1
|
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
|
2
|
Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
3
|
Goggin K, Bradley-Ewing A, Myers AL, Lee BR, Hurley EA, Delay KB, Schlachter S, Ramphal A, Pina K, Yu D, Weltmer K, Linnemayr S, Butler CC, Newland JG. Protocol for a randomised trial of higher versus lower intensity patient-provider communication interventions to reduce antibiotic misuse in two paediatric ambulatory clinics in the USA. BMJ Open 2018; 8:e020981. [PMID: 29743330 PMCID: PMC5942422 DOI: 10.1136/bmjopen-2017-020981] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Children with acute respiratory tract infections (ARTIs) are prescribed up to 11.4 million unnecessary antibiotic prescriptions annually. Inadequate parent-provider communication is a chief contributor, yet efforts to reduce overprescribing have only indirectly targeted communication or been impractical. This paper describes our multisite, parallel group, cluster randomised trial comparing two feasible interventions for enhancing parent-provider communication on the rate of inappropriate antibiotic prescribing (primary outcome) and revisits, adverse drug reactions and parent-rated quality of shared decision-making, parent-provider communication and visit satisfaction (secondary outcomes). METHODS/ANALYSIS We will attempt to recruit all eligible paediatricians and nurse practitioners (currently 47) at an academic children's hospital and a private practice. Using a 1:1 randomisation, providers will be assigned to a higher intensity education and communication skills or lower intensity education-only intervention and trained accordingly. We will recruit 1600 eligible parent-child dyads. Parents of children ages 1-5 years who present with ARTI symptoms will be managed by providers trained in either the higher or lower intensity intervention. Before their consultation, all parents will complete a baseline survey and view a 90 s gain-framed antibiotic educational video. Parent-child dyads consulting with providers trained in the higher intensity intervention will, in addition, receive a gain-framed antibiotic educational brochure promoting cautious use of antibiotics and rate their interest in receiving an antibiotic which will be shared with their provider before the visit. All parents will complete a postconsultation survey and a 2-week follow-up phone survey. Due to the two-stage nested design (parents nested within providers and clinics), we will employ generalised linear mixed-effect regression models. ETHICS/DISSEMINATION Ethical approval was obtained from the Children's Mercy Hospital Pediatric Institutional Review Board (#16060466). Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03037112; Pre-results.
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, Missouri, USA
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Angela L Myers
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- Infectious Diseases, Children's Mercy, Kansas City, Missouri, 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, Missouri, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kirsten B Delay
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Sarah Schlachter
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Areli Ramphal
- 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
| | - David Yu
- Sunflower Medical Group, Kansas City, Kansas, USA
| | - Kirsten Weltmer
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason G Newland
- Pediatric Infectious Disease, St. Louis Children's Hospital, St. Louis, Missouri, USA
| |
Collapse
|
4
|
Porcheret M, Main C, Croft P, Dziedzic K. Enhancing delivery of osteoarthritis care in the general practice consultation: evaluation of a behaviour change intervention. BMC FAMILY PRACTICE 2018; 19:26. [PMID: 29409449 PMCID: PMC5801670 DOI: 10.1186/s12875-018-0715-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/24/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Professionally-focussed behaviour change intervention (BCI) workshops were utilised in the Management of OsteoArthritis in Consultations (MOSAICS) trial investigating the feasibility of implementing the National Institute for Health and Care Excellence (NICE) Osteoarthritis (OA) Guideline in general practice. The workshops aimed to implement the general practitioner (GP) component of the trial intervention: an enhanced consultation for patients presenting with possible OA. This study presents an evaluation of the BCI workshops on GP competency in conducting these enhanced consultations. METHODS A before-and-after evaluation of the workshops, delivered to GPs participating in the intervention arm of the MOSAICS trial, using video-recorded GP consultations with simulated OA patients. GPs attended four workshops, which had been developed using an implementation framework. Videos were undertaken at three time-points (before workshops and at one- and five-months after) and were assessed by independent observers, blinded to time points, for GP competency in undertaking 14 predetermined consultation tasks. RESULTS Videos of 15 GPs were assessed. GP competency increased from a median of seven consultation tasks undertaken by each GP at baseline to 11 at both time-points after the workshops. Specific tasks which were undertaken more frequently after the workshops related to explaining that OA is treatable and not inevitably progressive, eliciting and addressing patient expectations of the consultation, and providing written OA information. However, the use of the word "osteoarthritis" in giving the diagnosis of OA was not enhanced by the workshops. CONCLUSIONS BCI workshops can enhance GP competency in undertaking consultations for OA. Further initiatives to implement the NICE OA Guideline and enhance the care of people with OA in primary care can be informed by the content and delivery of the workshops evaluated in this study.
Collapse
Affiliation(s)
- Mark Porcheret
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
| | - Chris Main
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Peter Croft
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| |
Collapse
|
5
|
Healey EL, Main CJ, Ryan S, McHugh GA, Porcheret M, Finney AG, Morden A, Dziedzic KS. A nurse-led clinic for patients consulting with osteoarthritis in general practice: development and impact of training in a cluster randomised controlled trial. BMC FAMILY PRACTICE 2016; 17:173. [PMID: 28003026 PMCID: PMC5178095 DOI: 10.1186/s12875-016-0568-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 11/30/2016] [Indexed: 01/20/2023]
Abstract
Background Despite a lack of service provision for people with osteoarthritis (OA), each year 1 in 5 of the general population consults a GP about a musculoskeletal condition such as OA. Consequently this may provide an opportunity for practice nurses to take an active role in helping patients manage their condition. A nurse led clinic for supporting patients with OA was developed for the MOSAICS study investigating how to implement the NICE 2014 OA Guideline core recommendations. This paper has two main objectives, firstly to provide an overview of the nurse-led OA clinic, and secondly to describe the development, key learning objectives, content and impact of the training to support its delivery. Methods A training programme was developed and delivered to provide practice nurses with the knowledge and skill set needed to run the nurse-led OA clinic. The impact of the training programme on knowledge, confidence and OA management was evaluated using case report forms and pre and post training questionnaires. Results The pre-training questionnaire identified a gap between what practice nurses feel they can do and what they should be doing in line with NICE OA guidelines. Evaluation of the training suggests that it enabled practice nurses to feel more knowledgeable and confident in supporting patients to manage their OA and this was reflected in the clinical management patients received in the nurse-led OA clinics. Conclusions A significant gap between what is recommended and what practice nurses feel they can currently provide in terms of OA management was evident. The development of a nurse training programme goes some way to develop a system in primary care for delivering the core recommendations by NICE. Trial registration The cluster trial linked to this training was conducted from May 2012 through February 2014 by the Arthritis Research UK Primary Care Centre, Keele University, UK (Trial registration number ISRCTN06984617). Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0568-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Emma L Healey
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK.
| | - Chris J Main
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
| | - Sarah Ryan
- Staffordshire and Stoke on Trent Partnership NHS Trust, Haywood Hospital, Stoke-on-Trent, UK.,Keele University, School of Nursing and Midwifery, Clinical Education Centre, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Gretl A McHugh
- School of Healthcare, University of Leeds, Yorkshire, UK
| | - Mark Porcheret
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
| | - Andrew G Finney
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK.,Keele University, School of Nursing and Midwifery, Clinical Education Centre, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Andrew Morden
- School of Social and Community Medicine, University of Bristol, Gloucestershire, UK
| | - Krysia S Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
| |
Collapse
|
6
|
Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016; 65:1-12. [PMID: 27832047 DOI: 10.15585/mmwr.rr6506a1] [Citation(s) in RCA: 358] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings. In 2014 and 2015, respectively, CDC released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management. The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic prescribing practices. Clinicians and leaders of outpatient clinics and health care systems can track antibiotic prescribing practices and regularly report these data back to clinicians. Clinicians can provide educational resources to patients and families on appropriate antibiotic use. Finally, leaders of outpatient clinics and health systems can provide clinicians with education aimed at improving antibiotic prescribing and with access to persons with expertise in antibiotic stewardship. Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings.
Collapse
|
7
|
|
8
|
Avent ML, Hansen MP, Gilks C, Del Mar C, Halton K, Sidjabat H, Hall L, Dobson A, Paterson DL, van Driel ML. General Practitioner Antimicrobial Stewardship Programme Study (GAPS): protocol for a cluster randomised controlled trial. BMC FAMILY PRACTICE 2016; 17:48. [PMID: 27098971 PMCID: PMC4839086 DOI: 10.1186/s12875-016-0446-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/14/2016] [Indexed: 12/13/2022]
Abstract
Background There is a strong link between antibiotic consumption and the rate of antibiotic resistance. In Australia, the vast majority of antibiotics are prescribed by general practitioners, and the most common indication is for acute respiratory infections. The aim of this study is to assess if implementing a package of integrated, multifaceted interventions reduces antibiotic prescribing for acute respiratory infections in general practice. Methods/design This is a cluster randomised trial comparing two parallel groups of general practitioners in 28 urban general practices in Queensland, Australia: 14 intervention and 14 control practices. The protocol was peer-reviewed by content experts who were nominated by the funding organization. This study evaluates an integrated, multifaceted evidence-based package of interventions implemented over a six month period. The included interventions, which have previously been demonstrated to be effective at reducing antibiotic prescribing for acute respiratory infections, are: delayed prescribing; patient decision aids; communication training; commitment to a practice prescribing policy for antibiotics; patient information leaflet; and near patient testing with C-reactive protein. In addition, two sub-studies are nested in the main study: (1) point prevalence estimation carriage of bacterial upper respiratory pathogens in practice staff and asymptomatic patients; (2) feasibility of direct measures of antibiotic resistance by nose/throat swabbing. The main outcome data are from Australia’s national health insurance scheme, Medicare, which will be accessed after the completion of the intervention phase. They include the number of antibiotic prescriptions and the number of patient visits per general practitioner for periods before and during the intervention. The incidence of antibiotic prescriptions will be modelled using the numbers of patients as the denominator and seasonal and other factors as explanatory variables. Results will compare the change in prescription rates before and during the intervention in the two groups of practices. Semi-structured interviews will be conducted with the general practitioners and practice staff (practice nurse and/or practice manager) from the intervention practices on conclusion of the intervention phase to assess the feasibility and uptake of the interventions. An economic evaluation will be conducted to estimate the costs of implementing the package, and its cost-effectiveness in terms of cost per unit reduction in prescribing. Discussion The results on the effectiveness, cost-effectiveness, acceptability and feasibility of this package of interventions will inform the policy for any national implementation. Trial registration The GAPS trial is registered under the Australian New Zealand Clinical Trials Register, reference number: ACTRN12615001128583 (registered 26/10/2015).
Collapse
Affiliation(s)
- Minyon L Avent
- The University of Queensland, School of Public Health, Herston, QLD, 4006, Australia. .,The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4006, Australia.
| | - Malene Plejdrup Hansen
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4226, Australia
| | - Charles Gilks
- The University of Queensland, School of Public Health, Herston, QLD, 4006, Australia
| | - Chris Del Mar
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4226, Australia
| | - Kate Halton
- Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Kelvin Grove, QLD, 4059, Australia
| | - Hanna Sidjabat
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4006, Australia
| | - Lisa Hall
- Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Kelvin Grove, QLD, 4059, Australia
| | - Annette Dobson
- The University of Queensland, School of Public Health, Herston, QLD, 4006, Australia
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4006, Australia
| | - Mieke L van Driel
- The University of Queensland, Discipline of General Practice, School of Medicine, Herston, QLD, 4006, Australia
| |
Collapse
|
9
|
Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014; 5:229-41. [PMID: 25436105 DOI: 10.1177/2042098614554919] [Citation(s) in RCA: 855] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians' interest, such as complications and clinical outcomes.
Collapse
Affiliation(s)
- Carl Llor
- School of Medicine, Cardiff University, Department of Primary Care and Public Health, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
10
|
Butler CC, Francis NA. Asthma prevalence and humoral immune response in Somali immigrants in the US: implications for the hygiene hypothesis. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 22:262-4. [PMID: 23959045 PMCID: PMC6442840 DOI: 10.4104/pcrj.2013.00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
|
11
|
Porcheret M, Main C, Croft P, McKinley R, Hassell A, Dziedzic K. Development of a behaviour change intervention: a case study on the practical application of theory. Implement Sci 2014; 9:42. [PMID: 24708880 PMCID: PMC3983864 DOI: 10.1186/1748-5908-9-42] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/25/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Use of theory in implementation of complex interventions is widely recommended. A complex trial intervention, to enhance self-management support for people with osteoarthritis (OA) in primary care, needed to be implemented in the Managing Osteoarthritis in Consultations (MOSAICS) trial. One component of the trial intervention was delivery by general practitioners (GPs) of an enhanced consultation for patients with OA. The aim of our case study is to describe the systematic selection and use of theory to develop a behaviour change intervention to implement GP delivery of the enhanced consultation. METHODS The development of the behaviour change intervention was guided by four theoretical models/frameworks: i) an implementation of change model to guide overall approach, ii) the Theoretical Domains Framework (TDF) to identify relevant determinants of change, iii) a model for the selection of behaviour change techniques to address identified determinants of behaviour change, and iv) the principles of adult learning. Methods and measures to evaluate impact of the behaviour change intervention were identified. RESULTS The behaviour change intervention presented the GPs with a well-defined proposal for change; addressed seven of the TDF domains (e.g., knowledge, skills, motivation and goals); incorporated ten behaviour change techniques (e.g., information provision, skills rehearsal, persuasive communication); and was delivered in workshops that valued the expertise and professional values of GPs. The workshops used a mixture of interactive and didactic sessions, were facilitated by opinion leaders, and utilised 'context-bound communication skills training.' Methods and measures selected to evaluate the behaviour change intervention included: appraisal of satisfaction with workshops, GP report of intention to practise and an assessment of video-recorded consultations of GPs with patients with OA. CONCLUSIONS A stepped approach to the development of a behaviour change intervention, with the utilisation of theoretical frameworks to identify determinants of change matched with behaviour change techniques, has enabled a systematic and theory-driven development of an intervention designed to enhance consultations by GPs for patients with OA. The success of the behaviour change intervention in practice will be evaluated in the context of the MOSAICS trial as a whole, and will inform understanding of practice level and patient outcomes in the trial.
Collapse
Affiliation(s)
- Mark Porcheret
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
| | | | | | | | | | | |
Collapse
|
12
|
Mustafa M, Wood F, Butler CC, Elwyn G. Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Ann Fam Med 2014; 12:29-36. [PMID: 24445101 PMCID: PMC3896536 DOI: 10.1370/afm.1583] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Communication experts have suggested that it is good practice to ask patients' directly whether they expect to receive antibiotics as part of asking about the triad of ideas, concerns, and expectations for health care. Our aim was to explore the views and experiences of family physicians about using this strategy with their patients, focusing the interview on the problem of eliciting expectations of antibiotics as a possible treatment for upper respiratory tract infections. METHODS We conducted a qualitative study using semistructured interviews with 20 family physicians in South Wales, United Kingdom, and performing thematic analysis. RESULTS Family physicians assumed most patients or parents wanted antibiotics, as well as wanting to be "checked out" to make sure the illness was "nothing serious." Physicians said they did not ask direct questions about expectations, as that might lead to confrontation. They preferred to elicit expectations for antibiotics in an indirect manner, before performing a physical examination. The majority described reporting their findings of the examination as a "running commentary" so as to influence expectations and help avoid generating resistance to a soon-to-be-made-explicit plan not to prescribe antibiotics. The physicians used the running commentary to preserve and enhance the physician-patient relationship. CONCLUSIONS Real-world family physicians use indirect methods to explore expectations for treatment and, on the basis of their physical examination, build an argument for reassuring the patient or parent. In contrast to proposed models in the communication literature, interventions to promote appropriate antibiotic prescribing might include a focus on training in communication skills that (1) integrates these indirect methods as part of building collaborative physician-patient relationships and (2) uses the running commentary of examination findings to facilitate participation in clinical decisions.
Collapse
Affiliation(s)
- Mohammed Mustafa
- Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | | |
Collapse
|
13
|
Cals JWL, van Leeuwen ME, Chappin FHF, de Bont EGPM, Dinant GJ, Butler CC. "How Do You Feel about Antibiotics for This?" A Qualitative Study of Physician Attitudes towards a Context-Rich Communication Skills Method. Antibiotics (Basel) 2013; 2:439-49. [PMID: 27029312 PMCID: PMC4790273 DOI: 10.3390/antibiotics2030439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 11/25/2022] Open
Abstract
To explore experiences with and views of general practitioners (GPs) on a physician communication training method in primary care and its applicability and implementation in daily practice, we performed a semi-structured qualitative study of GPs’ experience of training in and implementing a communication skills training program for managing lower respiratory tract infection (LRTI) which included a seminar, simulated patient consultation together with providing and receiving feedback on ones own transcript, and a seminar in a structured approach to the LRTI consultation. Seventeen out of 20 eligible GPs who had participated in the IMPAC3T trial and were allocated to receiving enhanced physician communication training for managing lower respiratory tract infection participated. GPs’ experiences with the physician communication training method and its specific components were positive. The method gave GPs additional tools for managing LRTI consultations and increased their sense of providing evidence-based management. During the study, GPs reported using almost all communication items covered in the training, but some GPs stated that the communication skills diluted over time, and that they continued to use a selected set of the skills. The general communication items were most regularly used. Implementation of the method in daily practice helped GPs to prescribe fewer antibiotics in LRTI with the only perceived disadvantage being time-pressure. This study suggests that GPs felt positive about the physician communication training method for enhanced management of LRTI in primary care. GPs continued to use some of the communication items, of which general communication items were the most common. Furthermore, GPs believed that implementation of the communication skills in daily practice helped them to prescribe fewer antibiotics. The context-rich communication method could have wider application in common conditions in primary care.
Collapse
Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Mirjam E van Leeuwen
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Fleur H F Chappin
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Eefje G P M de Bont
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Geert-Jan Dinant
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK.
| |
Collapse
|
14
|
Houwink EJF, Muijtjens AMM, van Teeffelen SR, Henneman L, Rethans JJ, van der Jagt LEJ, van Luijk SJ, Dinant GJ, van der Vleuten C, Cornel MC. Effectiveness of oncogenetics training on general practitioners' consultation skills: a randomized controlled trial. Genet Med 2013; 16:45-52. [PMID: 23722870 PMCID: PMC3914027 DOI: 10.1038/gim.2013.69] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 04/16/2013] [Indexed: 01/25/2023] Open
Abstract
PURPOSE General practitioners are increasingly called upon to deliver genetic services and could play a key role in translating potentially life-saving advancements in oncogenetic technologies to patient care. If general practitioners are to make an effective contribution in this area, their genetics competencies need to be upgraded. The aim of this study was to investigate whether oncogenetics training for general practitioners improves their genetic consultation skills. METHODS In this pragmatic, blinded, randomized controlled trial, the intervention consisted of a 4-h training (December 2011 and April 2012), covering oncogenetic consultation skills (family history, familial risk assessment, and efficient referral), attitude (medical ethical issues), and clinical knowledge required in primary-care consultations. Outcomes were measured using observation checklists by unannounced standardized patients and self-reported questionnaires. RESULTS Of 88 randomized general practitioners who initially agreed to participate, 56 completed all measurements. Key consultation skills significantly and substantially improved; regression coefficients after intervention were equivalent to 0.34 and 0.28 at 3-month follow-up, indicating a moderate effect size. Satisfaction and perceived applicability of newly learned skills were highly scored. CONCLUSION The general practitioner-specific training proved to be a feasible, satisfactory, and clinically applicable method to improve oncogenetics consultation skills and could be used as an educational framework to inform future training activities with the ultimate aim of improving medical care.
Collapse
Affiliation(s)
- Elisa J F Houwink
- 1] Department of Clinical Genetics, Section of Community Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands [2] Department of General Practice, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Arno M M Muijtjens
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Sarah R van Teeffelen
- Department of Clinical Genetics, Section of Community Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Lidewij Henneman
- Department of Clinical Genetics, Section of Community Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jan Joost Rethans
- Skills Lab, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Scheltus J van Luijk
- Department of Education and Resident Training, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Geert Jan Dinant
- Department of General Practice, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Cees van der Vleuten
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Martina C Cornel
- Department of Clinical Genetics, Section of Community Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
15
|
El Maghraoui A, Ngbanda AR, Bensaoud N, Bensaoud M, Rezqi A, Tazi MA. Age-adjusted incidence rates of hip fractures between 2006 and 2009 in Rabat, Morocco. Osteoporos Int 2013; 24:1267-73. [PMID: 22736070 DOI: 10.1007/s00198-012-2061-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 06/13/2012] [Indexed: 01/28/2023]
Abstract
UNLABELLED This study, characterizing the incidence of hip fracture in the province of Rabat, showed that age- and sex-specific rates remained stable between 2006 and 2009. The demographic projections estimated for Morocco indicate that between 2010 and 2030, the expected annual number of hip fractures would increase about twofold. INTRODUCTION No data on hip fracture incidence trends exist from Africa. The aim of the study was to determine time trends in hip fracture rates for the province of Rabat and to forecast the number of hip fractures expected in Morocco up to 2030. METHODS All hip fracture cases registered during the years 2006-2009 were collected at all the public hospitals and private clinics with a trauma unit and/or a permanent orthopedic surgeon across the province. RESULTS Over the 4-year period, 723 (54.3%) hip fractures were recorded in women and 607 (45.6%) in men. The age- and gender-specific incidence of hip fracture rose steeply with advancing age. Hip fractures occurred later in women 75.0 (10.7) years than in men 73.3 (11.0) years (p=0.014), and its incidence was higher in women than in men [85.9 (95% CI 79.7-92.2) per 100,000 person-years vs. 72.7 (95% CI 66.9-78.5)]. The incidence remained globally stable over the period study, and the linear regression analysis showed no significant statistical difference. For the year 2010, there were 4,327 hip fractures estimated in Morocco (53.3% in women). Assuming no change in the age- and sex-specific incidence of hip fracture from 2010 to 2030, the number of hip fractures in men is expected to increase progressively from 2,019 to 3,961 and from 2,308 to 4,259 in women. CONCLUSION The age-specific incidence of hip fracture between the years 2006 and 2009 remained stable in Morocco, and the number of expected hip fractures would double between 2010 and 2030.
Collapse
Affiliation(s)
- A El Maghraoui
- Rheumatology Department, Military Hospital Mohammed V, PO box 1018, Rabat, Morocco.
| | | | | | | | | | | |
Collapse
|
16
|
Cals JWL, de Bock L, Beckers PJHW, Francis NA, Hopstaken RM, Hood K, de Bont EGPM, Butler CC, Dinant GJ. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med 2013; 11:157-64. [PMID: 23508603 PMCID: PMC3601394 DOI: 10.1370/afm.1477] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of the study was to assess the long-term effect of family physicians' use of C-reactive protein (CRP) point-of-care testing and/or physician training in enhanced communication skills on office visit rates and antibiotic prescriptions for patients with respiratory tract infections. METHODS We conducted a 3.5-year follow-up of a pragmatic, factorial, cluster-randomized controlled trial; 379 patients (20 family practices in the Netherlands) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available (88% of original trial cohort). Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year (PPPY), and the percentage of the episodes for which patients were treated with antibiotics during follow-up. RESULTS The mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group (P = .12). In the communication skills training group, there was a mean of 0.36 PPPY episodes of respiratory tract infections, and in the no training group the mean was 0.57 PPPY (P = .09). During follow-up 30.7% of all episodes of respiratory tract infection were treated with antibiotics in the CRP test group compared with 35.7% in the no test group (P = .36). Family physicians trained in communication skills treated 26.3% of all episodes of respiratory tract infection with antibiotics compared with 39.1% treated by family physicians without training in communication skills (P = .02) CONCLUSIONS Family physicians' use of CRP point-of-care testing and/or training in enhanced communication skills did not significantly affect office visit rates related to respiratory tract infections. Patients who saw a family physician trained in enhanced communication skills were prescribed significantly fewer antibiotics during episodes of respiratory tract infection in the subsequent 3.5 years.
Collapse
Affiliation(s)
- Jochen W L Cals
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, Evans MR, Alam MF, Bekkers MJ, Evans J, Moore L, Howe R, Hayes J, Hare M, Hood K. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ 2012; 344:d8173. [PMID: 22302780 PMCID: PMC3270575 DOI: 10.1136/bmj.d8173] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care. DESIGN Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation. SETTING 68 general practices with about 480,000 patients in Wales, United Kingdom. PARTICIPANTS 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed. INTERVENTIONS Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care. MAIN OUTCOME MEASURES Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs. RESULTS The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice. CONCLUSION The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.
Collapse
Affiliation(s)
- Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Brookes-Howell L, Hood K, Cooper L, Little P, Verheij T, Coenen S, Godycki-Cwirko M, Melbye H, Borras-Santos A, Worby P, Jakobsen K, Goossens H, Butler CC. Understanding variation in primary medical care: a nine-country qualitative study of clinicians' accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection. BMJ Open 2012; 2:bmjopen-2011-000796. [PMID: 22918670 PMCID: PMC4401816 DOI: 10.1136/bmjopen-2011-000796] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES There is a wide variation between European countries in antibiotic prescribing for patients in primary care with lower respiratory tract infection (LRTI) that is not explained by case mix and clinical factors alone. Variation in antibiotic prescribing that is not warranted by differences in illness and clinical presentation may increase selection of resistant organisms, contributing to the problem of antibiotic resistance. This study aimed to investigate clinicians' accounts of non-clinical factors that influence their antibiotic prescribing decision for patients with LRTI, to understand variation and identify opportunities for addressing possible unhelpful variation. DESIGN Multicountry qualitative semistructured interview study, with data subjected to a five-stage analytic framework approach (familiarisation, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation), and with interviewers commenting on preliminary analytic themes. SETTING Primary care. PARTICIPANTS Eighty primary care clinicians randomly selected from primary care research networks based in nine European cities. RESULTS Clinicians' accounts identified non-clinical factors imposed by the healthcare system operating within specific regional primary care research networks, including patient access to antibiotics before consulting a doctor (Barcelona and Milan), systems to reduce patient expectations for antibiotics (Southampton and Antwerp) and lack of consistent treatment guidelines (Balatonfüred and Łódź). Secondly, accounts revealed factors related to specific characteristics of clinicians regardless of network (professional ethos, self-belief in decision-making and commitment to shared decision-making). CONCLUSIONS Addressing healthcare system factors (eg, limiting patients' self-management with antibiotics before consulting in primary care, increased public awareness and provision of more consistent guidelines) may assist in reducing unhelpful variation in antibiotic prescribing. Promoting clinicians' receptivity to change, confidence in decision-making and readiness to invest in explaining prescribing decisions may also be beneficial. As factors were emphasised differently between networks, local flexibility in interventions is likely to maximise effectiveness.
Collapse
Affiliation(s)
- Lucy Brookes-Howell
- South East Wales Trials Unit, Institute for Translation, Innovation, Methodology and Engagement (TIME), Cardiff University, Cardiff, Wales, UK
| | - Kerenza Hood
- South East Wales Trials Unit, Institute for Translation, Innovation, Methodology and Engagement (TIME), Cardiff University, Cardiff, Wales, UK
| | - Lucy Cooper
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, England, UK
| | - Paul Little
- Community Clinical Sciences Division, University of Southampton, Southampton, England, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Samuel Coenen
- Centre for General Practice, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Łódź, Łódź, Poland
| | - Hasse Melbye
- Institute of Community Medicine, University of Tromsø, Tromsø, Norway
| | | | - Patricia Worby
- Research and Innovation Services, University of Southampton, Southampton, England, UK
| | - Kristin Jakobsen
- Institute of Community Medicine, University of Tromsø, Tromsø, Norway
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales, UK
| |
Collapse
|
19
|
Essers G, van Dulmen S, van Weel C, van der Vleuten C, Kramer A. Identifying context factors explaining physician's low performance in communication assessment: an explorative study in general practice. BMC FAMILY PRACTICE 2011; 12:138. [PMID: 22166064 PMCID: PMC3262758 DOI: 10.1186/1471-2296-12-138] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 12/13/2011] [Indexed: 12/04/2022]
Abstract
Background Communication is a key competence for health care professionals. Analysis of registrar and GP communication performance in daily practice, however, suggests a suboptimal application of communication skills. The influence of context factors could reveal why communication performance levels, on average, do not appear adequate. The context of daily practice may require different skills or specific ways of handling these skills, whereas communication skills are mostly treated as generic. So far no empirical analysis of the context has been made. Our aim was to identify context factors that could be related to GP communication. Methods A purposive sample of real-life videotaped GP consultations was analyzed (N = 17). As a frame of reference we chose the MAAS-Global, a widely used assessment instrument for medical communication. By inductive reasoning, we analyzed the GP behaviour in the consultation leading to poor item scores on the MAAS-Global. In these cases we looked for the presence of an intervening context factor, and how this might explain the actual GP communication behaviour. Results We reached saturation after having viewed 17 consultations. We identified 19 context factors that could potentially explain the deviation from generic recommendations on communication skills. These context factors can be categorized into doctor-related, patient-related, and consultation-related factors. Conclusions Several context factors seem to influence doctor-patient communication, requiring the GP to apply communication skills differently from recommendations on communication. From this study we conclude that there is a need to explicitly account for context factors in the assessment of GP (and GP registrar) communication performance. The next step is to validate our findings.
Collapse
Affiliation(s)
- Geurt Essers
- Department of Primary & Community Care, Radboud University Nijmegen Medical Centre, (Geert Groteplein 21), Nijmegen, (6525 EP), The Netherlands.
| | | | | | | | | |
Collapse
|
20
|
Cals JWL, Ament AJHA, Hood K, Butler CC, Hopstaken RM, Wassink GF, Dinant GJ. C-reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial. J Eval Clin Pract 2011; 17:1059-69. [PMID: 20666881 DOI: 10.1111/j.1365-2753.2010.01472.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES An economic evaluation of general practitioner (GP) use of C-reactive protein (CRP) point of care test, GP communication skills training, and both GP use of CRP and communication skills training on antibiotic use for lower respiratory tract infections (LRTIs) in general practice. METHODS Cost-effectiveness analysis with a time horizon of 28 days alongside a factorial, cluster randomized trial in 431 patients with LRTIs recruited by 40 GPs. INTERVENTIONS usual care (control group), GP use of CRP point of care test, GP communication skills training, and both CRP use and communication skills training. MAIN OUTCOME MEASURE health care costs. Cost-effectiveness, using the primary outcome measure antibiotic prescribing at index consultation, was assessed by incremental cost-effectiveness ratios (ICER). To adjust for skewed data and clustering, we used non-parametric bootstrapping re-sampling to derive percentile intervals for the mean difference in total costs and the mean difference in effectiveness between the groups. Various implementation scenarios according to GP preference were modelled with corresponding net monetary benefit (NMB) curves based on a given willingness-to-pay (λ) for a 1% lower antibiotic prescribing rate. RESULTS The total mean cost per patient in the usual care group was €35.96 with antibiotic prescribing of 68%, €37.58 per patient managed by GPs using CRP tests (antibiotic prescribing 39%, ICER €5.79), €25.61 per patient managed by GPs trained in enhanced communication skills (antibiotic prescribing 33%, dominant) and €37.78 per patient managed by GPs using both interventions (antibiotic prescribing 23%, ICER €4.15). The interventions are cost-effective in any combination (yielding NMB at no willingness-to-pay), taking into account GPs' preferences where at least 15% of GPs chose to implement the communication skills training. CONCLUSIONS The two strategies, both singly and combined, are cost-effective interventions to reduce antibiotic prescribing for LRTI, at no, or low willingness-to-pay. Taking GP preferences into account will optimize investment in strategies to reduce antibiotic prescribing for LRTI.
Collapse
Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, the Netherlands.
| | | | | | | | | | | | | |
Collapse
|
21
|
Björkman I, Erntell M, Röing M, Lundborg CS. Infectious disease management in primary care: perceptions of GPs. BMC FAMILY PRACTICE 2011; 12:1. [PMID: 21223592 PMCID: PMC3025850 DOI: 10.1186/1471-2296-12-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 01/11/2011] [Indexed: 12/21/2022]
Abstract
Background It is important to keep the level of antibiotic prescribing low to contain the development of resistant bacteria. This study was conducted to reveal new knowledge about how GPs think in relation to the prescribing of antibiotics - knowledge that could be used in efforts toward rational treatment of infectious diseases in primary care. The aim was to explore and describe the variations in GPs' perceptions of infectious disease management, with special reference to antibiotic prescribing. Methods Twenty GPs working at primary care centres in a county in south-west Sweden were purposively selected based on the strategy of including GPs with different kinds of experience. The GPs were interviewed and perceptions among GPs were analysed by a phenomenographic approach. Results Five qualitatively different perceptions of infectious disease management were identified. They were: (A) the GP must help the patient to achieve health and well-being; (B) the management must meet the GP's perceived personal, professional and organisational demands; (C) restrictive antibiotic prescribing is time-consuming; (D) restrictive antibiotic prescribing can protect the effectiveness of antibiotics; and (E) patients benefit personally from restrictive antibiotic prescribing. Conclusions Restrictive antibiotic prescribing was considered important in two perceptions, was not an issue as such in two others, and was considered in one perception although the actual prescribing was greatly influenced by the interaction between patient and GP. Accordingly, to encourage restrictive antibiotic prescribing several aspects must be addressed. Furthermore, different GPs need various kinds of support. Infectious disease management in primary care is complex and time-consuming, which must be acknowledged in healthcare organisation and planning.
Collapse
|
22
|
Cals JWL, Chappin FHF, Hopstaken RM, van Leeuwen ME, Hood K, Butler CC, Dinant GJ. C-reactive protein point-of-care testing for lower respiratory tract infections: a qualitative evaluation of experiences by GPs. Fam Pract 2010; 27:212-8. [PMID: 20022909 DOI: 10.1093/fampra/cmp088] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To explore GPs' attitudes to and experiences of introducing C-reactive protein (CRP) point-of-care testing (POCT) for lower respiratory tract infections (LRTI) in primary care. METHODS Semi-structured interview study with 20 GPs who participated in the IMPAC(3)T randomized trial evaluating the effect of GP use of CRP POCT on management of LRTI. Main outcomes were GPs' experiences and views about CRP POCT in general practice, including its role in guiding antibiotic prescribing decisions and applicability and implementation in daily practice. RESULTS GPs expressed mainly positive attitudes. Test results were rapidly available to support diagnostic and therapeutic processes for LRTI and other common infections, enhancing patient and GP confidence in prescribing decisions and empowering GPs to prescribe antibiotics less often. GPs were concerned about responding to ambiguous test results. They regarded financial reimbursement for using the test as essential for successful uptake. CONCLUSIONS GPs were generally positive about CRP POCT, and they felt that it empowered them to safely prescribe fewer antibiotics for LRTI without alienating their patients. Successful wider implementation should address reimbursement and updating management guidelines to include the place of CRP POCT.
Collapse
Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
23
|
Cals JWL, Butler CC, Dinant GJ. 'Experience talks': physician prioritisation of contrasting interventions to optimise management of acute cough in general practice. Implement Sci 2009; 4:57. [PMID: 19737382 PMCID: PMC2742510 DOI: 10.1186/1748-5908-4-57] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 09/08/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uptake of interventions to improve quality of care by clinicians is variable and is influenced by clinicians' attitudes. The influence of clinicians' experience with an intervention on their preference for adopting interventions is largely unknown. METHODS Thematic analysis of semi-structured interviews exploring views and attitudes towards an illness-focused intervention (specific communication skills training) and a disease-focused intervention (C-reactive protein, or CRP, point-of-care testing) to optimize management of lower respiratory tract infections (LRTI) among general practitioners (GPs) who had used both interventions for two years in a randomised trial (exposed GPs), and GPs without experience of either intervention (non-exposed GPs). RESULTS All but two of the ten non-exposed GPs indicated that they would prioritize implementation of the disease-focused intervention of CRP testing over communication skills training, while all but one GP in the exposed group said that they would prioritize the illness-focused approach of communication skills training as it was more widely applicable, whereas CRP testing was confirmatory and useful in a subgroups of patients. CONCLUSION There are differences in attitudes to prioritizing contrasting interventions for optimising LRTI management among GPs with and without experience of using the interventions, although GPs in both groups recognised the importance of both approaches to optimise management of acute cough. GPs' experiences with and attitudes towards interventions need to be taken into account when planning rollout of interventions aimed at changing clinical practice.
Collapse
Affiliation(s)
- Jochen W L Cals
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, The Netherlands.
| | | | | |
Collapse
|
24
|
Cals JWL, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009; 338:b1374. [PMID: 19416992 PMCID: PMC2677640 DOI: 10.1136/bmj.b1374] [Citation(s) in RCA: 290] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2009] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection. DESIGN Pragmatic, 2x2 factorial, cluster randomised controlled trial. SETTING 20 general practices in the Netherlands. PARTICIPANTS 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection. MAIN OUTCOME MEASURES The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days' follow-up, reconsultation, clinical recovery, and patients' satisfaction and enablement. INTERVENTIONS General practitioners' use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care. RESULTS General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days' follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients' recovery and satisfaction were similar in all study groups. CONCLUSION Both general practitioners' use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients' recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care. TRIAL REGISTRATION Current Controlled Trials ISRCTN85154857.
Collapse
Affiliation(s)
- Jochen W L Cals
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, Netherlands.
| | | | | | | | | |
Collapse
|