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Gulliford MC, Juszczyk D, Prevost AT, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore M, Yardley L, Ashworth M, Charlton J. Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study. Health Technol Assess 2020; 23:1-70. [PMID: 30900550 DOI: 10.3310/hta23110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN A parallel-group, cluster randomised controlled trial. SETTING The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS All registered patients were included. MAIN OUTCOME MEASURES The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN95232781. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Public Health, Imperial College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, London, UK
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Gulliford MC, Prevost AT, Charlton J, Juszczyk D, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Ashworth M. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ 2019; 364:l236. [PMID: 30755451 PMCID: PMC6371944 DOI: 10.1136/bmj.l236] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections. DESIGN Open label, two arm, cluster randomised controlled trial. SETTING UK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017. PARTICIPANTS 79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care. INTERVENTIONS AMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial. MAIN OUTCOME MEASURES Primary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported. RESULTS The trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13). CONCLUSIONS Electronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation. TRIAL REGISTRATION ISRCTN95232781.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Robin Fox
- The Health Centre, Bicester, Oxfordshire, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, 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
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
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Joseph RM, Soames J, Wright M, Sultana K, van Staa TP, Dixon WG. Supplementing electronic health records through sample collection and patient diaries: A study set within a primary care research database. Pharmacoepidemiol Drug Saf 2017; 27:239-242. [PMID: 28924986 PMCID: PMC5846885 DOI: 10.1002/pds.4323] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/14/2017] [Accepted: 08/24/2017] [Indexed: 11/10/2022]
Abstract
PURPOSE To describe a novel observational study that supplemented primary care electronic health record (EHR) data with sample collection and patient diaries. METHODS The study was set in primary care in England. A list of 3974 potentially eligible patients was compiled using data from the Clinical Practice Research Datalink. Interested general practices opted into the study then confirmed patient suitability and sent out postal invitations. Participants completed a drug-use diary and provided saliva samples to the research team to combine with EHR data. RESULTS Of 252 practices contacted to participate, 66 (26%) mailed invitations to patients. Of the 3974 potentially eligible patients, 859 (22%) were at participating practices, and 526 (13%) were sent invitations. Of those invited, 117 (22%) consented to participate of whom 86 (74%) completed the study. CONCLUSIONS We have confirmed the feasibility of supplementing EHR with data collected directly from patients. Although the present study successfully collected essential data from patients, it also underlined the requirement for improved engagement with both patients and general practitioners to support similar studies.
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Affiliation(s)
- Rebecca M Joseph
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Tjeerd P van Staa
- Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, UK
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, UK.,Rheumatology Department, Salford Royal NHS Foundation Trust, Salford, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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Juszczyk D, Charlton J, McDermott L, Soames J, Sultana K, Ashworth M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Prevost AT, Gulliford MC. Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol. BMJ Open 2016; 6:e010892. [PMID: 27491663 PMCID: PMC4985802 DOI: 10.1136/bmjopen-2015-010892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. METHODS AND ANALYSIS 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. ETHICS AND DISSEMINATION Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. TRIAL REGISTRATION NUMBER ISRCTN95232781; Pre-results.
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Affiliation(s)
- Dorota Juszczyk
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Judith Charlton
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, 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
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - A Toby Prevost
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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Abstract
CONCLUSION Ki67 is not a reliable marker of malignant transformation in laryngeal dysplasia. OBJECTIVES No reliable means of predicting which cases of laryngeal dysplasia will undergo malignant transformation currently exists. Our aim was to evaluate Ki67, a marker of cell proliferation, as a potential marker for the transformation of laryngeal dysplasia to squamous cell carcinoma. PATIENTS AND METHODS Eighty consecutive cases of previously untreated patients with a histological diagnosis of laryngeal dysplasia from 1987 to 1993 were identified from the pathological archives. Standard immunohistochemical techniques were used to identify Ki67-positive cells and activity was scored on a scale of 0-4 using defined criteria. RESULTS Of the 80 cases there were 24 females and 56 males with a mean age of 56 years (range 29-80 years). Twenty cases subsequently transformed to a squamous cell carcinoma. For each Ki67 score (0-4), the rate of malignant transformation was: 0, 1 of 6 patients (17%); 1, 7 of 33 patients (21%); 2, 5 of 22 patients (23%); 3, 4 of 13 patients (31%); and 4, 3 of 6 patients (50%). A higher Ki67 score seemed to correlate with a higher likelihood of malignant transformation but this did not reach statistical significance (p=0.17, Pearson chi(2) test). Considering a score of 3 or 4 as positive for predicting malignant transformation produced a test of relatively high specificity (80%) but poor sensitivity (35%).
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Affiliation(s)
- S Mirza
- Department of Otolaryngology-Head & Neck Surgery, Freeman University Hospital, Newcastle-upon-Tyne, UK.
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Odell EW, Farthing PM, High A, Potts J, Soames J, Thakker N, Toner M, Williams HK. British Society for Oral and Maxillofacial Pathology, UK: minimum curriculum in oral pathology. Eur J Dent Educ 2004; 8:177-184. [PMID: 15469445 DOI: 10.1111/j.1600-0579.2004.00350.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This paper describes a minimum curriculum in oral pathology for undergraduate dental education in the United Kingdom prepared by the Teachers Group of The British Society of Oral and Maxillofacial Pathology. Curricular development in UK dental schools is overseen by the General Dental Council (GDC), the Quality Assurance Agency for Higher Education (QAA) and the European Union. These organisations define the framework for education and learning outcomes but provide little or no detailed guidance on syllabus or curriculum. This recommended minimum curriculum has been drawn up by a consensus process involving teachers of oral pathology from all 13 UK and one Irish dental schools and is cross-referenced to the GDC and QAA published requirements for undergraduate dental education.
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Affiliation(s)
- E W Odell
- Guy's King's and St Thomas' Dental Institute, King's College London, London, UK.
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Jeannon JP, Soames J, Lunec J, Awwaad S, Ashton V, Wilson J. Expression of cyclin-dependent kinase inhibitor p21(WAFI) and p53 tumour suppressor gene in laryngeal cancer. Clin Otolaryngol 2000. [DOI: 10.1046/j.1365-2273.2000.00405.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jeannon JP, Soames J, Lunec J, Awwad S, Ashton V, Wilson JA. Expression of cyclin-dependent kinase inhibitor p21(WAF1) and p53 tumour suppressor gene in laryngeal cancer. Clin Otolaryngol Allied Sci 2000; 25:23-7. [PMID: 10764233 DOI: 10.1046/j.1365-2273.2000.00318.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The prognostic value of the expression of the cyclin-dependent kinase inhibitor p21 and the p53 tumour suppressor gene was examined using immunohistochemistry in 60 patients with laryngeal cancer. Multivariate analysis using Cox's proportional hazard method, showed that p21 expression (P = 0.02) and advanced T stage (P = 0.003) significantly predicted survival. It was concluded that p21 expression may be a useful prognostic indicator in laryngeal cancer.
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Affiliation(s)
- J P Jeannon
- Department of Otolaryngology/Head and Neck Surgery, University of Newcastle upon Tyne, UK.
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