of Planned Behaviour (n = 7), Social Cognitive Theory (n = 5) and Operant Learning Theory (n = 5). The use of theory to inform the design and choice of intervention varied, with no optimal use as recommended in the TCS. CONCLUSIONS This SR is the first to investigate theoretically based BCIs around AP. Few studies were identified; most were suboptimal in theory use. There is a need to consider how theory is used and reported and the systematic use of the TCS could help.
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Affiliation(s)
- Hend Talkhan
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Trudi Mcintosh
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Hisham Ziglam
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Moza Al-Hail
- Pharmacy Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Diab
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
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10
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Seume P, Bevan S, Young G, Ingram J, Clement C, Cabral C, Lucas PJ, Beech E, Taylor J, Horwood J, Dixon P, Gulliford MC, Francis N, Creavin ST, Lane A, Hay AD, Blair PS. Protocol for an 'efficient design' cluster randomised controlled trial to evaluate a complex intervention to improve antibiotic prescribing for CHIldren presenting to primary care with acute COugh and respiratory tract infection: the CHICO study. BMJ Open 2021; 11:e041769. [PMID: 33782018 PMCID: PMC8009213 DOI: 10.1136/bmjopen-2020-041769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Respiratory tract infections (RTIs) in children are common and present major resource implications for primary care. Unnecessary use of antibiotics is associated with the development and proliferation of antimicrobial resistance. In 2016, the National Institute for Health Research (NIHR)-funded 'TARGET' programme developed a prognostic algorithm to identify children with acute cough and RTI at very low risk of 30-day hospitalisation and unlikely to need antibiotics. The intervention includes: (1) explicit elicitation of parental concerns, (2) the results of the prognostic algorithm accompanied by prescribing guidance and (3) provision of a printout for carers including safety netting advice. The CHIldren's COugh feasibility study suggested differential recruitment of healthier patients in control practices. This phase III 'efficiently designed' trial uses routinely collected data at the practice level, thus avoiding individual patient consent. The aim is to assess whether embedding a multifaceted intervention into general practitioner (GP) practice Information Technology (IT) systems will result in reductions of antibiotic prescribing without impacting on hospital attendance for RTI. METHODS AND ANALYSIS The coprimary outcomes are (1) practice rate of dispensed amoxicillin and macrolide antibiotics, (2) hospital admission rate for RTI using routinely collected data by Clinical Commissioning Groups (CCGs). Data will be collected for children aged 0-9 years registered at 310 practices (155 intervention, 155 usual care) over a 12-month period. Recruitment and randomisation of practices (using the Egton Medical Information Systems web data management system) is conducted via each CCG stratified for children registered and baseline dispensing rates of each practice. Secondary outcomes will explore intervention effect modifiers. Qualitative interviews will explore intervention usage. The economic evaluation will be limited to a between-arm comparison in a cost-consequence analysis. ETHICS AND DISSEMINATION Research ethics approval was given by London-Camden and Kings Cross Research Ethics Committee (ref:18/LO/0345). This manuscript refers to protocol V.4.0. Results will be disseminated through peer-reviewed journals and international conferences. TRIAL REGISTRATION NUMBER ISRCTN11405239.
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Affiliation(s)
- Penny Seume
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Scott Bevan
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Grace Young
- Bristol Trials Centre (Bristol Randomised Trial Collaboration), Bristol Medical School, University of Bristol, University of Bristol, Bristol, Avon, UK
| | - Jenny Ingram
- Centre for Academic Child Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Trials Centre (Bristol Randomised Trial Collaboration), Bristol Medical School, University of Bristol, University of Bristol, Bristol, Avon, UK
| | - Christie Cabral
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Elizabeth Beech
- Regional Antimicrobial Stewardship Lead South West Region, NHS Improvement, London, UK
| | - Jodi Taylor
- Bristol Trials Centre (Bristol Randomised Trial Collaboration), Bristol Medical School, University of Bristol, University of Bristol, Bristol, Avon, UK
| | - Jeremy Horwood
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Padraig Dixon
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Nick Francis
- School of Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, Hampshire, UK
| | - Sam T Creavin
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Athene Lane
- Bristol Trials Centre (Bristol Randomised Trial Collaboration), Bristol Medical School, University of Bristol, University of Bristol, Bristol, Avon, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter S Blair
- Centre for Academic Child Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
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11
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Rose J, Crosbie M, Stewart A. A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing. Perspect Public Health 2019; 141:19-27. [PMID: 31633458 DOI: 10.1177/1757913919879183] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS This qualitative literature review aims to critically assess and analyse published literature to determine drivers influencing over-prescribing by general practitioners (GPs) in primary care, exploring their views and opinions, and also to determine how antibiotic prescribing can be improved and unnecessary prescribing reduced, thus reducing the threat to public health from antibiotic resistance. It is intended to develop new thinking in this area and add to existing knowledge concerning GPs' antibiotic prescribing behaviour. METHODS Thematic analysis following Braun and Clarke's 2006 framework was used to analyse 17 qualitative studies chosen from EBSCOhost databases, focusing on GPs' views of antibiotic prescribing in primary care, with specific search strategies and inclusion criteria to ensure study quality and trustworthiness. RESULTS Three main themes and nine sub-themes were generated from the studies. The first main theme discussed GP factors related to over-prescribing, the main drivers being GP attitudes and feelings and anxiety/fear concerning prescribing. The second theme highlighted external factors, with pressures from time and financial issues as the main drivers within this theme. The final theme marked patient pressure, demand and expectation with lack of patient education as the major drivers affecting GP over-prescribing. CONCLUSION The findings of this research show GPs' antibiotic prescribing in primary care is complex, being influenced by many internal and external factors. A multifaceted approach to interventions targeting the drivers identified could significantly reduce the level of antibiotic prescribing thus minimising the impact of antibiotic resistance and promoting a more efficient working environment for GPs and patients alike.
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Affiliation(s)
- Joanna Rose
- University of Wolverhampton, Wulfruna Street, Wolverhampton WV1 1LY, UK
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12
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Impact of antibiotics for children presenting to general practice with cough on adverse outcomes: secondary analysis from a multicentre prospective cohort study. Br J Gen Pract 2018; 68:e682-e693. [PMID: 30201827 PMCID: PMC6145994 DOI: 10.3399/bjgp18x698873] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/02/2018] [Indexed: 11/16/2022] Open
Abstract
Background Clinicians commonly prescribe antibiotics to prevent major adverse outcomes in children presenting in primary care with cough and respiratory symptoms, despite limited meaningful evidence of impact on these outcomes. Aim To estimate the effect of children’s antibiotic prescribing on adverse outcomes within 30 days of initial consultation. Design and setting Secondary analysis of 8320 children in a multicentre prospective cohort study, aged 3 months to <16 years, presenting in primary care across England with acute cough and other respiratory symptoms. Method Baseline clinical characteristics and antibiotic prescribing data were collected, and generalised linear models were used to estimate the effect of antibiotic prescribing on adverse outcomes within 30 days (subsequent hospitalisations and reconsultation for deterioration), controlling for clustering and clinicians’ propensity to prescribe antibiotics. Results Sixty-five (0.8%) children were hospitalised and 350 (4%) reconsulted for deterioration. Clinicians prescribed immediate and delayed antibiotics to 2313 (28%) and 771 (9%), respectively. Compared with no antibiotics, there was no clear evidence that antibiotics reduced hospitalisations (immediate antibiotic risk ratio [RR] 0.83, 95% confidence interval [CI] = 0.47 to 1.45; delayed RR 0.70, 95% CI = 0.26 to 1.90, overall P = 0.44). There was evidence that delayed (rather than immediate) antibiotics reduced reconsultations for deterioration (immediate RR 0.82, 95% CI = 0.65 to 1.07; delayed RR 0.55, 95% CI = 0.34 to 0.88, overall P = 0.024). Conclusion Most children presenting with acute cough and respiratory symptoms in primary care are not at risk of hospitalisation, and antibiotics may not reduce the risk. If an antibiotic is considered, a delayed antibiotic prescription may be preferable as it is likely to reduce reconsultation for deterioration.
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