Recognising serious illness in feverish young children in primary care

Optimizing antibiotic prescribing for acutely ill children in primary care (ERNIE2 study protocol, part B): a cluster randomized, factorial controlled trial evaluating the effect of a point-of-care C-reactive protein test and a brief intervention combined with written safety net advice

BACKGROUND

Despite huge public campaigns, there is still overconsumption of antibiotics in children with self-limiting diseases. Possible explanations may be the physicians' and parents' uncertainty about the gravity of the disease and inadequate communication between physicians and parents leading to lack of reassurance for the parents. In this paper we describe the design and methods of a trial aiming to rationalize antibiotic prescribing by decreasing this uncertainty and parental anxiety.

METHODS/DESIGN

Acutely ill children without suspected serious disease consulting their family physician will be consecutively included in a four-armed cluster randomized factorial controlled trial. The intervention will consist a Point-of-Care C-reactive protein test and/or a brief intervention with safety net advice. The control group will receive usual care. We intend to include 2560 patients in 88 family practices. Patients will be followed up until cure. The primary outcome measure is the immediate antibiotic prescribing rate. Secondary outcomes are: comparison between groups of speed of clinical recovery, parental concern, parental perception of the quality of the communication, parental satisfaction, use of medication, use of diagnostic tests and medical services during the illness episode, and cost-effectiveness of the interventions. Besides this, we will observationally analyse data of the children included in the large ERNIE2-trial, but excluded in the cluster randomized trial, namely children suspected of serious disease presenting in primary care and children who initially present at the out-patient paediatric clinic or emergency department. We will search for predictors of antibiotic prescribing, speed of clinical recovery, parental concern, parental perception of communication, parental satisfaction, use of medication, diagnostic tests and medical services.

DISCUSSION

This is a unique multifaceted intervention, in that it targets both physicians and parents by aiming specifically at their uncertainty and concerns during the consultation. Both interventions are easy to implement without special training. When proven effective, they could offer a feasible way to decrease inappropriate antibiotic prescribing for children in family practice and thus avoid emergence of bacterial resistance, side effects and unnecessary healthcare costs. Moreover, the observational part of the study will increase our insight in the course, management and parent's concern of acute illness in children.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02024282.

When and how do GPs record vital signs in children with acute infections? A cross-sectional study

BACKGROUND

NICE recommendations and evidence from ambulatory settings promotes the use of vital signs in identifying serious infections in children. This appears to differ from usual clinical practice where GPs report measuring vital signs infrequently.

AIM

To identify frequency of vital sign documentation by GPs, in the assessment of children with acute infections in primary care.

DESIGN AND SETTING

Observational study in 15 general practice surgeries in Oxfordshire and Somerset, UK.

METHOD

A standardised proforma was used to extract consultation details including documentation of numerical vital signs, and words or phrases used by the GP in assessing vital signs, for 850 children aged 1 month to 16 years presenting with acute infection.

RESULTS

Of the children presenting with acute infections 31.6% had one or more numerical vital signs recorded (269, 31.6%), however GP recording rate improved if free text proxies were also considered: at least one vital sign was then recorded in over half (54.1%) of children. In those with recorded numerical values for vital signs, the most frequent was temperature (210, 24.7%), followed by heart rate (62, 7.3%), respiratory rate (58, 6.8%), and capillary refill time (36, 4.2%). Words or phrases for vital signs were documented infrequently (temperature 17.6%, respiratory rate 14.6%, capillary refill time 12.5%, and heart rate 0.5%), Text relating to global assessment was documented in 313/850 (36.8%) of consultations.

CONCLUSION

GPs record vital signs using words and phrases as well as numerical methods, although overall documentation of vital signs is infrequent in children presenting with acute infections.

Clinicians' gut feeling about serious infections in children: observational study

OBJECTIVE

To investigate the basis and added value of clinicians' "gut feeling" that infections in children are more serious than suggested by clinical assessment.

DESIGN

Observational study.

SETTING

Primary care setting, Flanders, Belgium.

PARTICIPANTS

Consecutive series of 3890 children and young people aged 0-16 years presenting in primary care.

MAIN OUTCOME MEASURES

Presenting features, clinical assessment, doctors' intuitive response at first contact with children in primary care, and any subsequent diagnosis of serious infection determined from hospital records.

RESULTS

Of the 3369 children and young people assessed clinically as having a non-severe illness, six (0.2%) were subsequently admitted to hospital with a serious infection. Intuition that something was wrong despite the clinical assessment of non-severe illness substantially increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and acting on this gut feeling had the potential to prevent two of the six cases being missed (33%, 95% confidence interval 4.0% to 100%) at a cost of 44 false alarms (1.3%, 95% confidence interval 0.95% to 1.75%). The clinical features most strongly associated with gut feeling were the children's overall response (drowsiness, no laughing), abnormal breathing, weight loss, and convulsions. The strongest contextual factor was the parents' concern that the illness was different from their previous experience (odds ratio 36.3, 95% confidence interval 12.3 to 107).

CONCLUSIONS

A gut feeling about the seriousness of illness in children is an instinctive response by clinicians to the concerns of the parents and the appearance of the children. It should trigger action such as seeking a second opinion or further investigations. The observed association between intuition and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills.

Are physicians with better clinical skills on licensing examinations less likely to prescribe antibiotics for viral respiratory infections in ambulatory care settings?

BACKGROUND

Viral respiratory infections (VRIs) are a common reason for ambulatory visits, and 35% are treated with an antibiotic. Antibiotic use for VRIs is not recommended, and it promotes antibiotic resistance. Effective patient-physician communication is critical to address this problem. Recognizing the importance of physician communication skills, licensure examinations were reformed in the United States and Canada to evaluate these skills.

OBJECTIVE

To assess whether physician clinical and communication skills, as measured by the Canadian clinical skills examination (CSE), predict antibiotic prescribing for VRI in ambulatory care.

RESEARCH DESIGN AND SUBJECTS

A total of 442 Quebec general practitioners and pediatricians who wrote the CSE in 1993-1996 were followed from 1993 to 2007, and their 159,456 VRI visits were identified from physician claims.

MEASURES

The outcome was an antibiotic prescription from a study physician dispensed within 7 days of the VRI visit. Multivariate logistic regression analyses were used to estimate the association between antibiotic prescribing for VRI and CSE score, adjusting for physician, patient, and encounter characteristics.

RESULTS

Better clinical and communication skills were associated with a reduction in the risk of antibiotic prescribing, but only for female physicians. Every 1-standard deviation increase in CSE score was associated with a 19% reduction in the risk of antibiotic prescribing (risk ratio, 0.81; 95% confidence interval, 0.68-0.97). Better clinical skills were associated with an even greater reduction in risk among female physicians with higher workloads (risk ratio, 0.48; 95% confidence interval, 0.29-0.79).

CONCLUSION

Physician clinical and communication skills are important determinants of antibiotic prescribing for VRI and should be targeted by future interventions.