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Mills SE, Akbar SB, Hernandez-Santiago V. Barriers, enablers, benefits, and drawbacks to point-of-care testing: a survey of the general practice out-of-hours service in Scotland. BJGP Open 2024; 8:BJGPO.2023.0094. [PMID: 38092440 PMCID: PMC11300988 DOI: 10.3399/bjgpo.2023.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/27/2023] [Accepted: 09/13/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND The general practice out-of-hours (GPOOH) service is under pressure to treat more patients in less time, while reducing referrals and minimising diagnostic errors. Point-of-care (POC) testing involves rapid clinical tests that can be used to generate results during the consultation, and has the potential to facilitate managing these competing demands safely. AIM To describe current availability of POC tests in GPOOH in Scotland, and identify barriers, enablers, benefits, and drawbacks to its use. DESIGN & SETTING Cross-sectional mixed-methods study, which surveyed opinions of clinicians working in the GPOOH service in NHS Scotland. METHOD An electronic questionnaire was developed, designed, piloted, and distributed to clinicians, which had closed questions and areas for free text. RESULTS In total, 142 responses were received. Urine dipstick testing (99.2%), pregnancy tests (98.5%), oxygen saturation (97.7%), and blood glucose testing (93.9%), were the only POC tests commonly available in GPOOH in NHS Scotland. There was strongest support for the provision of POC tests, particularly C-reactive protein (CRP; 79.4%), strep A (76.0%), and D-dimer (75.2%). Responders felt that POC tests would improve confidence (92.3%) and safety (89.8%) surrounding clinical decision making, improve patient satisfaction (80.6%), and reduce hospital and secondary care referrals (77.5%). Barriers to POC test use were availability of the test kits and machines (94.5%), training requirements on how to use the machine (71.1%) and interpret results (56.3%), and time to do the test (62.0%). CONCLUSION Few POC tests are in regular use in GPOOH in Scotland. GPOOH clinicians are supportive of using POC testing. They identified a number of benefits to its use, with very few drawbacks. Increased provision of POC testing in GPOOH in NHS Scotland should be considered urgently.
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Affiliation(s)
- Sarah Ee Mills
- University of St Andrews, School of Medicine, North Haugh, St Andrews, UK
| | - Sm Babar Akbar
- NHS Fife, General Practice Out of Hours Department, Victoria Hospital Kirkcaldy, Kirkcaldy, USA
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Lapi F, Marconi E, Rossi A, Lagolio E, Concia E, Cricelli C. The use of C-reactive protein testing and antibiotic prescribing in Italy: A population-based study in primary care. Br J Clin Pharmacol 2024:e16166. [PMID: 38922983 DOI: 10.1111/bcp.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Testing serum C-reactive protein (CRP) levels can help determine whether there is a need for antibiotics and can limit prescribing of antibiotics for illnesses that are likely viral or non-infectious in origin. Using Health Search, an Italian primary care database, we identified all patients, aged 15 years or older, being registered in the period between 1 January 2000 and 31 December 2019 and newly diagnosed with upper respiratory tract infections (URTIs) or COPD- or asthma-related exacerbations. From the date of these diagnoses, patients were followed up until occurrence of antibiotic prescription (for these indications) up to 31 December 2019. The association between the CRP testing and the outcome was investigated using a nested case-control analysis. In a cohort of 469 684 patients being diagnosed for URTI (83%), COPD- (11%) and asthma (7%)-related exacerbations, 28 688 (6.11%) were prescribed with antibiotics because of the aforementioned indications. Of note, 98% of cases, nominally those prescribed with antibiotics, were not tested with CRP. However, those receiving antibiotics were more likely to have been previously tested for CRP than controls who did not receive antibiotics (833/28 601 [3%] and 4128/277 968 [1.5%]; OR 2.0 [95% CI: 1.8-2.1]). Our findings indicate that most of the antibiotic prescriptions for the investigated conditions were given without any prior CRP testing. A small minority of GPs did properly use CRP to determine whether antibiotics were needed. Further guidance is needed in Italy on the use of CRP in guiding antibiotic prescribing in primary care.
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Affiliation(s)
- Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Ettore Marconi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Alessandro Rossi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Erik Lagolio
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Ercole Concia
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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Hoste ME, Colman E, Wanat M, Hayward G, Tissier JL, Postma M, Goossens H, Anthierens S, Tonkin-Crine S. Stakeholders' views and experiences on implementing new diagnostics in primary care to support management of community-acquired acute respiratory tract infections: a qualitative study. Front Public Health 2023; 11:1216940. [PMID: 37583883 PMCID: PMC10425264 DOI: 10.3389/fpubh.2023.1216940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/06/2023] [Indexed: 08/17/2023] Open
Abstract
Background The majority of antibiotics are prescribed in primary care for respiratory tract infections. Point-of-care tests (POCTs) for the management of community-acquired acute respiratory tract infections (CA-ARTI) have been developed to help optimize antibiotic prescribing. While some countries in Europe have adopted these tests in primary care settings, most have not. Stakeholders, such as policy-makers, regulators, the diagnostic industry, and scientific associations, have roles in the implementation of new diagnostics in primary care. The aim of this study is to explore these stakeholders' views and experiences, and identify areas of unmet need relating to POCT implementation. Methods Stakeholders were recruited using purposive sampling and snowballing. Between March 2021 and May 2022, semi-structured interviews were conducted online with stakeholders in Belgium, the UK and from European Union (EU) -level organizations. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed inductively and deductively using thematic analysis. Results Twenty-six stakeholders participated: eleven from EU-level organizations, seven from Belgium, and eight from the UK. Five themes were identified. Stakeholders felt a balance of top-down and bottom-up approaches were an optimal strategy to the implementation of POCTs. Stakeholders stressed the need to engage with clinicians to act as champions for tests to help raise awareness and generate new evidence on how tests are used. While acknowledging the potential of POCTs for improving patient outcomes and impacting antibiotic prescribing behavior, some raised concerns on how tests would be used in practice and wished to see national data on effectiveness. COVID-19 catalyzed the use of tests, but stakeholders were pessimistic that processes for approving diagnostics during the pandemic would be replicated in the future. Conclusion Stakeholders provided recommendations for research and practice. Robust reimbursement policies could alleviate financial burden from clinicians and patients, encouraging practices to adopt POCTs. Industry is likely to benefit from engaging as early on as possible with other stakeholders. Due to uncertainty among stakeholders on the impact of POCTs on antibiotic prescribing, further evidence is needed to understand how practices adopt POCTs and the implications for stewardship. Monitoring how POCTs are used can inform future guidelines on successful diagnostic implementation.
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Affiliation(s)
- Melanie Eugenie Hoste
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Elien Colman
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Maarten Postma
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Geis D, Canova N, Lhopitallier L, Kronenberg A, Meuwly JY, Senn N, Mueller Y, Fasseur F, Boillat-Blanco N. Exploration of the Acceptance of the Use of Procalcitonin Point-of-Care Testing and Lung Ultrasonography by General Practitioners to Decide on Antibiotic Prescriptions for Lower Respiratory Infections: A Qualitative Study. BMJ Open 2023; 13:e063922. [PMID: 37169498 PMCID: PMC10186440 DOI: 10.1136/bmjopen-2022-063922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 04/12/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES We aimed to explore the acceptance and opinions of general practitioners (GPs) on the use of procalcitonin point-of-care and lung ultrasonography for managing patients with lower respiratory tract infections in primary care. We suppose that there are several factors that can influence the physician's antibiotic prescribing decision, and the implementation of a new tool will only be possible when it can be inserted into the physician's daily practice, helping him/her in the decision-making process. DESIGN Semistructured interviews; data analysis using the grounded theory method. SETTING Lausanne, Switzerland. PARTICIPANTS 12 GPs who participated in the randomised clinical trial UltraPro, which evaluated the impact of the use of procalcitonin only or an algorithm combining procalcitonin and lung ultrasonography on antibiotic prescription. RESULTS GPs had mostly positive attitudes towards the use of point-of-care procalcitonin in lower respiratory tract infections and uncertainties regarding the usefulness of ultrasonography. Physicians' prescribing decisions result from interactions between three kinds of TrustS (core category): 'self-confidence', 'trust in the results' and 'trust in the doctor-patient relationship'. Procalcitonin reinforced the three levels of trust, while ultrasonography only strengthened the physician-patient relationship. To facilitate implementation of procalcitonin, physicians pointed out the need of coverage by insurance and of clear guidelines describing the targeted patient population. CONCLUSIONS Our data show that there is a preference for the implementation of procalcitonin rather than lung ultrasonography for the management of patients with lower respiratory tract infections in primary care. Coverage by insurance plans and updated guidelines are prerequisite to the successful implementation of procalcitonin testing in primary care. TRIAL REGISTRATION NUMBER NCT03191071.
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Affiliation(s)
- Daniel Geis
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
| | - Nina Canova
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
| | - Loïc Lhopitallier
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
- gare10 medical practice, Lausanne, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Medix General Practice, Bern, Switzerland
| | - Jean-Yves Meuwly
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
| | - Fabienne Fasseur
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
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Tenorio-Mucha J, Busta-Flores P, Lazo-Porras M, Vetter B, Safary E, Moran AE, Gupta R, Bernabé-Ortiz A. Facilitators and barriers of the implementation of point-of-care devices for cardiometabolic diseases: a scoping review. BMC Health Serv Res 2023; 23:412. [PMID: 37118750 PMCID: PMC10144879 DOI: 10.1186/s12913-023-09419-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Point-of-care testing (POCT) devices may facilitate the delivery of rapid and timely results, providing a clinically important advantage in patient management. The challenges and constraints in the implementation process, considering different levels of actors have not been much explored. This scoping review aimed to assess literature pertaining to implementation facilitators and barriers of POCT devices for the diagnosis or monitoring of cardiometabolic diseases. METHODS A scoping review of the literature was conducted. The inclusion criteria were studies on the inception, planning, or implementation of interventions with POCT devices for the diagnosis or monitoring of cardiometabolic diseases defined as dyslipidemia, cardiovascular diseases, type 2 diabetes, and chronic kidney disease. We searched MEDLINE, Embase, and Global Health databases using the OVID searching engine until May 2022. The Consolidated Framework of Implementation Research (CFIR) was used to classify implementation barriers and facilitators in five constructs. Also, patient, healthcare professional (HCP), and organization level was used. RESULTS Twenty studies met the eligibility criteria for data extraction. All studies except two were conducted in high-income countries. Some findings are: 1) Intervention: the most widely recognized facilitator was the quick turnaround time with which results are obtained. 2) Outer setting: at the organizational level, the lack of clear regulatory and accreditation mechanisms has hindered the adoption and sustainability of the use of POCT. 3) Inner setting: for HCP, performing POCT during the consultation was both a facilitator and a barrier in terms of time, personnel, and service delivery. 4) Individuals: the implementation of POCT may generate stress and discomfort in some HCP in terms of training and new responsibilities. 5) Process: for patients, it is highly appreciated that obtaining the sample was simple and more comfortable if venipuncture was not used. CONCLUSION This scoping review has described the facilitators and barriers of implementing a POCT device for cardiometabolic conditions using the CFIR. The information can be used to design better strategies to implement these devices and benefit more populations that have low access to cardiometabolic tests.
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Affiliation(s)
- Janeth Tenorio-Mucha
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445 - Miraflores, Lima, Peru
| | - Patricia Busta-Flores
- CONEVID - Unidad de Conocimiento y Evidencia, Facultad de Medicina "Alberto Hurtado", Universidad Peruana Cayetano Heredia, Lima, Peru
| | - María Lazo-Porras
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445 - Miraflores, Lima, Peru
| | | | | | | | - Reena Gupta
- Resolve to Save Lives, New York, NY, USA
- Department of Medicine of Medicine, University of California, San Francisco, USA
| | - Antonio Bernabé-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445 - Miraflores, Lima, Peru.
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Suttels V, Van Singer M, Clack LC, Plüss-Suard C, Niquille A, Mueller Y, Boillat Blanco N. Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review. Antibiotics (Basel) 2022; 12:antibiotics12010030. [PMID: 36671230 PMCID: PMC9854946 DOI: 10.3390/antibiotics12010030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.
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Affiliation(s)
- Véronique Suttels
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Correspondence:
| | - Mathias Van Singer
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Lauren Catherine Clack
- Institute for Implementation Science in Health Care, Medical Faculty, University of Zurich, 8006 Zürich, Switzerland
| | - Catherine Plüss-Suard
- Swiss Centre for Antibiotic Resistance, Institute for Infectious Diseases, University of Bern, 3001 Bern, Switzerland
| | - Anne Niquille
- Center for Primary Care and Public Health (Unisanté), Pharmacy University of Lausanne, 1011 Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, 1011 Lausanne, Switzerland
| | - Yolanda Mueller
- Center for Primary Care and Public Health (Unisanté), Department of Family Medicine, 1011 Lausanne, Switzerland
| | - Noémie Boillat Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
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Martínez-González NA, Plate A, Jäger L, Senn O, Neuner-Jehle S. The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners. Antibiotics (Basel) 2022; 11:antibiotics11050543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023] Open
Abstract
Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92–98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65–87%). Faced with intermediate CRP results, GPs preferred 3–5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland
- Correspondence: or
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Levy Jäger
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
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Implementing point-of-care CRP testing for better diagnosis of acute respiratory infections. Br J Gen Pract 2022; 72:87-88. [PMID: 35091415 PMCID: PMC8813101 DOI: 10.3399/bjgp22x718517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Implementation and Use of Point-of-Care C-Reactive Protein Testing in Nursing Homes. J Am Med Dir Assoc 2021; 23:968-975.e3. [PMID: 34626578 DOI: 10.1016/j.jamda.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents. DESIGN This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents. SETTING AND PARTICIPANTS Eleven NHs in the Netherlands. METHODS Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs. RESULTS Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice. CONCLUSIONS AND IMPLICATIONS This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.
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Li E, Dewez JE, Luu Q, Emonts M, Maconochie I, Nijman R, Yeung S. Role of point-of-care tests in the management of febrile children: a qualitative study of hospital-based doctors and nurses in England. BMJ Open 2021; 11:e044510. [PMID: 33972339 PMCID: PMC8112413 DOI: 10.1136/bmjopen-2020-044510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The use of rapid point-of-care tests (POCTs) has been advocated for improving patient management and outcomes and for optimising antibiotic prescribing. However, few studies have explored healthcare workers' views about their use in febrile children. The aim of this study was to explore the perceptions of hospital-based doctors and nurses regarding the use of POCTs in England. STUDY DESIGN Qualitative in-depth interviews with purposively selected hospital doctors and nurses. Data were analysed thematically. SETTING Two university teaching hospitals in London and Newcastle. PARTICIPANTS 24 participants (paediatricians, emergency department doctors, trainee paediatricians and nurses). RESULTS There were diverse views about the use of POCTs in febrile children. The reported advantages included their ease of use and the rapid availability of results. They were seen to contribute to faster clinical decision-making; the targeting of antibiotic use; improvements in patient care, flow and monitoring; cohorting (ie, the physical clustering of hospitalised patients with the same infection to limit spread) and enhancing communication with parents. These advantages were less evident when the turnaround for results of laboratory tests was 1-2 hours. Factors such as clinical experience and specialty, as well as the availability of guidelines recommending POCT use, were also perceived as influential. However, in addition to their perceived inaccuracy, participants were concerned about POCTs not resolving diagnostic uncertainty or altering clinical management, leading to a commonly expressed preference for relying on clinical skills rather than test results solely. CONCLUSION In this study conducted at two university teaching hospitals in England, participants expressed mixed opinions about the utility of current POCTs in the management of febrile children. Understanding the current clinical decision-making process and the specific needs and preferences of clinicians in different settings will be critical in ensuring the optimal design and deployment of current and future tests.
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Affiliation(s)
- Edmond Li
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Department of Surgery & Cancer, Imperial College, London, UK
| | - Juan Emmanuel Dewez
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Queena Luu
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Marieke Emonts
- Department of Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Paediatric Emergency Department, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Ruud Nijman
- Section of Paediatric Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Shunmay Yeung
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Department of Paediatric Infectious Disease, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
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Borek AJ, Campbell A, Dent E, Butler CC, Holmes A, Moore M, Walker AS, McLeod M, Tonkin-Crine S. Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices. BMC FAMILY PRACTICE 2021; 22:25. [PMID: 33485324 PMCID: PMC7825381 DOI: 10.1186/s12875-021-01371-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. METHODS This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. RESULTS Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience - participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' - participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities - participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context - various other situational and practical issues were raised with implementing the strategies. CONCLUSIONS High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Thi Thuy Do N, Greer RC, Lubell Y, Dittrich S, Vandendorpe M, Nguyen VA, Ngoc Thach P, Thi Dieu Ngan T, Van Kinh N, Hung Thai C, Dung LTK, Nguyen Thi Cam T, Nguyen TH, Nadjm B, van Doorn HR, Lewycka S. Implementation of C-reactive protein point of care testing to improve antibiotic targeting in respiratory illness in Vietnamese primary care (ICAT): a study protocol for a cluster randomised controlled trial. BMJ Open 2020; 10:e040977. [PMID: 33361164 PMCID: PMC7759760 DOI: 10.1136/bmjopen-2020-040977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION C-reactive protein (CRP), a biomarker of infection, has been used widely in high-income settings to guide antibiotic treatment in patients presenting with respiratory illnesses in primary care. Recent trials in low- and middle-income countries showed that CRP testing could safely reduce antibiotic use in patients with non-severe acute respiratory infections (ARIs) and fever in primary care. The studies, however, were conducted in a research-oriented context, with research staff closely monitoring healthcare behaviour thus potentially influencing healthcare workers' prescribing practices. For policy-makers to consider wide-scale roll-out, a pragmatic implementation study of the impact of CRP point of care (POC) testing in routine care is needed. METHODS AND ANALYSIS A pragmatic, cluster-randomised controlled trial, with two study arms, consisting of 24 commune health centres (CHC) in the intervention arm (provision of CRP tests with additional healthcare worker guidance) and 24 facilities acting as controls (routine care). Comparison between the treatment arms will be through logistic regression, with the treatment assignment as a fixed effect, and the CHC as a random effect. With 48 clusters, an average of 10 consultations per facility per week will result in approximately 520 over 1 year, and 24 960 in total (12 480 per arm). We will be able to detect a reduction of 12% to 23% or more in immediate antibiotic prescription as a result of the CRP POC intervention. The primary endpoint is the proportion of patient consultations for ARI resulting in immediate antibiotic prescription. Secondary endpoints include the proportion of all patients receiving an antibiotic prescription regardless of ARI diagnosis, frequency of re-consultation, subsequent antibiotic use when antibiotics are not prescribed, referral and hospitalisation. ETHICS AND DISSEMINATION The study protocol was approved by the Oxford University Tropical Research Ethics Committee (OxTREC, Reference: 53-18), and the ethical committee of the National Hospital for Tropical Diseases in Vietnam (Reference:07/HDDD-NDTW/2019). Results from this study will be disseminated via meetings with stakeholders, conferences and publications in peer-reviewed journals. Authorship and reporting of this work will follow international guidelines. TRIAL REGISTRATION DETAILS NCT03855215; Pre-results.
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Affiliation(s)
| | - Rachel Claire Greer
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabine Dittrich
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Malaria/Fever Program, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Maida Vandendorpe
- Malaria/Fever Program, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Van Anh Nguyen
- Foundation for Innovative New Diagnostics (FIND), Hanoi, Vietnam
| | | | | | | | - Cao Hung Thai
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | - Le Thi Kim Dung
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | | | | | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- Clinical Services Department, MRC Unit The Gambia at The London School of Hygiene, Banjul, Gambia
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sonia Lewycka
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University of Auckland, Auckland, New Zealand
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C-reactive protein cut-offs used for acute respiratory infections in Danish general practice. BJGP Open 2020; 5:bjgpopen20X101136. [PMID: 33234515 PMCID: PMC7960524 DOI: 10.3399/bjgpopen20x101136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/29/2020] [Indexed: 11/25/2022] Open
Abstract
Background GPs can use the C-reactive protein (CRP) point-of-care test (POCT) to assist when deciding whether to prescribe antibiotics for patients with acute respiratory tract infections (RTIs). Aim To estimate the CRP cut-off levels that Danish GPs use to guide antibiotic prescribing for patients presenting with different signs and symptoms of RTIs. Design & setting A cross-sectional study conducted in general practice in Denmark. Method During the winters of 2017 and 2018, 143 GPs and their staff registered consecutive patients with symptoms of an RTI according to the Audit Project Odense (APO) method. CRP cut-offs were estimated as the lowest level at which half of the patients were prescribed an antibiotic. Results In total, 7813 patients were diagnosed with an RTI, of whom 4617 (59%) had a CRP test performed. At least 25% of the patients were prescribed an antibiotic when the CRP level was >20 mg/L, at least 50% when CRP was >40 mg/L, and at least 75% when CRP was >50 mg/L. Lower thresholds were identified for patients aged ≥65 years and those presenting with a fever, poor general appearance, dyspnoea, abnormal lung auscultation, or ear/facial pain, and if the duration of symptoms was either short (≤1 day) or long (>14 days). Conclusion More than half of patients presenting to Danish general practice with symptoms of an RTI have a CRP test performed. At CRP levels >40 mg/L, the majority of patients have an antibiotic prescribed.
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14
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Eley CV, Sharma A, Lee H, Charlett A, Owens R, McNulty CAM. Effects of primary care C-reactive protein point-of-care testing on antibiotic prescribing by general practice staff: pragmatic randomised controlled trial, England, 2016 and 2017. ACTA ACUST UNITED AC 2020; 25. [PMID: 33153517 PMCID: PMC7645970 DOI: 10.2807/1560-7917.es.2020.25.44.1900408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background C-reactive protein (CRP) testing can be used as a point-of-care test (POCT) to guide antibiotic use for acute cough. Aim We wanted to determine feasibility and effect of introducing CRP POCT in general practices in an area with high antibiotic prescribing for patients with acute cough and to evaluate patients’ views of the test. Methods We used a McNulty–Zelen cluster pragmatic randomised controlled trial design in general practices in Northern England. Eight intervention practices accepted CRP testing and eight control practices maintained usual practice. Data collection included process evaluation, patient questionnaires, practice audit and antibiotic prescribing data. Results Eight practices with over 47,000 patient population undertook 268 CRP tests over 6 months: 78% of patients had a CRP < 20 mg/L, 20% CRP 20–100 mg/L and 2% CRP > 100 mg/L, where 90%, 22% and 100%, respectively, followed National Institute for Health and Care Excellence (NICE) antibiotic prescribing guidance. Patients reported that CRP testing was comfortable (88%), convenient (84%), useful (92%) and explained well (85%). Patients believed CRP POCT aided clinical diagnosis, provided quick results and reduced unnecessary antibiotic use. Intervention practices had an estimated 21% reduction (95% confidence interval: 0.46–1.35) in the odds of prescribing for cough compared with the controls, a non-significant but clinically relevant reduction. Conclusions In routine general practice, CRP POCT use was variable. Non-significant reductions in antibiotic prescribing may reflect small sample size due to non-use of tests. While CRP POCT may be useful, primary care staff need clearer CRP guidance and action planning according to NICE guidance.
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Affiliation(s)
| | - Anita Sharma
- An NHS Clinical Commissioning Group, Greater Manchester, United Kingdom
| | - Hazel Lee
- An NHS Clinical Commissioning Group, Greater Manchester, United Kingdom
| | - Andre Charlett
- Statistics Unit, Public Health England, London, United Kingdom
| | - Rebecca Owens
- Primary Care Unit, Public Health England, Gloucester, United Kingdom
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15
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Kuil SD, Schneeberger C, van Leth F, de Jong MD, Harting J. "A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: a qualitative study. BMC Geriatr 2020; 20:450. [PMID: 33148189 PMCID: PMC7643302 DOI: 10.1186/s12877-020-01853-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent non-specific symptomatology and asymptomatic bacteriuria. The objective of this study was to explore health care professionals' perceptions of the proposed use of inflammatory marker Point-Of-Care Testing (POCT) in this respect. METHODS We conducted a qualitative inquiry (2018-2019) alongside the multicenter PROGRESS study (NL6293), which assessed the sensitivity of C-reactive protein and procalcitonin POCT in UTI. We used semi-structured face-to-face interviews. The participants were physicians (n = 12) and nurses (n = 6) from 13 nursing homes in the Netherlands. Most respondents were not familiar with inflammatory marker POCT, while some used POCT for respiratory tract infections. Both the interview guide and the analysis of the interview transcripts were based on the Consolidated Framework for Implementation Research. RESULTS All respondents acknowledged that sufficiently sensitive POCT could decrease diagnostic uncertainty to some extent in residents presenting with non-specific symptoms. They primarily thought that negative test results would rule out UTI and justify withholding antibiotic treatment. Secondly, they described how positive test results could rule in UTI and justify antimicrobial treatment. However, most respondents also expected new diagnostic uncertainties to arise. Firstly, in case of negative test results, they were not sure how to deal with residents' persisting non-specific symptoms. Secondly, in case of positive test results, they feared overlooking infections other than UTI. These new uncertainties could lead to inappropriate antibiotics use. Therefore, POCT was thought to create a false sense of confidence. CONCLUSIONS Our study suggests that inflammatory marker POCT will only improve UTI management in nursing homes to some extent. To realize the expected added value, any implementation of POCT requires thorough guidance to ensure appropriate use. Developing UTI markers with high negative and positive predictive values may offer greater potential to improve UTI management in nursing homes.
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Affiliation(s)
- S D Kuil
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - C Schneeberger
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - F van Leth
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - M D de Jong
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J Harting
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Martínez-González NA, Keizer E, Plate A, Coenen S, Valeri F, Verbakel JYJ, Rosemann T, Neuner-Jehle S, Senn O. Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials. Antibiotics (Basel) 2020; 9:antibiotics9090610. [PMID: 32948060 PMCID: PMC7559694 DOI: 10.3390/antibiotics9090610] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/16/2022] Open
Abstract
C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, PO Box 4466, CH-6002 Lucerne, Switzerland
- Correspondence:
| | - Ellen Keizer
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp-Campus Drie Eiken, Doornstraat 331, 2610 Antwerp (Wilrijk), Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp-Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp (Wilrijk), Belgium
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Jan Yvan Jos Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Kapucijnenvoer 33, 3000 Leuven, Belgium;
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
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C-reactive protein-guided antibiotic prescribing for COPD exacerbations: a qualitative evaluation. Br J Gen Pract 2020; 70:e505-e513. [PMID: 32424045 PMCID: PMC7239040 DOI: 10.3399/bjgp20x709865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background Antibiotics are prescribed to >70% of patients presenting in primary care with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The PACE randomised controlled trial found that a C-reactive protein point-of-care test (CRP-POCT) management strategy for AECOPD in primary care resulted in a 20% reduction in patient-reported antibiotic consumption over 4 weeks. Aim To understand perceptions of the value of CRP-POCT for guiding antibiotic prescribing for AECOPD; explore possible mechanisms, mediators, and pathways to effects; and identify potential barriers and facilitators to implementation from the perspectives of patients and clinicians. Design and setting Qualitative process evaluation in UK general practices. Method Semi-structured telephone interviews with 20 patients presenting with an AECOPD and 20 primary care staff, purposively sampled from the PACE study. Interviews were audio-recorded, transcribed, and analysed using framework analysis. Results Patients and clinicians felt that CRP-POCT was useful in guiding clinicians’ antibiotic prescribing decisions for AECOPD, and were positive about introduction of the test in routine care. The CRP-POCT enhanced clinician confidence in antibiotic prescribing decisions, reduced decisional ambiguity, and facilitated communication with patients. Some clinicians thought the CRP-POCT should be routinely used in consultations for AECOPD; others favoured use only when there was decisional uncertainty. CRP-POCT cartridge preparation time and cost were potential barriers to implementation. Conclusion CRP-POCT-guided antibiotic prescribing for AECOPD had high acceptability, but commissioning arrangements and further simplification of the CRP-POCT need attention to facilitate implementation in routine practice.
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Francis NA, Gillespie D, White P, Bates J, Lowe R, Sewell B, Phillips R, Stanton H, Kirby N, Wootton M, Thomas-Jones E, Hood K, Llor C, Cals J, Melbye H, Naik G, Gal M, Fitzsimmons D, Alam MF, Riga E, Cochrane A, Butler CC. C-reactive protein point-of-care testing for safely reducing antibiotics for acute exacerbations of chronic obstructive pulmonary disease: the PACE RCT. Health Technol Assess 2020; 24:1-108. [PMID: 32202490 PMCID: PMC7132534 DOI: 10.3310/hta24150] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed antibiotics, but these may not be beneficial, and they can cause side effects and increase the risk of subsequent resistant infections. Point-of-care tests (POCTs) could safely reduce inappropriate antibiotic prescribing and antimicrobial resistance. OBJECTIVE To determine whether or not the use of a C-reactive protein (CRP) POCT to guide prescribing decisions for AECOPD reduces antibiotic consumption without having a negative impact on chronic obstructive pulmonary disease (COPD) health status and is cost-effective. DESIGN A multicentre, parallel-arm, randomised controlled open trial with an embedded process, and a health economic evaluation. SETTING General practices in Wales and England. A UK NHS perspective was used for the economic analysis. PARTICIPANTS Adults (aged ≥ 40 years) with a primary care diagnosis of COPD, presenting with an AECOPD (with at least one of increased dyspnoea, increased sputum volume and increased sputum purulence) of between 24 hours' and 21 days' duration. INTERVENTION CRP POCTs to guide antibiotic prescribing decisions for AECOPD, compared with usual care (no CRP POCT), using remote online randomisation. MAIN OUTCOME MEASURES Patient-reported antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status as measured with the Clinical COPD Questionnaire (CCQ) at 2 weeks. For the economic evaluation, patient-reported resource use and the EuroQol-5 Dimensions were included. RESULTS In total, 653 participants were randomised from 86 general practices. Three withdrew consent and one was randomised in error, leaving 324 participants in the usual-care arm and 325 participants in the CRP POCT arm. Antibiotics were consumed for AECOPD by 212 out of 274 participants (77.4%) and 150 out of 263 participants (57.0%) in the usual-care and CRP POCT arm, respectively [adjusted odds ratio 0.31, 95% confidence interval (CI) 0.20 to 0.47]. The CCQ analysis comprised 282 and 281 participants in the usual-care and CRP POCT arms, respectively, and the adjusted mean CCQ score difference at 2 weeks was 0.19 points (two-sided 90% CI -0.33 to -0.05 points). The upper limit of the CI did not contain the prespecified non-inferiority margin of 0.3. The total cost from a NHS perspective at 4 weeks was £17.59 per patient higher in the CRP POCT arm (95% CI -£34.80 to £69.98; p = 0.408). The mean incremental cost-effectiveness ratios were £222 per 1% reduction in antibiotic consumption compared with usual care at 4 weeks and £15,251 per quality-adjusted life-year gained at 6 months with no significant changes in sensitivity analyses. Patients and clinicians were generally supportive of including CRP POCT in the assessment of AECOPD. CONCLUSIONS A CRP POCT diagnostic strategy achieved meaningful reductions in patient-reported antibiotic consumption without impairing COPD health status or increasing costs. There were no associated harms and both patients and clinicians valued the diagnostic strategy. FUTURE WORK Implementation studies that also build on our qualitative findings could help determine the effect of this intervention over the longer term. TRIAL REGISTRATION Current Controlled Trials ISRCTN24346473. 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. 24, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - David Gillespie
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Patrick White
- Department of Primary Care & Public Health Sciences, King's College London, London, UK
| | - Janine Bates
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Rachel Lowe
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Bernadette Sewell
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Rhiannon Phillips
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Helen Stanton
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Nigel Kirby
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, University Hospital of Wales, Cardiff, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Jochen Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Gurudutt Naik
- Department of Wound Healing, University Hospital Wales, Cardiff, UK
| | - Micaela Gal
- Wales Primary and Emergency Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Mohammed Fasihul Alam
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Evgenia Riga
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Cochrane
- Department of Primary Care & Public Health Sciences, King's College London, London, UK
| | - Christopher C Butler
- Primary Care and Vaccines Collaborative Clinical Trials Unit, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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20
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van Hecke O, Butler C, Mendelson M, Tonkin-Crine S. Introducing new point-of-care tests for common infections in publicly funded clinics in South Africa: a qualitative study with primary care clinicians. BMJ Open 2019; 9:e029260. [PMID: 31772084 PMCID: PMC6887073 DOI: 10.1136/bmjopen-2019-029260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/20/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022] Open
Abstract
Broad-spectrum antibiotics are routinely prescribed empirically in the resource-poor settings for suspected acute common infections, which drive antimicrobial resistance. Point-of-care testing (POCT) might increase the appropriateness of decisions about whether and which antibiotic to prescribe, but implementation will be most effective if clinician's perspectives are taken into account. OBJECTIVES To explore the perceptions of South African primary care clinicians working in publicly funded clinics about: making antibiotic prescribing decisions for two common infection syndromes (acute cough, urinary tract infection); their experiences of existing POCTs; their perceptions of the barriers and opportunities for introducing (hypothetical) new POCTs. DESIGN, METHOD, PARTICIPANTS, SETTING Qualitative semistructured interviews with 23 primary care clinicians (nurses and doctors) at publicly funded clinics in the Western Cape Metro district, South Africa. Data were analysed using thematic analysis. RESULTS Clinicians reported that their antibiotic prescribing decisions were influenced by their clinical assessment, patient comorbidities, social factors (eg, access to care) and perceived patient expectations. Their experiences with currently available POCTs were largely positive, and they were optimistic about the potential for new POCTs to: support evidence-based prescribing decisions that might reduce unnecessary antibiotic prescriptions; reduce the need for further investigations; support effective communication with patients, especially when antibiotics were unlikely to be of benefit. Resources and workflow disruption were seen as the main barriers to uptake into routine care. CONCLUSIONS Clinicians working in publicly funded clinics in the Western Cape Metro of South Africa saw POCTs as potentially useful for positively addressing both clinical and social drivers of the overprescribing of broad-spectrum antibiotics, but were concerned about the resource implications and disruption of existing patient workflows.
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Affiliation(s)
- Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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21
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Groeneveld GH, van de Peppel RJ, de Waal MWM, Verheij TJM, van Dissel JT. Clinical factors, C-reactive protein point of care test and chest X-ray in patients with pneumonia: A survey in primary care. Eur J Gen Pract 2019; 25:229-235. [PMID: 31455104 PMCID: PMC6853238 DOI: 10.1080/13814788.2019.1649651] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: In patients with an acute lower respiratory tract infection (LRTI), general practitioners (GPs) often find it challenging to decide to prescribe antibiotics or not. C-reactive protein (CRP) point of care test (POCT), and chest X-ray are diagnostic tests that can optimize the treatment decision. However, their usefulness in clinical practice is unknown. Objectives: To determine the proportion of Dutch GPs using CRP and chest X-ray in patients with an acute LRTI. To determine whether clinical factors and C-reactive protein point of care test affect the behaviour in requesting chest X-rays. Methods: In 2014, a questionnaire was sent to a random sample of 900 Dutch GPs. Outcome parameters are the use of CRP and chest X-ray, the percentage of GPs who guide their decision in requesting chest X-rays by CRP testing and the GP’s expectation regarding presence or absence of pneumonia. In addition, considerations for requesting chest X-rays were assessed. Results: Two hundred and fifty-five completed questionnaires (29%) were returned. In 2014, 54% of the responding GPs used the CRP test. These GPs tend to use fewer chest X-rays (p = 0.07). GPs overestimate the chance that pneumonia will be present on the radiograph. Seventy percent consider the possibility of abnormalities other than pneumonia as the main reason for requesting a chest X-ray. Conclusion: In patients with an acute lower respiratory tract infection, GPs report that CRP results affect their behaviour regarding the request of a chest X-ray in patients with lower respiratory tract infection and therefore research is needed to substantiate the use of these diagnostic tools for this purpose.
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Affiliation(s)
- Geert H Groeneveld
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Margot W M de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap T van Dissel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Infectious Disease Control, Dutch National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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22
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Schols AMR, Meijs E, Dinant GJ, Stoffers HEJH, Krekels MME, Cals JWL. General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands. BMJ Open 2019; 9:e026846. [PMID: 31142527 PMCID: PMC6549605 DOI: 10.1136/bmjopen-2018-026846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To investigate how many general practitioner (GP)-referred venous thromboembolic events (VTEs) are diagnosed during 1 year in one geographical region and to investigate the (urgent) referral pathway of VTE diagnoses, including the role of laboratory D-dimer testing. DESIGN Historical cohort study. SETTING GP patients of 47 general practices in a demarcated geographical region of 161 503 inhabitants in the Netherlands. PARTICIPANTS We analysed all 895 primary care patients in whom either the GP determined a D-dimer value or who had a diagnostic work-up for suspected VTE in a non-academic hospital during 2015. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes of this study were the total number of VTEs per year and the diagnostic pathways-including the role of GP determined D-dimer testing-of patients urgently referred to secondary care for suspected VTE. Additionally, we explored the use of an age-adjusted D-dimer cut-off. RESULTS The annual VTE incidence was 0.9 per 1000 inhabitants. GPs annually ordered 5.1 D-dimer tests per 1000 inhabitants. Of 470 urgently GP-referred patients, 31.3% had a VTE. Of those urgently referred based on clinical assessment only (without D-dimer testing), 73.8% (96/130) had a VTE; based on clinical assessment and laboratory D-dimer testing yielded 15.0% (51/340) VTE. Applying age-adjusted D-dimer cut-offs to all patients aged 50 years or older resulted in a reduction of positive D-dimer results from 97.9% to 79.4%, without missing any VTE. CONCLUSIONS Although D-dimer testing contributes to the diagnostic work-up of VTE, GPs have a high detection rate for VTE in patients who they urgently refer to secondary care based on clinical assessment only.
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Affiliation(s)
- Angel M R Schols
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Eline Meijs
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Henri E J H Stoffers
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Mariëlle M E Krekels
- Zuyderland Medical Centre, Sittard, the Netherlands
- MCC Omnes Centre for Diagnostics and Innovation, Sittard, the Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
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Moragas A, Molero JM, Bjerrum L, Llor C. General practitioners' opinions and perceptions about antibiotic use for respiratory tract infections in primary care. Aten Primaria 2019; 51:460-461. [PMID: 30922676 PMCID: PMC6837051 DOI: 10.1016/j.aprim.2019.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 01/19/2019] [Accepted: 01/24/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ana Moragas
- University Rovira i Virgili, Jaume I Health Centre, Tarragona, Catalonia, Spain.
| | | | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carles Llor
- Via Roma Health Centre, Barcelona, Catalonia, Spain
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24
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C-reactive protein: guiding antibiotic prescribing decisions at the point of care. Br J Gen Pract 2019; 68:112-113. [PMID: 29472204 DOI: 10.3399/bjgp18x694901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Verbakel JY, Lee JJ, Goyder C, Tan PS, Ananthakumar T, Turner PJ, Hayward G, Van den Bruel A. Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis. BMJ Open 2019; 9:e025036. [PMID: 30782747 PMCID: PMC6361331 DOI: 10.1136/bmjopen-2018-025036] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/12/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care. DESIGN This was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied. DATA EXTRACTION Data were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool. RESULTS 11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission. CONCLUSIONS Performing a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes. PROSPERO REGISTRATION NUMBER CRD42016035426; Results.
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Affiliation(s)
- Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Clare Goyder
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Thanusha Ananthakumar
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Philip J Turner
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
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Althaus T, Greer RC, Swe MMM, Cohen J, Tun NN, Heaton J, Nedsuwan S, Intralawan D, Sumpradit N, Dittrich S, Doran Z, Waithira N, Thu HM, Win H, Thaipadungpanit J, Srilohasin P, Mukaka M, Smit PW, Charoenboon EN, Haenssgen MJ, Wangrangsimakul T, Blacksell S, Limmathurotsakul D, Day N, Smithuis F, Lubell Y. Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar: an open-label, randomised, controlled trial. Lancet Glob Health 2019; 7:e119-e131. [PMID: 30554748 PMCID: PMC6293968 DOI: 10.1016/s2214-109x(18)30444-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/27/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment. METHODS We did a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with ClinicalTrials.gov, number NCT02758821, and is now completed. FINDINGS Between June 8, 2016, and Aug 25, 2017, we recruited 2410 patients, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio (aOR) of 0·80 (95% CI 0·65-0·98) and risk difference of -5·0 percentage points (95% CI -9·7 to -0·3) between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86 [0·70-1·06]; risk difference -3·3 percentage points [-8·0 to 1·4]). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A). INTERPRETATION In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention. FUNDING Wellcome Trust Institutional Strategic Support Fund grant (105605/Z/14/Z) and Foundation for Innovative New Diagnostics (FIND) funding from the Australian Government.
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Affiliation(s)
- Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rachel C Greer
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Myo Maung Maung Swe
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - Joshua Cohen
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - Ni Ni Tun
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - James Heaton
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - Supalert Nedsuwan
- Primary Care Department, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Daranee Intralawan
- Primary Care Department, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Nithima Sumpradit
- Thai Food and Drug Administration, Ministry of Public Health, Bangkok, Thailand
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Zoë Doran
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Naomi Waithira
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Han Win
- Department of Medical Research, Yangon, Myanmar
| | - Janjira Thaipadungpanit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prapaporn Srilohasin
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mavuto Mukaka
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Pieter W Smit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ern Nutcha Charoenboon
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marco Johannes Haenssgen
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Tri Wangrangsimakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Stuart Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Eley CV, Sharma A, Lecky DM, Lee H, McNulty CAM. Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England. BMJ Open 2018; 8:e023925. [PMID: 30361406 PMCID: PMC6224729 DOI: 10.1136/bmjopen-2018-023925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To explore the knowledge, skills, attitudes and beliefs of general practice staff about C reactive protein (CRP) point-of-care tests (POCTs) in routine general practice and associated barriers and facilitators to implementing it to improve the management of acute cough. DESIGN A qualitative methodology including interviews and focus groups using the Com-B framework to understand individuals' behaviour to implement CRP POCT in routine general practice. Data were analysed inductively and then aligned to the Com-B framework. SETTING A service evaluation of CRP POCT over a 6-month period was previously conducted in randomly selected GP practices from a high prescribing National Health Service Clinicial Commissioning Groups in England. All 11 intervention practices (eight accepting CRPs; three declining CRPs) and the eight control practices, which were not offered CRP POCT, were also invited to interview. A further randomly selected practice not allocated to intervention or control was also invited to participate. PARTICIPANTS Seven of eight accepting CRP, one of three declining CRP and four of nine control practices consented to participate. 12 practices and 26 general practice staff participated; 11 interviews, 3 focus groups and 1 hand-written response. RESULTS Participants reported that CRP POCT can increase diagnostic certainty for acute cough, inform appropriate management, manage patient expectations for antibiotics, support patient education and improve appropriate antibiotic prescribing. Reported barriers to implementing CRP POCT included: CRP cost, time, easy access to the POCT machine and effects on clinical workflow. Participants with greater CRP use usually had a dedicated staff member with the machine located in their consultation room. CONCLUSIONS CRP POCT can help general practice staff improve patient care and education if incorporated into routine care, but this will need enthusiasts with dedicated POCT instruments or smaller, cheaper, more portable machines. In addition, funding will be needed to support test costs and staff time.
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Affiliation(s)
| | - Anita Sharma
- NHS Oldham Clinical Commissioning Group, Oldham, UK
| | | | - Hazel Lee
- NHS Oldham Clinical Commissioning Group, Oldham, UK
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Early detection of multiple myeloma in primary care using blood tests: a case-control study in primary care. Br J Gen Pract 2018; 68:e586-e593. [PMID: 30104326 PMCID: PMC6104875 DOI: 10.3399/bjgp18x698357] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/14/2018] [Indexed: 12/14/2022] Open
Abstract
Background Multiple myeloma is a haematological cancer characterised by numerous non-specific symptoms leading to diagnostic delay in a large proportion of patients. Aim To identify which blood tests are useful in suggesting or excluding a diagnosis of myeloma. Design and setting A matched case–control study set in UK primary care using routinely collected data from the Clinical Practice Research Datalink. Method Symptom prevalence and blood tests were analysed up to 5 years before diagnosis in 2703 cases and 12 157 matched controls. Likelihood ratios (LR) were used to classify tests or their combinations as useful rule-in tests (LR+ = ≥5), or rule-out tests (LR− = ≤0.2). Results Raised plasma viscosity (PV) had an LR+ = 2.0, 95% confidence interval [CI] = 1.7 to 2.3; erythrocyte sedimentation rate (ESR) 1.9, 95% CI = 1.7 to 2.0; and C-reactive protein (CRP) 1.2, 95% CI = 1.1 to 1.4. A normal haemoglobin had an LR− = 0.42, 95% CI = 0.39 to 0.45; calcium LR− = 0.81, 95% CI = 0.78 to 0.83; and creatinine LR− = 0.80, 95% CI = 0.77 to 0.83. The test combination with the lowest LR− was all normal haemoglobin with calcium and PV, which had an LR− = 0.06, 95% CI = 0.02 to 0.18, though the LR− for normal haemoglobin and PV together was 0.12 (95% CI = 0.07 to 0.23). Conclusion Plasma viscosity and ESR are better for both ruling in and ruling out the disease compared with C-reactive protein. A combination of a normal ESR or PV and normal haemoglobin is a simple rule-out approach for patients currently being tested in primary care.
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Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography. Br J Gen Pract 2018; 68:e633-e645. [PMID: 29914880 DOI: 10.3399/bjgp18x697889] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/15/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections. AIM The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists). DESIGN AND SETTING Systematic review and meta-ethnography of qualitative studies. METHOD A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed. RESULTS In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary). CONCLUSION Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities.
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C-reactive protein point-of-care testing in children with cough: qualitative study of GPs' perceptions. BJGP Open 2017; 1:bjgpopen17X101193. [PMID: 30564689 PMCID: PMC6181107 DOI: 10.3399/bjgpopen17x101193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/18/2017] [Indexed: 11/18/2022] Open
Abstract
Background Point-of-care C-reactive protein (CRP) testing is widely accepted in Dutch general practice for adult patients with acute cough, but GPs’ perceptions of its use in children with suspected lower respiratory tract infection (LRTI) are unknown. Knowledge of these perceptions is important when considering broadening its indication to use in children. Aim To explore the perceptions of Dutch GPs of the addition of point-of-care CRP testing to the diagnostic evaluation of children, and compare these to their perceptions of use in adults. Design & setting A qualitative study in general practice in the Netherlands. Method Semi-structured interviews were held with 11 GPs. Interviews were analysed using open coding and a thematic approach. Results GPs’ perceptions of the addition of point-of-care CRP testing to diagnostic process in children with suspected LRTI differ from their perceptions of this in adults. Five themes were identified: patient characteristics; vulnerability of the child; clinical presentation; availability of evidence; the impact of the procedure; and use of point-of-care CRP testing as a communication tool. Conclusion Differences between the perceptions of using point-of-care CRP testing in children and adults need to be addressed when considering the possible implementation of this diagnostic instrument.
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Haldrup S, Thomsen RW, Bro F, Skov R, Bjerrum L, Søgaard M. Microbiological point of care testing before antibiotic prescribing in primary care: considerable variations between practices. BMC FAMILY PRACTICE 2017; 18:9. [PMID: 28125965 PMCID: PMC5270219 DOI: 10.1186/s12875-016-0576-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/16/2016] [Indexed: 11/10/2022]
Abstract
Background Point-of-care testing (POCT) in primary care may improve rational antibiotic prescribing. We examined use of POCT in Denmark, including patient- and general practitioner (GP)-related predictors. Methods We linked nationwide health care databases to assess POCT use (C-reactive protein (CRP), group A streptococcal (GAS) antigen swabs, bacteriological cultures, and urine test strips) per 1,000 overall GP consultations, 2004–2013. We computed odds ratios (OR) of POCT in patients prescribed antibiotics according to patient and GP age and sex, GP practice type, location, and workload. Results The overall use of POCT in Denmark increased by 45.8% during 2004–2013, from 147.2 per 1,000 overall consultations to 214.8. CRP tests increased by 132%, bacteriological cultures by 101.7% while GAS swabs decreased by 8.6%. POCT preceded 28% of antibiotic prescriptions in 2004 increasing to 44% in 2013. The use of POCT varied more than 5-fold among individual practices, from 54.9 to 394.7 per 1,000 consultations in 2013. POCT use varied substantially with patient age, and males were less likely to receive POCT than females (adjusted OR = 0.75, 95% CI 0.74-0.75) driven by usage of urine test strips among females (18% vs. 7%). Odds of POCT were higher among female GPs and decreased with higher GP age, with lowest usage among male GPs >60 years. GP urban/rural location and workload had little impact. Conclusion GPs use POCT increasingly with the highest use among young female GPs. In 2013, 44% of all antibiotic prescriptions were preceded by POCT but testing rates vary greatly across individual GPs.
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Affiliation(s)
- Steffen Haldrup
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark. .,Department of General Practice, Institute of Public Health, Aarhus University, Aarhus, Denmark.
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
| | - Flemming Bro
- Department of General Practice, Institute of Public Health, Aarhus University, Aarhus, Denmark
| | - Robert Skov
- Antimicrobial Resistance Reference Laboratory and Surveillance Unit, Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, Copenhagen University, Copenhagen, Denmark
| | - Mette Søgaard
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark.
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Translation of clinical prediction rules for febrile children to primary care practice: an observational cohort study. Br J Gen Pract 2016; 65:e224-33. [PMID: 25824182 DOI: 10.3399/bjgp15x684373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Clinical prediction rules (CPRs) to identify children with serious infections lack validation in low-prevalence populations, which hampers their implementation in primary care practice. AIM To evaluate the diagnostic value of published CPRs for febrile children in primary care. DESIGN AND SETTING Observational cohort study among febrile children (<16 years) who consulted five GP cooperatives (GPCs) in the Netherlands. METHOD Alarm signs of serious infection and clinical management were extracted from routine clinical practice data and manually recoded with a structured electronic data-entry program. Eight CPRs were selected from literature. CPR-variables were matched with alarm signs and CPRs were applied to the GPC-population. 'Referral to emergency department (ED)' was used as a proxy outcome measure for 'serious infection'. CPR performance was assessed by calibration analyses, sensitivity, specificity, and area under the ROC-curve (ROC-area). RESULTS A total of 9794 GPC-contacts were eligible, 54% male, median age 2.3 years (interquartile range 1.0-4.6 years) and 8.1% referred to ED. Frequencies of CPR-variables varied from 0.5% (cyanosis, drowsy) to 25% (temperature ≥40°C). Alarm signs frequently included in CPRs were 'ill appearance', 'inconsolable', and 'abnormal circulatory or respiratory signs'. The height of the CPR's predicted risks generally corresponded with being (or not being) referred to the ED in practice. However, calibration-slopes indicated that three CPRs underestimated the risk of serious infection in the GPC-population. Sensitivities ranged from 42% to 54%, specificities from 68% to 89%. ROC-areas ranged from 0.52 to 0.81, with best performance of CPRs for children aged <3 months. CONCLUSION Published CPRs performed moderately well in the primary out-of-hours care population. Advice is given on how to improve translation of CPRs to primary care practice.
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Jones CHD, Glogowska M, Locock L, Lasserson DS. Embedding new technologies in practice - a normalization process theory study of point of care testing. BMC Health Serv Res 2016; 16:591. [PMID: 27756282 PMCID: PMC5070078 DOI: 10.1186/s12913-016-1834-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 10/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Many point of care diagnostic technologies are available which produce results within minutes, and offer the opportunity to deliver acute care out of hospital settings. Increasing access to diagnostics at the point of care could increase the volume and scope of acute ambulatory care. Yet these technologies are not routinely used in many settings. We aimed to explore how point of care testing is used in a setting where it has become ‘normalized’ (embedded in everyday practice), in order to inform future adoption and implementation in other settings. We used normalization process theory to guide our case study approach. Methods We used a single case study design, choosing a community based ambulatory care unit where point of care testing is used routinely. A focused ethnographic approach was taken, including non-participant observation of all activities related to point of care testing, and semi-structured interviews, with all clinical staff involved in point of care testing at the unit. Data were analysed thematically, guided by normalization process theory. Results Fourteen days of observation and six interviews were completed. Staff had a shared understanding of the purpose, value and benefits of point of care testing, believing it to be integral to the running of the unit. They organised themselves as a team to ensure that point of care testing worked effectively; and one key individual led a change in practice to ensure more consistency and trust in procedures. Staff assessed point of care testing as worthwhile for the unit, their patients, and themselves in terms of job satisfaction and knowledge. Potential barriers to adoption of point of care testing were evident (including lack of trust in the accuracy of some results compared to laboratory testing; and lack of ease of use of some aspects of the equipment); but these did not prevent point of care testing from becoming embedded, because the importance and value attributed to it were so strong. Conclusions This case study offers insights into successful adoption of new diagnostic technologies into every day practice. Such analyses may be critical to realising their potential to change processes of care. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1834-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Caroline H D Jones
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - Louise Locock
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Daniel S Lasserson
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headley Way, Oxford, OX3 9DU, UK
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Point-of-care C-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in Vietnamese primary health care: a randomised controlled trial. LANCET GLOBAL HEALTH 2016; 4:e633-41. [PMID: 27495137 PMCID: PMC4985565 DOI: 10.1016/s2214-109x(16)30142-5] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 05/25/2016] [Accepted: 06/21/2016] [Indexed: 12/18/2022]
Abstract
Background Inappropriate antibiotic use for acute respiratory tract infections is common in primary health care, but distinguishing serious from self-limiting infections is difficult, particularly in low-resource settings. We assessed whether C-reactive protein point-of-care testing can safely reduce antibiotic use in patients with non-severe acute respiratory tract infections in Vietnam. Method We did a multicentre open-label randomised controlled trial in ten primary health-care centres in northern Vietnam. Patients aged 1–65 years with at least one focal and one systemic symptom of acute respiratory tract infection were assigned 1:1 to receive either C-reactive protein point-of-care testing or routine care, following which antibiotic prescribing decisions were made. Patients with severe acute respiratory tract infection were excluded. Enrolled patients were reassessed on day 3, 4, or 5, and on day 14 a structured telephone interview was done blind to the intervention. Randomised assignments were concealed from prescribers and patients but not masked as the test result was used to assist treatment decisions. The primary outcome was antibiotic use within 14 days of follow-up. All analyses were prespecified in the protocol and the statistical analysis plan. All analyses were done on the intention-to-treat population and the analysis of the primary endpoint was repeated in the per-protocol population. This trial is registered under number NCT01918579. Findings Between March 17, 2014, and July 3, 2015, 2037 patients (1028 children and 1009 adults) were enrolled and randomised. One adult patient withdrew immediately after randomisation. 1017 patients were assigned to receive C-reactive protein point-of-care testing, and 1019 patients were assigned to receive routine care. 115 patients in the C-reactive protein point-of-care group and 72 patients in the routine care group were excluded in the intention-to-treat analysis due to missing primary endpoint. The number of patients who used antibiotics within 14 days was 581 (64%) of 902 patients in the C-reactive protein group versus 738 (78%) of 947 patients in the control group (odds ratio [OR] 0·49, 95% CI 0·40–0·61; p<0·0001). Highly significant differences were seen in both children and adults, with substantial heterogeneity of the intervention effect across the 10 sites (I2=84%, 95% CI 66–96). 140 patients in the C-reactive protein group and 137 patients in the routine care group missed the urine test on day 3, 4, or 5. Antibiotic activity in urine on day 3, 4, or 5 was found in 267 (30%) of 877 patients in the C-reactive protein group versus 314 (36%) of 882 patients in the routine treatment group (OR 0·78, 95% CI 0·63–0·95; p=0·015). Time to resolution of symptoms was similar in both groups. Adverse events were rare, with no deaths and a total of 14 hospital admissions (six in the C-reactive protein group and eight in the control group). Interpretation C-reactive protein point-of-care testing reduced antibiotic use for non-severe acute respiratory tract infection without compromising patients' recovery in primary health care in Vietnam. Health-care providers might have become familiar with the clinical picture of low C-reactive protein, leading to reduction in antibiotic prescribing in both groups, but this would have led to a reduction in observed effect, rather than overestimation. Qualitative analysis is needed to address differences in context in order to implement this strategy to improve rational antibiotic use for patients with acute respiratory infection in low-income and middle-income countries. Funding Wellcome Trust, UK, and Global Antibiotic Resistance Partnership, USA.
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Huddy JR, Ni MZ, Barlow J, Majeed A, Hanna GB. Point-of-care C reactive protein for the diagnosis of lower respiratory tract infection in NHS primary care: a qualitative study of barriers and facilitators to adoption. BMJ Open 2016; 6:e009959. [PMID: 26940107 PMCID: PMC4785316 DOI: 10.1136/bmjopen-2015-009959] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Point-of-care (POC) C reactive protein (CRP) is incorporated in National Institute of Health and Care Excellence (NICE) guidelines for the diagnosis of pneumonia, reduces antibiotic prescribing and is cost effective. AIM To determine the barriers and facilitators to adoption of POC CRP testing in National Health Service (NHS) primary care for the diagnosis of lower respiratory tract infection. DESIGN The study followed a qualitative methodology based on grounded theory. The study was undertaken in 2 stages. Stage 1 consisted of semistructured interviews with 8 clinicians from Europe and the UK who use the test in routine practice, and focused on their subjective experience in the challenges of implementing POC CRP testing. Stage 2 was a multidisciplinary-facilitated workshop with NHS stakeholders to discuss barriers to adoption, impact of adoption and potential adoption scenarios. Emergent theme analysis was undertaken. PARTICIPANTS Participants included general practitioners (including those with commissioning experience), biochemists, pharmacists, clinical laboratory scientists and industry representatives from the UK and abroad. RESULTS Barriers to the implementation of POC CRP exist, but successful adoption has been demonstrated abroad. Analysis highlighted 7 themes: reimbursement and incentivisation, quality control and training, laboratory services, practitioner attitudes and experiences, effects on clinic flow and workload, use in pharmacy and gaps in evidence. CONCLUSIONS Successful adoption models from the UK and abroad demonstrate a distinctive pattern and involve collaboration with central laboratory services. Incorporating antimicrobial stewardship into quality improvement frameworks may incentivise adoption. Further research is needed to develop scaling-up strategies to address the resourcing, clinical governance and economic impact of widespread NHS implementation.
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Affiliation(s)
- Jeremy R Huddy
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Melody Z Ni
- Department of Surgery and Cancer, Imperial College, London, UK
| | - James Barlow
- Imperial College Business School, South Kensington Campus, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
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Borsci S, Buckle P, Hanna GB. Why you need to include human factors in clinical and empirical studies ofin vitropoint of care devices? Review and future perspectives. Expert Rev Med Devices 2016; 13:405-16. [DOI: 10.1586/17434440.2016.1154277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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'I'm fishing really'--inflammatory marker testing in primary care: a qualitative study. Br J Gen Pract 2016; 66:e200-6. [PMID: 26852797 PMCID: PMC4758500 DOI: 10.3399/bjgp16x683857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/24/2015] [Indexed: 12/17/2022] Open
Abstract
Background Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking. Aim To identify clinicians’ approaches to inflammatory marker testing in primary care. Design and setting Qualitative study with 26 GPs and nurse practitioners. Method Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors. Results Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety. Conclusion Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.
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Yebyo H, Medhanyie AA, Spigt M, Hopstaken R. C-reactive protein point-of-care testing and antibiotic prescribing for acute respiratory tract infections in rural primary health centres of North Ethiopia: a cross-sectional study. NPJ Prim Care Respir Med 2016; 26:15076. [PMID: 26769226 PMCID: PMC4714524 DOI: 10.1038/npjpcrm.2015.76] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 10/03/2015] [Accepted: 10/21/2015] [Indexed: 12/31/2022] Open
Abstract
Unjustified antibiotic prescribing for acute upper respiratory infections (URTIs) is probably more common in poor-resource settings where physicians are scarce. Introducing C-reactive protein (CRP) point-of-care testing in such settings could reduce the misuse of antibiotics, which could avert antibiotic resistance. However, information useful for the applicability of CRP test in resource-limited settings is lacking. This study aimed to elicit the frequency of antibiotic prescribing and distribution of CRP levels in remote, rural settings in Ethiopia. We included 414 patients with acute URTIs from four health centres. Health professionals recorded the clinical features of the patients, but the laboratory professionals measured the CRP levels of all patients at the point of care. The most prominent respiratory causes for consultation were acute URTIs combined (44.4%), and lower respiratory tract infections—pneumonia (29.71%) and acute bronchitis (25.84%). The CRP distribution was <20 mg/l, 20–99 mg/l and 100 mg/l or more in 66.6%, 27.9% and 5.5% of the patients, respectively. The CRP levels were significantly different among these clinical diagnoses (X2=114.3, P<0.001, d.f.=4). A wide range of antibiotics was administered for 87.8% of the patients, regardless of the diagnostic or prognostic nature of their diseases. Antibiotic prescribing for acute URTIs in the rural areas of Ethiopia is unduly high, with high proportions of mild, self-limiting illness, mostly URTIs. Implementation of CRP point-of-care testing in such resource-constrained settings, with low- or middle-grade healthcare professionals, could help reconcile the inappropriate use of antibiotics by withholding from patients who do not benefit from antibiotic treatment.
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Affiliation(s)
- Henock Yebyo
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Mark Spigt
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands.,General Practice Research Unit, Department of Community Medicine, the Arctic University of Norway, Tromsø, Norway
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Lindström J, Nordeman L, Hagström B. What a difference a CRP makes. A prospective observational study on how point-of-care C-reactive protein testing influences antibiotic prescription for respiratory tract infections in Swedish primary health care. Scand J Prim Health Care 2015; 33:275-82. [PMID: 26643196 PMCID: PMC4750737 DOI: 10.3109/02813432.2015.1114348] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 10/02/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore how C-reactive protein (CRP) tests serve to support physicians in decisions concerning antibiotic prescription to patients with respiratory tract infections (RTI). DESIGN Prospective observational study. SETTING Primary health care centres in western Sweden. SUBJECTS Physicians in primary health care. Patients with acute RTI. MAIN OUTCOME MEASURES Physician willingness to measure CRP, their ability to estimate CRP, and changes in decision-making concerning antibiotic treatment based on error estimate and the physician's opinion of whether CRP measurement was crucial. RESULTS Data from 340 consultations were gathered. CRP testing was found to be crucial in 130 cases. In 86% of visits decisions regarding antibiotic prescription were unchanged. Physicians considering CRP crucial and physicians making an error estimate of CRP altered their decisions concerning antibiotic prescription after CRP testing more often than those who considered CRP unnecessary, and those making a more accurate estimate. Physicians changed their decision on antibiotic prescription in 49 cases. In the majority of these 49 cases physicians underestimated CRP levels, and the majority of changes were from "no" to "yes" as to whether to prescribe antibiotics. CONCLUSION CRP is an important factor in the decision on whether to prescribe antibiotics for RTIs. Error estimates of CRP and willingness to measure CRP are important factors leading to physicians changing decisions on antibiotic treatment. Key points There is a generally low antibiotic prescription rate and a high frequency of C-reactive protein (CRP) testing for respiratory tract infections (RTIs) in Sweden. CRP testing was considered essential to further management in 38% of cases. In 86% of visits decisions concerning antibiotic prescription were unchanged. The strongest predictors for revised decisions on antibiotic treatment were error estimates of CRP and the physician's opinion that CRP measurement was crucial.
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Affiliation(s)
| | - Lena Nordeman
- Närhälsan, Research and Development Primary Health Care Region Västra Götaland, Research and Development Center Södra Älvsborg, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Unit of Physiotherapy, Sweden
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Cooke J, Butler C, Hopstaken R, Dryden MS, McNulty C, Hurding S, Moore M, Livermore DM. Narrative review of primary care point-of-care testing (POCT) and antibacterial use in respiratory tract infection (RTI). BMJ Open Respir Res 2015; 2:e000086. [PMID: 25973210 PMCID: PMC4426285 DOI: 10.1136/bmjresp-2015-000086] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance is a global problem and is being addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) and procalcitonin, measurements to guide antibacterial prescribing in adult patients presenting to GP practices with symptoms of respiratory tract infection (RTI). Studies that were included were randomised controlled trials, controlled before and after studies, cohort studies and economic evaluations. Many studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces antibiotic prescribing by 23.3% to 36.16%. Procalcitonin is not currently available as a point-of-care testing (POCT), but has shown value for patients with RTI admitted to hospital. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. CRP POCT can better target antibacterial prescribing by GPs and contribute to national antimicrobial resistance strategies. Health services need to develop ways to ensure funding is transferred in order for POCT to be implemented.
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Affiliation(s)
- Jonathan Cooke
- Division of Infectious Diseases, Department of Medicine, The Centre for Infection Prevention and Management, Imperial College London, London, UK
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Christopher Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Rogier Hopstaken
- Saltro Diagnostic Centre for Primary Care, Utrecht, The Netherlands
| | - Matthew Scott Dryden
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Simon Hurding
- Scottish Government, Clinical Lead Therapeutics Branch, Edinburgh, UK
- Medicines Management Adviser NHS Lothian, Edinburgh, UK
| | - Michael Moore
- Primary Care and Population Sciences, University of Southampton Aldermoor Health Centre, Aldermoor Close, UK
| | - David Martin Livermore
- Norwich Medical School, University of East Anglia, Norwich, UK
- Antimicrobial Resistance & Healthcare Associated Infections Reference Unit, Public Health England, London, UK
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Wang S, Pulcini C, Rabaud C, Boivin JM, Birgé J. Inventory of antibiotic stewardship programs in general practice in France and abroad. Med Mal Infect 2015; 45:111-23. [DOI: 10.1016/j.medmal.2015.01.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/18/2014] [Accepted: 01/28/2015] [Indexed: 12/18/2022]
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Clinicians' views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections. J Gen Intern Med 2015; 30:408-16. [PMID: 25373834 PMCID: PMC4370987 DOI: 10.1007/s11606-014-3076-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/01/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority. OBJECTIVE We aimed to explore clinicians' experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs). DESIGN We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions. PARTICIPANTS General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study. APPROACH Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis. KEY RESULTS Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician's own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics. CONCLUSION Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.
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Validation and evaluation of eight commercially available point of care CRP methods. Clin Chim Acta 2015; 439:195-201. [DOI: 10.1016/j.cca.2014.10.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 10/01/2014] [Accepted: 10/20/2014] [Indexed: 01/22/2023]
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Tonkin-Crine S, Anthierens S, Francis NA, Brugman C, Fernandez-Vandellos P, Krawczyk J, Llor C, Yardley L, Coenen S, Godycki-Cwirko M, Butler CC, Verheij TJM, Goossens H, Little P, Cals JW. Exploring patients' views of primary care consultations with contrasting interventions for acute cough: a six-country European qualitative study. NPJ Prim Care Respir Med 2014; 24:14026. [PMID: 25030621 PMCID: PMC4373386 DOI: 10.1038/npjpcrm.2014.26] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/07/2014] [Accepted: 05/26/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In a pan-European randomised controlled trial (GRACE INTRO) of two interventions, (i) a point-of-care C-reactive protein test and/or (ii) training in communication skills and use of an interactive patient booklet, both interventions resulted in large reductions in antibiotic prescribing for acute cough. AIMS This process evaluation explored patients' views of primary care consultations using the two interventions in six European countries. METHODS Sixty-two interviews were conducted with patients who had participated in the GRACE INTRO trial. Interviews were transcribed verbatim and translated into English where necessary. Analysis used techniques from thematic and framework analysis. RESULTS Most patients were satisfied with their consultation despite many not receiving an antibiotic. Patients appeared to accept the use of both intervention approaches. A minority, but particularly in the trial arm with both interventions, reported that they would wait longer before consulting for cough in future. CONCLUSIONS Patients perceived that both interventions supported the general practitioner's (GP's) prescribing decisions by helping them understand when an antibiotic was, and was not, needed. Patients consulting with acute cough had largely positive views about the GP's enhanced communication skills, which included understanding their concerns, and the use of a near-patient test as an additional investigation.
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Affiliation(s)
- Sarah Tonkin-Crine
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sibyl Anthierens
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Curt Brugman
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jaroslaw Krawczyk
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Carl Llor
- Primary Care Centre Jaume I, University Rovira i Virgili, Tarragona, Spain
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Christopher C Butler
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Theo JM Verheij
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Jochen W Cals
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
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Kotani K, Minami T, Abe T, Sato J, Taniguchi N, Yamada T. Development of a new point-of-care testing system for measuring white blood cell and C-reactive protein levels in whole blood samples. Clin Chim Acta 2014; 433:145-9. [DOI: 10.1016/j.cca.2014.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/31/2014] [Accepted: 03/07/2014] [Indexed: 11/28/2022]
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van Ierland Y, Elshout G, Moll HA, Nijman RG, Vergouwe Y, van der Lei J, Berger MY, Oostenbrink R. Use of alarm features in referral of febrile children to the emergency department: an observational study. Br J Gen Pract 2014; 64:e1-9. [PMID: 24567576 PMCID: PMC3876161 DOI: 10.3399/bjgp14x676393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/16/2013] [Accepted: 11/08/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The diagnostic value of alarm features of serious infections in low prevalence settings is unclear. AIM To explore to what extent alarm features play a role in referral to the emergency department (ED) by GPs who face a febrile child during out-of-hours care. DESIGN AND SETTING Observational study using semi-structured, routine clinical practice data of febrile children (<16 years) presenting to GP out-of-hours care. METHOD Logistic regression analyses were performed to assess the association between alarm features of serious infections (selected from two guidelines and one systematic review) and referral to the ED. Adherence to the guideline was explored by a 2×2 contingency table. RESULTS In total 794 (8.1%) of 9794 eligible patients were referred to the ED. Alarm signs most strongly associated with referral were 'age <1 month', 'decreased consciousness', 'meningeal irritation', and 'signs of dehydration'. Nineteen percent of 3424 children with a positive referral indication according to the guideline were referred to the ED. The majority of those not referred had only one or two alarm features present. A negative referral indication was adhered to for the majority of children. Still, in 20% of referred children, alarm features were absent. CONCLUSION In contrast to guidance, GPs working in primary out-of-hours care seem more conservative in referring febrile children to the ED, especially if only one or two alarm features of serious infection are present. In addition, in 20% of referred children, alarm features were absent, which suggests that other factors may be important in decisions about referral of febrile children to the hospital ED.
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Affiliation(s)
- Yvette van Ierland
- Department of General Paediatrics, ErasmusMC - Sophia Children's Hospital, Rotterdam, The Netherlands
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Drain PK, Hyle EP, Noubary F, Freedberg KA, Wilson D, Bishai WR, Rodriguez W, Bassett IV. Diagnostic point-of-care tests in resource-limited settings. THE LANCET. INFECTIOUS DISEASES 2013; 14:239-49. [PMID: 24332389 DOI: 10.1016/s1473-3099(13)70250-0] [Citation(s) in RCA: 440] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The aim of diagnostic point-of-care testing is to minimise the time to obtain a test result, thereby allowing clinicians and patients to make a quick clinical decision. Because point-of-care tests are used in resource-limited settings, the benefits need to outweigh the costs. To optimise point-of-care testing in resource-limited settings, diagnostic tests need rigorous assessments focused on relevant clinical outcomes and operational costs, which differ from assessments of conventional diagnostic tests. We reviewed published studies on point-of-care testing in resource-limited settings, and found no clearly defined metric for the clinical usefulness of point-of-care testing. Therefore, we propose a framework for the assessment of point-of-care tests, and suggest and define the term test efficacy to describe the ability of a diagnostic test to support a clinical decision within its operational context. We also propose revised criteria for an ideal diagnostic point-of-care test in resource-limited settings. Through systematic assessments, comparisons between centralised testing and novel point-of-care technologies can be more formalised, and health officials can better establish which point-of-care technologies represent valuable additions to their clinical programmes.
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Affiliation(s)
- Paul K Drain
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Farzad Noubary
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA; The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - William R Bishai
- Johns Hopkins University, Baltimore, USA; KwaZulu-Natal Research Institute for Tuberculosis and HIV, Durban, South Africa
| | | | - Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Yardley L, Douglas E, Anthierens S, Tonkin-Crine S, O’Reilly G, Stuart B, Geraghty AWA, Arden-Close E, van der Velden AW, Goosens H, Verheij TJM, Butler CC, Francis NA, Little P. Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial. Implement Sci 2013; 8:134. [PMID: 24238118 PMCID: PMC3922910 DOI: 10.1186/1748-5908-8-134] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/12/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners' (GPs') and patients' attitudes. METHODS GPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics. RESULTS GPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful. CONCLUSIONS Our findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.
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Affiliation(s)
- Lucy Yardley
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton SO17 1BG, UK
| | - Elaine Douglas
- Department of Epidemiology & Public Health, Health Behaviour Research Centre, UCL, Gower Street, London WC1E 6BT, UK
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care, University of Antwerp, Universiteitsplein 1 Wilrijk, Antwerp BE-2610, Belgium
| | - Sarah Tonkin-Crine
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Gilly O’Reilly
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Beth Stuart
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Adam W A Geraghty
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Emily Arden-Close
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton SO17 1BG, UK
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands
| | - Herman Goosens
- Laboratory of Medical Microbiology, VAXINFECTIO, University of Antwerp, Antwerp, Belgium
| | - Theo JM Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands
| | - Chris C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4YS, UK
| | - Nick A Francis
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4YS, UK
| | - Paul Little
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
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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.
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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.
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Jones CHD, Howick J, Roberts NW, Price CP, Heneghan C, Plüddemann A, Thompson M. Primary care clinicians' attitudes towards point-of-care blood testing: a systematic review of qualitative studies. BMC FAMILY PRACTICE 2013; 14:117. [PMID: 23945264 PMCID: PMC3751354 DOI: 10.1186/1471-2296-14-117] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 07/29/2013] [Indexed: 11/16/2022]
Abstract
Background Point-of-care blood tests are becoming increasingly available and could replace current venipuncture and laboratory testing for many commonly used tests. However, at present very few have been implemented in most primary care settings. Understanding the attitudes of primary care clinicians towards these tests may help to identify the barriers and facilitators to their wider adoption. We aimed to systematically review qualitative studies of primary care clinicians’ attitudes to point-of-care blood tests. Methods We systematically searched Medline, Embase, ISI Web of Knowledge, PsycINFO and CINAHL for qualitative studies of primary care clinicians’ attitudes towards point-of-care blood tests in high income countries. We conducted a thematic synthesis of included studies. Results Our search identified seven studies, including around two hundred participants from Europe and Australia. The synthesis generated three main themes: the impact of point-of-care testing on decision-making, diagnosis and treatment; impact on clinical practice more broadly; and impact on patient-clinician relationships and perceived patient experience. Primary care clinicians believed point-of-care testing improved diagnostic certainty, targeting of treatment, self-management of chronic conditions, and clinician-patient communication and relationships. There were concerns about test accuracy, over-reliance on tests, undermining of clinical skills, cost, and limited usefulness. Conclusions We identified several perceived benefits and barriers regarding point-of-care tests in primary care. These imply that if point-of-care tests are to become more widely adopted, primary care clinicians require evidence of their accuracy, rigorous testing of the impact of introduction on patient pathways and clinical practice, and consideration of test funding.
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