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Wayop IYA, de Vet E, Leerlooijer JN, Wagenaar JA, Speksnijder DC. Using Implementation Mapping to develop an intervention program to support veterinarians' adherence to the guideline on Streptococcus suis clinical practice in weaned pigs. PLoS One 2024; 19:e0299905. [PMID: 38635508 PMCID: PMC11025762 DOI: 10.1371/journal.pone.0299905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/17/2024] [Indexed: 04/20/2024] Open
Abstract
Streptococcus suis (S. suis) infections in weaned pigs are common and responsible for a high consumption of antimicrobials, and their presence is assumed to be multi-factorial. A specific evidence-based veterinary guideline to support the control of S. suis in weaned pigs was developed for veterinary practitioners in the Netherlands in 2014. Adherence to the S. suis clinical practice guideline helps veterinary practitioners to prevent and control the disease in a systematical approach and thereby improve antimicrobial stewardship and contribute to the prevention of antimicrobial resistance in animals and humans. The impact of such a clinical practice guideline on (animal) disease management depends not only on its content, but also largely on the extent to which practitioners adhere to the clinical guideline in practice. When the S. suis guideline was published, no specific activities were undertaken to support veterinarians' uptake and implementation, thereby contributing to suboptimal adherence in clinical practice. As the S. suis guideline was comprehensively written by veterinary experts following an evidence-based approach, our aim was not to judge the (scientific) quality of the guideline but to study the possibility to improve the currently low adherence of this guideline in veterinary practice. This paper describes the systematic development, using Implementation Mapping, of a theory-based intervention program to support swine veterinarians' adherence to the S. suis guideline. The knowledge, skills, beliefs about capabilities, and beliefs about consequences domains are addressed in the program, which includes seven evidence-based methods (modelling, tailoring, feedback, discussion, persuasive communication, active learning, and self-monitoring) for use in program activities such as a peer-learning meeting and an e-learning module. The intervention program has been developed for practicing swine veterinarians, lasts eight months, and is evaluated through a stepped-wedge design. The Implementation Mapping approach ensured that all relevant adopters and implementers were involved, and that outcomes, determinants (influencing factors), and objectives were systematically discussed.
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Affiliation(s)
- Isaura Y. A. Wayop
- Faculty of Veterinary Medicine, Department Biomolecular Health Sciences, Division of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - Emely de Vet
- Consumption and Healthy Lifestyles Group, Wageningen University and Research, Wageningen, The Netherlands
| | - Joanne N. Leerlooijer
- Knowledge, Technology and Innovation, Wageningen University and Research, Wageningen, The Netherlands
| | - Jaap A. Wagenaar
- Faculty of Veterinary Medicine, Department Biomolecular Health Sciences, Division of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
- Wageningen Bioveterinary Research, Lelystad, The Netherlands
| | - David C. Speksnijder
- Faculty of Veterinary Medicine, Department Biomolecular Health Sciences, Division of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
- University Farm Animal Clinic ULP, Harmelen, The Netherlands
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Ackerhans S, Huynh T, Kaiser C, Schultz C. Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review. Implement Sci 2024; 19:11. [PMID: 38347525 PMCID: PMC10860285 DOI: 10.1186/s13012-024-01339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity. METHODS We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists). RESULTS One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation. CONCLUSION This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.
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Affiliation(s)
- Sophia Ackerhans
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany.
| | - Thomas Huynh
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Kaiser
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Schultz
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
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Wayop IYA, de Vet E, Wagenaar JA, Speksnijder DC. Why Veterinarians (Do Not) Adhere to the Clinical Practice Streptococcus suis in Weaned Pigs Guideline: A Qualitative Study. Antibiotics (Basel) 2023; 12:antibiotics12020320. [PMID: 36830232 PMCID: PMC9952329 DOI: 10.3390/antibiotics12020320] [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: 12/02/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
The Netherlands has been very successful in the last decade in reducing antimicrobial use in animals. On about a quarter of farms, antimicrobial use in weaned pigs remains relatively high. As Streptococcus suis (S. suis) infections are responsible for a high consumption of antimicrobials, a specific veterinary guideline to control S. suis was developed, but seemed to be poorly adopted by veterinarians. Guided by the theoretical domains framework, the aim of this study was to identify determinants influencing veterinarians' adherence to this guideline. We interviewed 13 pig veterinarians. Interviewees described multiple approaches to managing S. suis problems and adherence to the guideline. Mentioned determinants could be categorized into 12 theoretical domains. The following six domains were mentioned in all interviews: knowledge, skills, beliefs about capabilities, beliefs about consequences, social influences, and environmental context and resources. The insights derived from this study are relevant for understanding factors influencing veterinarians' adoption of scientific evidence and guidelines and can be used to develop evidence-based implementation strategies for veterinary guidelines.
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Affiliation(s)
- Isaura Y. A. Wayop
- Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands
| | - Emely de Vet
- Consumption and Healthy Lifestyles Group, Wageningen University and Research, 6700 EW Wageningen, The Netherlands
| | - Jaap A. Wagenaar
- Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands
- Wageningen Bioveterinary Research, Houtribweg 39, 8221 RA Lelystad, The Netherlands
| | - David C. Speksnijder
- Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands
- University Farm Animal Clinic ULP, Reijerscopse Overgang 1, 3481 LZ Harmelen, The Netherlands
- Correspondence:
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Ramgopal S, Sanchez-Pinto LN, Horvat CM, Carroll MS, Luo Y, Florin TA. Artificial intelligence-based clinical decision support in pediatrics. Pediatr Res 2023; 93:334-341. [PMID: 35906317 PMCID: PMC9668209 DOI: 10.1038/s41390-022-02226-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/29/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
Machine learning models may be integrated into clinical decision support (CDS) systems to identify children at risk of specific diagnoses or clinical deterioration to provide evidence-based recommendations. This use of artificial intelligence models in clinical decision support (AI-CDS) may have several advantages over traditional "rule-based" CDS models in pediatric care through increased model accuracy, with fewer false alerts and missed patients. AI-CDS tools must be appropriately developed, provide insight into the rationale behind decisions, be seamlessly integrated into care pathways, be intuitive to use, answer clinically relevant questions, respect the content expertise of the healthcare provider, and be scientifically sound. While numerous machine learning models have been reported in pediatric care, their integration into AI-CDS remains incompletely realized to date. Important challenges in the application of AI models in pediatric care include the relatively lower rates of clinically significant outcomes compared to adults, and the lack of sufficiently large datasets available necessary for the development of machine learning models. In this review article, we summarize key concepts related to AI-CDS, its current application to pediatric care, and its potential benefits and risks. IMPACT: The performance of clinical decision support may be enhanced by the utilization of machine learning-based algorithms to improve the predictive performance of underlying models. Artificial intelligence-based clinical decision support (AI-CDS) uses models that are experientially improved through training and are particularly well suited toward high-dimensional data. The application of AI-CDS toward pediatric care remains limited currently but represents an important area of future research.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - L. Nelson Sanchez-Pinto
- grid.16753.360000 0001 2299 3507Division of Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Health and Biomedical Informatics), Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Christopher M. Horvat
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Michael S. Carroll
- grid.16753.360000 0001 2299 3507Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Yuan Luo
- grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Health and Biomedical Informatics), Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Todd A. Florin
- grid.16753.360000 0001 2299 3507Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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Palomo-Carrión R, De Araújo Ferreira Jesus CC, Santana CAS, Lindquist R, Alencar R, Romay-Barrero H, Contell-Gonzalo E, Monteiro KS, Pinero-Pinto E, Longo E. Co-Design of an Intervention to Increase the Participation in Leisure Activities Including Adolescents with Cerebral Palsy with GMFCS Levels IV and V: A Study Protocol. J Clin Med 2022; 12:jcm12010182. [PMID: 36614983 PMCID: PMC9821276 DOI: 10.3390/jcm12010182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
The participation of adolescents with cerebral palsy (CP) within the community is reduced compared to their peers and is a barrier to their socialization, self-determination and quality of life. Patient and Public Involvement (PPI) is a key strategy for successful interventions, especially when involvement of the stakeholders takes place at all stages of the research. Co-design can be crucial for success as researchers, patients with CP and their families work together to bring the necessary elements to the interventions to be designed. The objectives will be: (1) To co-design an intervention aimed at improving the participation of adolescents with significant motor disabilities within the community in partnership with adolescents with CP, families and rehabilitation professionals. (2) To assess the feasibility of the co-design process in partnership with interested parties. The study will be based on Participatory Action Research (PAR) and will be held in Spain and Brazil. In both countries, the study will be carried out remotely with nine adolescents aged 12 to 17 years with CP, Gross Motor Function Classification System (GMFCS) levels IV-V, their families and six health professionals (physiotherapists and occupational therapists). Different dialogue groups will be created to involve adolescents, families and health professionals to the research's project. To manage their involvement in the co-design process, the Involvement Matrix (IM) will be used, and according to the IM phases, four steps will be included in the research: (1) Preparation; (2) Co-design; (3) Analysis: results of the intervention protocol and the study's feasibility and (4) Dissemination of results. Partnering with the public to design an intervention to improve participation can bring better results compared to protocols designed only by health professionals. In addition, it will allow for knowing the needs of adolescents with CP in terms of participation within the community. The study will also explore which roles were chosen by all participants and how they felt while actively participating in the process of co-designing an intervention protocol and their own perspectives on the use of the involvement matrix.
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Affiliation(s)
- Rocío Palomo-Carrión
- Faculty of Physiotherapy, University of Castilla-La Mancha, 45071 Toledo, Spain
- Hemi Child-Research Unit, University of Castilla-La Mancha, 45071 Toledo, Spain
| | - Caline Cristine De Araújo Ferreira Jesus
- Rehabilitation Sciences Graduate Program, Faculty of Health Science of Trairi, Federal University of Rio Grande do Norte, Santa Cruz 59078-900, Brazil
- Correspondence:
| | | | - Raquel Lindquist
- Department of Physical Therapy, Faculty of Health Science, Federal University of Rio Grande do Norte, Campus Universitário Lagoa Nova, Natal 59076-740, Brazil
| | - Roselene Alencar
- Department of Physical Therapy, Faculty of Health Science, Federal University of Rio Grande do Norte, Campus Universitário Lagoa Nova, Natal 59076-740, Brazil
| | - Helena Romay-Barrero
- Faculty of Physiotherapy, University of Castilla-La Mancha, 45071 Toledo, Spain
- Hemi Child-Research Unit, University of Castilla-La Mancha, 45071 Toledo, Spain
| | | | - Karolinne Souza Monteiro
- Rehabilitation Sciences Graduate Program, Faculty of Health Science of Trairi, Federal University of Rio Grande do Norte, Santa Cruz 59078-900, Brazil
| | - Elena Pinero-Pinto
- Department of Physical Therapy, Faculty of Nursery, Physiotherapy and Podiatry, University of Seville, 41004 Seville, Spain
| | - Egmar Longo
- Rehabilitation Sciences Graduate Program, Faculty of Health Science of Trairi, Federal University of Rio Grande do Norte, Santa Cruz 59078-900, Brazil
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Abstract
Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change ‘tools’: behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.
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Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail:
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Hautala M, Koskela U, Pokka T, Rantala H, Uhari M, Serlo W, Mikkonen K. Efficacy of the implementation of the National Emergency X-Radiography Utilization Study II decision rule to clinical practice for paediatric head injury patients. Acta Paediatr 2021; 110:2200-2205. [PMID: 33774868 DOI: 10.1111/apa.15859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/03/2021] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Abstract
AIM To investigate the usefulness of the National Emergency X-Radiography Utilization Study (NEXUS) II head trauma decision rule in clinical practice for paediatric patients in a tertiary university hospital serving as the only paediatric hospital in the area. METHODS We compared how doctors evaluated and examined patients with head injury during two time periods, before and after the introduction of NEXUS II decision rule. Multiple implementation strategies were used as follows: education, tutoring and written instructions for the use of NEXUS II. RESULTS Two hundred and forty-four head injury patients visited the hospital before and 385 after the introduction of the NEXUS II decision rule. The number of hospital admissions (56%) and the mean duration of hospitalisation (2.5 days) remained the same during the two periods. In the NEXUS II evaluated group, there was a decrease of 40% in the number of hospital admissions. NEXUS II was applied in only 62 (16%) cases. The number of head imaging procedures remained the same. No patients with a clinically significant head injury were missed with the NEXUS II evaluation. CONCLUSION NEXUS II was ineffective as our implementation failed. When used, NEXUS II reduced expenses in our study population by decreasing the number of hospital admissions.
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Affiliation(s)
- Maria Hautala
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
| | - Ulla Koskela
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
| | - Tytti Pokka
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
| | - Heikki Rantala
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
| | - Matti Uhari
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
| | - Willy Serlo
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
| | - Kirsi Mikkonen
- PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology) Medical Research Center Oulu (MRC Oulu) Oulu University Hospital, University of Oulu Oulu Finland
- Epilepsia Helsinki Division of Child Neurology Children's Hospital, and Pediatric Research Center Helsinki University Hospital and University of Helsinki Helsinki Finland
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Development of a Secure Website to Facilitate Information Sharing in Families at High Risk of Bowel Cancer-The Familyweb Study. Cancers (Basel) 2021; 13:cancers13102404. [PMID: 34065728 PMCID: PMC8155923 DOI: 10.3390/cancers13102404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Families with an inherited high risk of bowel cancer may struggle to share information about their diagnosis. This means that relatives are not always aware of their increased risk of cancer or able to access screening for the early detection of cancer. Through this study, we aimed to help such families by creating a website where patients could share confidential information with their relatives securely online. Following a survey and telephone interviews with affected individuals, the content of the website was developed to suit the needs of families. Website function was tested with patients to check feasibility and acceptability. Most participants wanted more information to support their adaptation to the diagnosis and help inform their relatives. This study demonstrates how health professionals can improve access to genetic testing and cancer screening in families at high risk of cancer, thus reducing morbidity and mortality. Abstract Individuals with pathogenic variants in genes predisposing to bowel cancer are encouraged to share this information within their families. Close relatives at 50% risk can have access to bowel cancer surveillance. However, many relatives remain unaware of their vulnerability or have insufficient information. We investigated the feasibility and acceptability of using a secure website to support information sharing within families at high risk of bowel cancer. Patients (n = 286) answered an anonymous cross-sectional survey, with 14 participating in telephone interviews. They reported that the diagnosis had a profound effect on them and their family relationships, and consequently desired more support from health professionals. Website content was created in response to the preferences of survey and interview participants. Reactions to the website from 12 volunteers were captured through remote usability testing to guide further refinement of the website. Participants welcomed the opportunity to store and share personal information via the website and wanted more information and help informing their relatives about the diagnosis. Important website topics were: healthy lifestyle; genetic testing; and how to talk to children about the diagnosis. A website providing online access to confidential documents was both feasible and acceptable and could translate into increased uptake of cancer surveillance, resulting in lower morbidity and mortality in these families.
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Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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10
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Gransjøen AM, Thorsen K, Lysdahl KB, Wiig S, Hofmann BM. Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period. Acta Radiol Open 2021; 10:2058460120988171. [PMID: 33796335 PMCID: PMC7975584 DOI: 10.1177/2058460120988171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/27/2020] [Indexed: 12/01/2022] Open
Abstract
Background An ever-increasing technological development in the field of radiology urges
a need for guidelines to provide predictable and just health services. A
musculoskeletal guideline was developed in Norway in 2014, without active
implementation. Purpose To investigate the impact of active guideline implementation on the use of
musculoskeletal diagnostic imaging most frequently encountered in general
practice (pain in the neck, shoulders, lower back, and knees). Material and Methods The total number of outpatient radiological examinations across modalities
registered at the Norwegian Health Economics Administration between January
2013 and February 2019 was assessed using an interrupted time series
design. Results A 12% reduction in the total examination of Magnetic Resonance Imaging
shoulder and knee, and x-ray lower back and shoulder was found at a
significant level (p = 0.05). Stratified analysis (Magnetic
Resonance Imaging examination as one group and x-ray examinations as the
other) showed that this reduction mainly was due to the reduction in the use
of Magnetic Resonance Imaging examinations (shoulder and knee) which was
reduced by 24% at a significant level (p = 0.002), while
x-ray examinations had no significant level change
(p = 0.71). No other statistically significant changes were
found. Conclusion The impact of the implementation on the use of imaging of the neck, shoulder,
lower back, and knee is uncertain. Significant reductions were demonstrated
in the use of some examinations in the intervention county, but similar
effects were not seen when including a control group in the analysis. This
indicates a diffusion of the implementation, or other interventions or
events that affected both counties and occurred in the intervention
period.
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Affiliation(s)
- Ann M Gransjøen
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
| | | | - Kristin B Lysdahl
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Kongsberg, Norway
| | - Siri Wiig
- SHARE-Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Bjørn M Hofmann
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway.,Center for Medical Ethics, University of Oslo, Blindern, Oslo
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11
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Taheri Moghadam S, Sadoughi F, Velayati F, Ehsanzadeh SJ, Poursharif S. The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2021; 21:98. [PMID: 33691690 PMCID: PMC7944637 DOI: 10.1186/s12911-020-01376-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 12/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes. Methods This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I2 were then used to calculate heterogeneity. Results On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs. Conclusions Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.
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Affiliation(s)
- Sharare Taheri Moghadam
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farahnaz Sadoughi
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Rashid Yasemi Street, Vali-e Asr Avenue, Tehran, 1996713883, Iran.
| | - Farnia Velayati
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Jafar Ehsanzadeh
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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12
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Louwerse I, Huysmans MA, van Rijssen HJ, Gielen CLI, van der Beek AJ, Anema JR. Use of a Decision Support Tool on Prognosis of Work Ability in Work Disability Assessments: An Experimental Study Among Insurance Physicians. JOURNAL OF OCCUPATIONAL REHABILITATION 2021; 31:185-196. [PMID: 32529340 PMCID: PMC7954760 DOI: 10.1007/s10926-020-09907-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose Assessment of prognosis of work disability is a challenging task for occupational health professionals. An evidence-based decision support tool, based on a prediction model, could aid professionals in the decision-making process. This study aimed to evaluate the efficacy of such a tool on Dutch insurance physicians' (IPs) prognosis of work ability and their prognostic confidence, and assess IPs' attitudes towards use of the tool. Methods We conducted an experimental study including six case vignettes among 29 IPs. For each vignette, IPs first specified their own prognosis of future work ability and prognostic confidence. Next, IPs were informed about the outcome of the prediction model and asked whether this changed their initial prognosis and prognostic confidence. Finally, respondents reported their attitude towards use of the tool in real practice. Results The concordance between IPs' prognosis and the outcome of the prediction model was low: IPs' prognosis was more positive in 72 (41%) and more negative in 20 (11%) cases. Using the decision support tool, IPs changed their prognosis in only 13% of the cases. IPs prognostic confidence decreased when prognosis was discordant, and remained unchanged when it was concordant. Concerning attitudes towards use, the wish to know more about the tool was considered as the main barrier. Conclusion The efficacy of the tool on IPs' prognosis of work ability and their prognostic confidence was low. Although the perceived barriers were overall limited, only a minority of the IPs indicated that they would be willing to use the tool in practice.
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Affiliation(s)
- I Louwerse
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands.
- Dutch Institute of Employee Benefit Schemes (UWV), Amsterdam, The Netherlands.
- Research Center for Insurance Medicine, AMC-UMCG-VUmc-UWV, Amsterdam, The Netherlands.
| | - M A Huysmans
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-VUmc-UWV, Amsterdam, The Netherlands
| | - H J van Rijssen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
- Dutch Institute of Employee Benefit Schemes (UWV), Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-VUmc-UWV, Amsterdam, The Netherlands
| | - C L I Gielen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
- Dutch Institute of Employee Benefit Schemes (UWV), Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-VUmc-UWV, Amsterdam, The Netherlands
| | - A J van der Beek
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-VUmc-UWV, Amsterdam, The Netherlands
| | - J R Anema
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-VUmc-UWV, Amsterdam, The Netherlands
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13
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French B, Daley D, Perez Vallejos E, Sayal K, Hall CL. Development and evaluation of an online education tool on attention deficit hyperactivity disorder for general practitioners: the important contribution of co-production. BMC FAMILY PRACTICE 2020; 21:224. [PMID: 33131490 PMCID: PMC7604955 DOI: 10.1186/s12875-020-01289-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 10/18/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is underdiagnosed in the UK and the assessment and diagnosis pathway often involves a general practitioner (GP) referral to secondary care services. GPs' levels of knowledge and understanding about ADHD is often a significant barrier in patients accessing care. The development of an online education resource could improve GPs knowledge of ADHD and optimise appropriate referrals. Involving end-users in co-creating interventions may enhance their clinical utility and impact routine clinical practice. However, there is limited published evidence describing how to meaningfully involve stakeholders in both the design and development components of co-production. METHOD We report a step wise, co-production approach towards developing an online ADHD education intervention for GPs. Preparatory work highlighted the relevant topics to be included in the intervention, from which educational videos were then developed. Workshops were then conducted with GPs, leading to further refinement of the video content and subsequently the final intervention. A pilot usability study (n = 10 GPs) was then conducted to assess the intervention's acceptability, feasibility and accessibility. RESULTS The development of the online intervention was greatly facilitated by the involvement of GPs. Having a co-production development process ensured the consistent adaptation of the intervention to meet GPs' needs. The usability study showed that the content of the intervention was suitable, easily accessible, engaging and delivered at an acceptable level of intensity, validating the development approach taken. CONCLUSION While further studies are needed to evaluate the efficacy of the developed intervention, preliminary findings demonstrated that it was acceptable and well received. The importance of co-development was highlighted in developing an intervention that addresses specific needs for GPs. This development approach may be useful for other researchers and developers of clinical interventions.
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Affiliation(s)
- B French
- Division of Psychiatry & Applied Psychology, University of Nottingham, Nottingham, UK.
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan (CANDAL), Institute of Mental Health, University of Nottingham, Nottingham, UK.
| | - D Daley
- Division of Psychiatry & Applied Psychology, University of Nottingham, Nottingham, UK
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan (CANDAL), Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - E Perez Vallejos
- Division of Psychiatry & Applied Psychology, University of Nottingham, Nottingham, UK
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan (CANDAL), Institute of Mental Health, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre for Mental Health and Technology, Nottingham, UK
| | - K Sayal
- Division of Psychiatry & Applied Psychology, University of Nottingham, Nottingham, UK
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan (CANDAL), Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - C L Hall
- Division of Psychiatry & Applied Psychology, University of Nottingham, Nottingham, UK
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan (CANDAL), Institute of Mental Health, University of Nottingham, Nottingham, UK
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14
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Hashem F, Stephensen D, Drechsler WI, Bladen M, Carroll L, Tracy P, Saloniki E. Muscle strengthening intervention for boys with haemophilia: Developing and evaluating a best-practice exercise programme with boys, families and health-care professionals. Health Expect 2020; 23:1350-1361. [PMID: 33405345 PMCID: PMC7696141 DOI: 10.1111/hex.13119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/13/2020] [Accepted: 07/21/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Muscle strengthening exercises have the potential to improve outcomes for boys with haemophilia, but it is unclear what types of exercise might be of benefit. We elicited the views of health-care professionals, boys and their families to create and assess a home-based muscle strengthening programme. OBJECTIVE To design and develop a muscle strengthening programme with health-care professionals aimed at improving musculoskeletal health, and refine the intervention by engaging boys with haemophilia and their families (Study 1). Following delivery, qualitatively evaluate the feasibility and acceptability of the exercise programme with the boys and the study's physiotherapists (Study 2). DESIGN A person-based approach was used for planning and designing the exercise programme, and evaluating it post-delivery. The following methods were utilized: modified nominal group technique (NGT) with health-care professionals; focus group with families; exit interviews with boys; and interviews with the study's physiotherapists. RESULTS Themes identified to design and develop the intervention included exercises to lower limb and foot, dosage, age accommodating, location, supervision and monitoring and incentivization. Programme refinements were carried out following engagement with the boys and families who commented on: dosage, location, supervision and incentivization. Following delivery, the boys and physiotherapists commented on progression and adaptation, physiotherapist contact, goal-setting, creating routines and identifying suitable timeframes, and a repeated theme of incentivization. CONCLUSIONS An exercise intervention was designed and refined through engagement with boys and their families. Boys and physiotherapists involved in the intervention's delivery were consulted who found the exercises to be generally acceptable with some minor refinements necessary.
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Affiliation(s)
- Ferhana Hashem
- University of KentCentre for Health Service StudiesCanterburyUK
| | - David Stephensen
- East Kent Hospitals University NHS TrustHaemophilia and Thrombosis CentreCanterburyUK
- Royal London HospitalHaemophilia CentreLondonUK
| | - Wendy I. Drechsler
- Kings College LondonSchool of Population Health & Environmental SciencesLondonUK
| | - Melanie Bladen
- Great Ormond Street Hospital For Children NHS Foundation TrustHaemophilia CentreLondonUK
- Institute of Child HealthUniversity College LondonLondonUK
| | | | | | - Eirini‐Christina Saloniki
- University of KentCentre for Health Service StudiesCanterburyUK
- University of KentPersonal Social Services Research UnitCanterburyUK
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15
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Gulliford MC, Juszczyk D, Prevost AT, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore M, Yardley L, Ashworth M, Charlton J. Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study. Health Technol Assess 2020; 23:1-70. [PMID: 30900550 DOI: 10.3310/hta23110] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN A parallel-group, cluster randomised controlled trial. SETTING The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS All registered patients were included. MAIN OUTCOME MEASURES The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN95232781. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Public Health, Imperial College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, London, UK
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16
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Peiffer-Smadja N, Poda A, Ouedraogo AS, Guiard-Schmid JB, Delory T, Le Bel J, Bouvet E, Lariven S, Jeanmougin P, Ahmad R, Lescure FX. Paving the Way for the Implementation of a Decision Support System for Antibiotic Prescribing in Primary Care in West Africa: Preimplementation and Co-Design Workshop With Physicians. J Med Internet Res 2020; 22:e17940. [PMID: 32442155 PMCID: PMC7400049 DOI: 10.2196/17940] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/13/2020] [Accepted: 03/31/2020] [Indexed: 12/11/2022] Open
Abstract
Background Suboptimal use of antibiotics is a driver of antimicrobial resistance (AMR). Clinical decision support systems (CDSS) can assist prescribers with rapid access to up-to-date information. In low- and middle-income countries (LMIC), the introduction of CDSS for antibiotic prescribing could have a measurable impact. However, interventions to implement them are challenging because of cultural and structural constraints, and their adoption and sustainability in routine clinical care are often limited. Preimplementation research is needed to ensure relevant adaptation and fit within the context of primary care in West Africa. Objective This study examined the requirements for a CDSS adapted to the context of primary care in West Africa, to analyze the barriers and facilitators of its implementation and adaptation, and to ensure co-designed solutions for its adaptation and sustainable use. Methods We organized a workshop in Burkina Faso in June 2019 with 47 health care professionals representing 9 West African countries and 6 medical specialties. The workshop began with a presentation of Antibioclic, a publicly funded CDSS for antibiotic prescribing in primary care that provides personalized antibiotic recommendations for 37 infectious diseases. Antibioclic is freely available on the web and as a smartphone app (iOS, Android). The presentation was followed by a roundtable discussion and completion of a questionnaire with open-ended questions by participants. Qualitative data were analyzed using thematic analysis. Results Most of the participants had access to a smartphone during their clinical consultations (35/47, 74%), but only 49% (23/47) had access to a computer and none used CDSS for antibiotic prescribing. The participants considered that CDSS could have a number of benefits including updating the knowledge of practitioners on antibiotic prescribing, improving clinical care and reducing AMR, encouraging the establishment of national guidelines, and developing surveillance capabilities in primary care. The most frequently mentioned contextual barrier to implementing a CDSS was the potential risk of increasing self-medication in West Africa, where antibiotics can be bought without a prescription. The need for the CDSS to be tailored to the local epidemiology of infectious diseases and AMR was highlighted along with the availability of diagnostic tests and antibiotics using national guidelines where available. Participants endorsed co-design involving all stakeholders, including nurses, midwives, and pharmacists, as central to any introduction of CDSS. A phased approach was suggested by initiating and evaluating CDSS at a pilot site, followed by dissemination using professional networks and social media. The lack of widespread internet access and computers could be circumvented by a mobile app with an offline mode. Conclusions Our study provides valuable information for the development and implementation of a CDSS for antibiotic prescribing among primary care prescribers in LMICs and may, in turn, contribute to improving antibiotic use, clinical outcomes and decreasing AMR.
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Affiliation(s)
- Nathan Peiffer-Smadja
- Infection Antimicrobials Modelling Evolution (IAME), UMR 1137, University of Paris, French Institute for Medical Research (INSERM), Paris, France.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France.,Sorbonne Université, Paris, France
| | - Armel Poda
- Department of Infectious Diseases, University Hospital Souro Sanou, Bobo-Dioulasso, Burkina Faso.,Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Abdoul-Salam Ouedraogo
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso.,Service de Bactériologie Virologie, University Hospital Souro Sanou, Bobo-Dioulasso, Burkina Faso
| | | | - Tristan Delory
- Antibioclic, Paris, France.,Institut Pierre Louis d'Épidémiologie et de Santé Publique, Sorbonne Université, French Institute for Medical Research (INSERM), Paris, France.,Innovation and Clinical Research Unit, Annecy-Genevois Hospital, Épagny Metz-Tessy, France
| | - Josselin Le Bel
- Antibioclic, Paris, France.,Department of General Practice, Université Paris Diderot, Université de Paris, Paris, France
| | - Elisabeth Bouvet
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France.,Antibioclic, Paris, France
| | - Sylvie Lariven
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France.,Antibioclic, Paris, France
| | | | - Raheelah Ahmad
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,School of Health Sciences, City, University of London, London, United Kingdom
| | - François-Xavier Lescure
- Infection Antimicrobials Modelling Evolution (IAME), UMR 1137, University of Paris, French Institute for Medical Research (INSERM), Paris, France.,Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France.,Antibioclic, Paris, France
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17
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Albertini JG, Wang P, Fahim C, Hutfless S, Stasko T, Vidimos AT, Leshin B, Billingsley EM, Coldiron BM, Bennett RG, Marks VJ, Park A, Overton HN, Bruhn WE, Xu T, Krishnan A, Makary MA. Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse. JAMA Dermatol 2019; 155:906-913. [PMID: 31055597 DOI: 10.1001/jamadermatol.2019.1259] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. Objective To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. Design, Setting, and Participants This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. Interventions Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. Main Outcomes and Measures The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. Results Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. Conclusions and Relevance Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.
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Affiliation(s)
- John G Albertini
- The Skin Surgery Center, Winston Salem, North Carolina.,Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Christine Fahim
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Susan Hutfless
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas Stasko
- Department of Dermatology, University of Oklahoma, Oklahoma City
| | | | - Barry Leshin
- The Skin Surgery Center, Winston Salem, North Carolina.,Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | | | | | | | - Angela Park
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Heidi N Overton
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William E Bruhn
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Xu
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Aravind Krishnan
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Martin A Makary
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Howarth A, Quesada J, Donnelly T, Mills PR. The development of 'Make One Small Change': an e-health intervention for the workplace developed using the Person-Based Approach. Digit Health 2019; 5:2055207619852856. [PMID: 31210960 PMCID: PMC6546946 DOI: 10.1177/2055207619852856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background The application of digital health interventions is widespread and many
employers are implementing employee e-health programs. Intended to enhance
productivity by increasing wellbeing, workplace interventions often lack
evidence of effectiveness and have low rates of retention. Use of the
person-based approach (PBA) is one solution, which offers a systematic
framework for developing effective digital health interventions. This paper
describes the application of the PBA to the development of ‘Make one small
change’ (Cigna MSC™), an online behaviour change system for lifestyle habits
focused on resilience, movement, eating and sleep. Method and results The development of Cigna MSC™ took place over four stages with colleagues
(n = 79) across Cigna globally. Application of the PBA
entailed using high amounts of qualitative data to inform development and a
cyclical process of ‘listening, applying and delivering’ was adhered to
throughout. Early stages involved review of current literature and the
collection of feedback in relation to existing interventions. Combined,
results revealed key intervention development issues that were then used to
form guiding principles. Guiding principles ensured intervention objectives
translated into relevant design features. The final stages of evaluation
included testing images, text and content approaches. Feedback dictated that
the intervention should be fun, easy to use and include milestones for
self-monitoring. The resulting version was finalised and made ready to pilot
so future analysis can be made in relation to real-world engagement and the
embedded evaluative content can be used to provide evidence of intervention
effectiveness. Conclusions Using the PBA, which was evolved specifically to improve development of
digital interventions, resulted in a workplace intervention embedded with
in-depth user input combined with evidenced-based theory. This paper
illustrates how using a rigorous methodology can drive the creation of an
effective digital health intervention that uniquely allows for refinement at
each stage.
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Affiliation(s)
- Ana Howarth
- Cigna, Global Wellbeing Solutions Ltd, London, UK.,Population Health Research Institute, St George's, University of London, UK
| | - Jose Quesada
- Cigna Health and Life Insurance Company, Bloomfield, USA
| | | | - Peter R Mills
- Cigna, Global Wellbeing Solutions Ltd, London, UK.,Department of Respiratory Medicine, The Whittington Hospital NHS Trust, London, UK
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19
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Gulliford MC, Prevost AT, Charlton J, Juszczyk D, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Ashworth M. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ 2019; 364:l236. [PMID: 30755451 PMCID: PMC6371944 DOI: 10.1136/bmj.l236] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections. DESIGN Open label, two arm, cluster randomised controlled trial. SETTING UK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017. PARTICIPANTS 79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care. INTERVENTIONS AMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial. MAIN OUTCOME MEASURES Primary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported. RESULTS The trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13). CONCLUSIONS Electronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation. TRIAL REGISTRATION ISRCTN95232781.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Robin Fox
- The Health Centre, Bicester, Oxfordshire, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
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20
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Patomella AH, Mickols G, Asaba E, Nilsson G, Fridén C, Kottorp A, Bertilson BC, Tham K. General practitioners' reasoning on risk screening and primary prevention of stroke - a focus group study. BMC FAMILY PRACTICE 2018; 19:190. [PMID: 30514217 PMCID: PMC6278124 DOI: 10.1186/s12875-018-0883-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/23/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND By screening and modifying risk factors, stroke incidence can be reduced. Clinical guidelines states that primary prevention of stroke is a responsibility and task of primary health care, but research shows that this not always the case. The aim of the study was to explore and describe what characterizes GPs' reasoning around risk screening and primary prevention among persons at risk for stroke in primary health care. METHODS A qualitative design based in a grounded theory approach was chosen in order to investigate this unexplored research area. Data collection was done using focus group interviews and data was analysed using a constant comparative method. Twenty-two GPs were interviewed in four focus groups. RESULTS Findings showed that GPs perceived difficulties in prioritizing patients with an unhealthy lifestyle and described a lack of systematicity in their procedures, which complicated their clinical decisions concerning patients with stroke risk factors. The results showed a lack of systematic risk screening methods. Time constraints and the reimbursement system were described as hindering the preventive work. CONCLUSION There is a need for a more proactive, transparent and systematic approach in the distribution of GPs' time and reimbursement of prevention in primary health care. The findings suggest, by developing new methods and approaches such as digital clinical decision-making tools and by implementing inter-professional team-work, the quality of the primary prevention of stroke could be improved.
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Affiliation(s)
- Ann-Helen Patomella
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
| | - Gustav Mickols
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
| | - Eric Asaba
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
| | - Gunnar Nilsson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
| | - Cecilia Fridén
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
| | - Anders Kottorp
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
- Malmo Hogskola, Malmo, Sweden
| | - Bo Christer Bertilson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Alle 23, 141 83 Stockholm, Sweden
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21
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Winthereik AK, Neergaard MA, Jensen AB, Vedsted P. Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners. BMC FAMILY PRACTICE 2018; 19:91. [PMID: 29925332 PMCID: PMC6011239 DOI: 10.1186/s12875-018-0774-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 05/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice. METHODS We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation. RESULTS In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up. CONCLUSION We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care. TRIAL REGISTRATION Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.
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Affiliation(s)
- Anna Kirstine Winthereik
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark.
- Department of Clinical Medicine, Aarhus University, Noerrebrogade 44, 8000, Aarhus C, Denmark.
| | - Mette Asbjoern Neergaard
- Palliative Care Team, Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - Anders Bonde Jensen
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus, Denmark
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22
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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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23
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Sillice MA, Morokoff PJ, Ferszt G, Bickmore T, Bock BC, Lantini R, Velicer WF. Using Relational Agents to Promote Exercise and Sun Protection: Assessment of Participants' Experiences With Two Interventions. J Med Internet Res 2018; 20:e48. [PMID: 29415873 PMCID: PMC5822036 DOI: 10.2196/jmir.7640] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 10/27/2017] [Accepted: 12/06/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Relational agents (RAs) are electronic computational figures designed to engage participants in the change process. A recent study, Project RAISE, tested the effectiveness of RAs, combined with existing computer-based interventions to increase regular exercise and sun protection behaviors. Results showed these interventions can be effective but need further development. OBJECTIVE The purpose of this study was to examine participants' experiences using RAs to increase participant engagement and promote behavior change . METHODS A qualitative approach was primarily utilized. A 25-question interview guide assessed different components of participants' experiences with the intervention, including motivation, engagement, satisfaction or dissatisfaction, quality of their interaction with the RA, and behavior change. Quantitative assessment of satisfaction was based on a scale of 1 to 10, with 1 representing least satisfied and 10 representing most satisfied. A summative analytic approach was used to assess individuals' qualitative responses. A single analysis of variance (ANOVA) examined levels of satisfaction by gender. RESULTS Of the original 1354 participants enrolled in Project RAISE, 490 of 1354 (36%) were assigned to the RA group. A sample of 216 out of 490 (44%) participants assigned to the RA group completed the interventions, and follow-up assessments were contacted to participate in the semistructured interview. A total of 34 out of 216 (16%) completed the interview. Participants were motivated by, and satisfied with, the intervention. Participants viewed the RA as supportive, informative, caring, and reported positive behavior change in both exercise and sun protection. Some participants (15/34, 44%) noted the RA was less judgmental and less "overbearing" compared with a human counselor; other participants (12/34, 35%) said that the interaction was sometimes repetitive or overly general. The majority of participants (22/34, 65%) viewed the RA as an important contributor to their behavior change for exercise, sun protection, or both. Levels of satisfaction ranged between 7 and 10. There were no gender differences noted in levels of satisfaction (P=.51). CONCLUSIONS RAs provide an innovative and attractive platform to increase exercise and sun protection behaviors and potentially other health behaviors.
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Affiliation(s)
- Marie A Sillice
- Department of of Psychiatry and Human Behavior, Butler Hospital, Brown University, Providence, RI, United States
| | - Patricia J Morokoff
- College of Arts and Sciences, University of Rhode Island, Kingston, RI, United States
| | - Ginette Ferszt
- College of Nursing, University of Rhode Island, Kingston, RI, United States
| | - Timothy Bickmore
- College of Computer and Information Science, Northeastern University, Boston, MA, United States
| | - Beth C Bock
- Department of of Psychiatry and Human Behavior, The Miriam Hospital, Brown University, Providence, RI, United States
| | - Ryan Lantini
- The Miriam Hospital, Providence, RI, United States
| | - Wayne F Velicer
- Cancer Prevention Research Center, Department of Psychology, University of Rhode Island, Kingston, RI, United States
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24
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Rawson TM, Moore LSP, Hernandez B, Charani E, Castro-Sanchez E, Herrero P, Hayhoe B, Hope W, Georgiou P, Holmes AH. A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately? Clin Microbiol Infect 2017; 23:524-532. [PMID: 28268133 DOI: 10.1016/j.cmi.2017.02.028] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. METHOD PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. RESULTS Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. CONCLUSION Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.
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Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - B Hernandez
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - E Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - E Castro-Sanchez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - B Hayhoe
- School of Public Health, Imperial College, London, UK
| | - W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
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25
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Colquhoun HL, Squires JE, Kolehmainen N, Fraser C, Grimshaw JM. Methods for designing interventions to change healthcare professionals' behaviour: a systematic review. Implement Sci 2017; 12:30. [PMID: 28259168 PMCID: PMC5336662 DOI: 10.1186/s13012-017-0560-5] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 02/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic reviews consistently indicate that interventions to change healthcare professional (HCP) behaviour are haphazardly designed and poorly specified. Clarity about methods for designing and specifying interventions is needed. The objective of this review was to identify published methods for designing interventions to change HCP behaviour. METHODS A search of MEDLINE, Embase, and PsycINFO was conducted from 1996 to April 2015. Using inclusion/exclusion criteria, a broad screen of abstracts by one rater was followed by a strict screen of full text for all potentially relevant papers by three raters. An inductive approach was first applied to the included studies to identify commonalities and differences between the descriptions of methods across the papers. Based on this process and knowledge of related literatures, we developed a data extraction framework that included, e.g. level of change (e.g. individual versus organization); context of development; a brief description of the method; tasks included in the method (e.g. barrier identification, component selection, use of theory). RESULTS 3966 titles and abstracts and 64 full-text papers were screened to yield 15 papers included in the review, each outlining one design method. All of the papers reported methods developed within a specific context. Thirteen papers included barrier identification and 13 included linking barriers to intervention components; although not the same 13 papers. Thirteen papers targeted individual HCPs with only one paper targeting change across individual, organization, and system levels. The use of theory and user engagement were included in 13/15 and 13/15 papers, respectively. CONCLUSIONS There is an agreement across methods of four tasks that need to be completed when designing individual-level interventions: identifying barriers, selecting intervention components, using theory, and engaging end-users. Methods also consist of further additional tasks. Examples of methods for designing the organisation and system-level interventions were limited. Further analysis of design tasks could facilitate the development of detailed guidelines for designing interventions.
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Affiliation(s)
- Heather L Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, 160-500 University Ave, Toronto, Ontario, M5G 1V7, Canada.
| | - Janet E Squires
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Ottawa, Ontario, K1H 8L6, Canada.,School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Niina Kolehmainen
- Institute of Health and Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Health Sciences Building Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Ottawa, Ontario, K1H 8L6, Canada.,Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
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26
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Juszczyk D, Charlton J, McDermott L, Soames J, Sultana K, Ashworth M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Prevost AT, Gulliford MC. Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol. BMJ Open 2016; 6:e010892. [PMID: 27491663 PMCID: PMC4985802 DOI: 10.1136/bmjopen-2015-010892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. METHODS AND ANALYSIS 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. ETHICS AND DISSEMINATION Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. TRIAL REGISTRATION NUMBER ISRCTN95232781; Pre-results.
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Affiliation(s)
- Dorota Juszczyk
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Judith Charlton
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - A Toby Prevost
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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27
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Tonkin-Crine S, Anthierens S, Hood K, Yardley L, Cals JWL, Francis NA, Coenen S, van der Velden AW, Godycki-Cwirko M, Llor C, Butler CC, Verheij TJM, Goossens H, Little P. Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: achieving clarity through mixed methods triangulation. Implement Sci 2016; 11:66. [PMID: 27175799 PMCID: PMC4866290 DOI: 10.1186/s13012-016-0436-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 05/06/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Mixed methods are commonly used in health services research; however, data are not often integrated to explore complementarity of findings. A triangulation protocol is one approach to integrating such data. A retrospective triangulation protocol was carried out on mixed methods data collected as part of a process evaluation of a trial. The multi-country randomised controlled trial found that a web-based training in communication skills (including use of a patient booklet) and the use of a C-reactive protein (CRP) point-of-care test decreased antibiotic prescribing by general practitioners (GPs) for acute cough. The process evaluation investigated GPs' and patients' experiences of taking part in the trial. METHODS Three analysts independently compared findings across four data sets: qualitative data collected view semi-structured interviews with (1) 62 patients and (2) 66 GPs and quantitative data collected via questionnaires with (3) 2886 patients and (4) 346 GPs. Pairwise comparisons were made between data sets and were categorised as agreement, partial agreement, dissonance or silence. RESULTS Three instances of dissonance occurred in 39 independent findings. GPs and patients reported different views on the use of a CRP test. GPs felt that the test was useful in convincing patients to accept a no-antibiotic decision, but patient data suggested that this was unnecessary if a full explanation was given. Whilst qualitative data indicated all patients were generally satisfied with their consultation, quantitative data indicated highest levels of satisfaction for those receiving a detailed explanation from their GP with a booklet giving advice on self-care. Both qualitative and quantitative data sets indicated higher patient enablement for those in the communication groups who had received a booklet. CONCLUSIONS Use of CRP tests does not appear to engage patients or influence illness perceptions and its effect is more centred on changing clinician behaviour. Communication skills and the patient booklet were relevant and useful for all patients and associated with increased patient satisfaction. A triangulation protocol to integrate qualitative and quantitative data can reveal findings that need further interpretation and also highlight areas of dissonance that lead to a deeper insight than separate analyses.
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Affiliation(s)
- Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Sibyl Anthierens
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Wilrijk, Antwerp, Belgium
| | - Kerenza Hood
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Samuel Coenen
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Wilrijk, Antwerp, Belgium
- Vaccine and Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerp, Belgium
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Carl Llor
- Primary Healthcare Centre Via Roma, Barcelona, Spain
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Vaccine and Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
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28
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Nejad AS, Noori MRF, Haghdoost AA, Bahaadinbeigy K, Abu-Hanna A, Eslami S. The effect of registry-based performance feedback via short text messages and traditional postal letters on prescribing parenteral steroids by general practitioners--A randomized controlled trial. Int J Med Inform 2016; 87:36-43. [PMID: 26806710 DOI: 10.1016/j.ijmedinf.2015.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 12/08/2015] [Accepted: 12/11/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is conjectured that providing feedback on physicians' prescribing behavior improves quality of drug prescriptions. However, the effectiveness of feedback provision and mode of feedback delivery is not well understood. The objective of this study was to assess and compare the effect of traditional paper letters (TPL) and short text message (STM) feedback on general practitioners' prescribing behavior of parenteral steroids (PSs). METHODS In a single-blind randomized controlled trial, 906 general practitioners (GPs) having at least 10 monthly prescriptions were randomly recruited into two interventions and one control study arms with 1:1 allocation, stratified by percentage of prescriptions. The intervention was the provision of 3 feedback messages containing prescribing indices in TPL and STM (in the first two arms) versus the control arm (CG) with an interval of 3 months between these messages. We calculated the PS Defined Daily Dose (DDD) for every GP, every month, and compared between the 3 arms, before and after the interventions. The expected primary outcome was to reduce prescription of parenteral steroids by participants. The study was performed in the Kerman Social Security Organization in Iran. RESULTS A total of 906 GPs were selected for the trial, but only 721 of them (TPL=191, STM=228, CG=302) were recruited for the 1st feedback. The mean age of GPs was 44 and 59% of them were male. The prescribed parenteral steroid DDDs at baseline were similar (TPL=121.62, STM=127.49, CG=115.68, P>0.5). At the end of the study, DDDs in the TPL and STM arms were similar (TPL=104.38, STM=101.90, P>0.9) but DDDs in each intervention arm was statistically significantly lower than in CG (CG=156.17, P<0.0001). Being in TPL and STM arms resulted in 36.1 and 41.7 units of decrease in DDD respectively, compared to the control arm (P<0.02 and P<0.005) after the one-year duration of the study. CONCLUSION Feedback by TPLs and STMs on prescribing performance effectively reduced prescribing PSs by GPs. STM, being a cheap and fast tool, is potentially powerful and efficient for drug prescription rationalization.
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Affiliation(s)
- Afshin Sarafi Nejad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Ali Akbar Haghdoost
- Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Kambiz Bahaadinbeigy
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Saeid Eslami
- Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.
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Black E, Sketris I, Skedgel C, MacLean E, Hanly JG. Adherence to guidelines and the screening tool of older persons' potentially inappropriate prescriptions criteria for colchicine dosing for gout treatment in beneficiaries of the Nova Scotia Seniors' Pharmacare Program. Clin Ther 2015; 37:2339-46. [PMID: 26391146 DOI: 10.1016/j.clinthera.2015.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/17/2015] [Accepted: 08/18/2015] [Indexed: 12/22/2022]
Abstract
PURPOSE Colchicine is commonly used in the management of gout; however, older persons have higher risks of toxicity. Accordingly, the Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP) criteria for colchicine consider >3 months of treatment as potentially inappropriate in older persons. Recent evidence also suggests lower dosing of colchicine is as effective and results in fewer toxicities than high-dose colchicine. The objectives of this study were to determine the dose, duration, and prescribers of colchicine and to evaluate adherence to the STOPP criteria and international guidelines for colchicine in older persons. METHODS A retrospective, observational study was conducted from April 1, 2006 to March 31, 2011 to evaluate colchicine use. Nova Scotia Seniors' Pharmacare Program beneficiaries who met inclusion criteria for an incident case of gout and who filled at least 1 prescription for colchicine during the study period were included. Colchicine dose and duration were reported descriptively. Multivariate logistic regression was used to identify predictors of the study population in making a claim for colchicine >90 and >180 days. FINDINGS A total of 518 persons were dispensed 1327 courses of colchicine during the study period. The mean daily dose of colchicine ranged from 1.39 to 1.50 mg. Colchicine doses >1.2 mg were prescribed in approximately one-third of the study population. Colchicine was prescribed for >90 days in 14.2% of treatment courses and for >180 days in 8.1% of treatment courses. Female sex was the only predictor of treatment duration >90 days. IMPLICATIONS This study is the first to report on colchicine dose and duration using STOPP criteria in a specific cohort of older persons with incident gout. Strategies to improve colchicine prescribing in older persons are needed.
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Affiliation(s)
- Emily Black
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ingrid Sketris
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Chris Skedgel
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erica MacLean
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John G Hanly
- Division of Rheumatology, Nova Scotia Rehabilitation Centre, Capital Health, Halifax, Nova Scotia, Canada
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30
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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: 53] [Impact Index Per Article: 5.9] [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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31
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Yardley L, Morrison L, Bradbury K, Muller I. The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res 2015; 17:e30. [PMID: 25639757 PMCID: PMC4327440 DOI: 10.2196/jmir.4055] [Citation(s) in RCA: 657] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/05/2015] [Accepted: 01/09/2015] [Indexed: 12/15/2022] Open
Abstract
This paper describes an approach that we have evolved for developing successful digital interventions to help people manage their health or illness. We refer to this as the “person-based” approach to highlight the focus on understanding and accommodating the perspectives of the people who will use the intervention. While all intervention designers seek to elicit and incorporate the views of target users in a variety of ways, the person-based approach offers a distinctive and systematic means of addressing the user experience of intended behavior change techniques in particular and can enhance the use of theory-based and evidence-based approaches to intervention development. There are two key elements to the person-based approach. The first is a developmental process involving qualitative research with a wide range of people from the target user populations, carried out at every stage of intervention development, from planning to feasibility testing and implementation. This process goes beyond assessing acceptability, usability, and satisfaction, allowing the intervention designers to build a deep understanding of the psychosocial context of users and their views of the behavioral elements of the intervention. Insights from this process can be used to anticipate and interpret intervention usage and outcomes, and most importantly to modify the intervention to make it more persuasive, feasible, and relevant to users. The second element of the person-based approach is to identify “guiding principles” that can inspire and inform the intervention development by highlighting the distinctive ways that the intervention will address key context-specific behavioral issues. This paper describes how to implement the person-based approach, illustrating the process with examples of the insights gained from our experience of carrying out over a thousand interviews with users, while developing public health and illness management interventions that have proven effective in trials involving tens of thousands of users.
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Affiliation(s)
- Lucy Yardley
- Department of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, United Kingdom.
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32
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Overington JD, Huang YC, Abramson MJ, Brown JL, Goddard JR, Bowman RV, Fong KM, Yang IA. Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions. J Thorac Dis 2014; 6:1586-96. [PMID: 25478199 DOI: 10.3978/j.issn.2072-1439.2014.11.25] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/20/2014] [Indexed: 01/17/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a complex chronic lung disease characterised by progressive fixed airflow limitation and acute exacerbations that frequently require hospitalisation. Evidence-based clinical guidelines for the diagnosis and management of COPD are now widely available. However, the uptake of these COPD guidelines in clinical practice is highly variable, as is the case for many other chronic disease guidelines. Studies have identified many barriers to implementation of COPD and other guidelines, including factors such as lack of familiarity with guidelines amongst clinicians and inadequate implementation programs. Several methods for enhancing adherence to clinical practice guidelines have been evaluated, including distribution methods, professional education sessions, electronic health records (EHR), point of care reminders and computer decision support systems (CDSS). Results of these studies are mixed to date, and the most effective ways to implement clinical practice guidelines remain unclear. Given the significant resources dedicated to evidence-based medicine, effective dissemination and implementation of best practice at the patient level is an important final step in the process of guideline development. Future efforts should focus on identifying optimal methods for translating the evidence into everyday clinical practice to ensure that patients receive the best care.
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Affiliation(s)
- Jeff D Overington
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Yao C Huang
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Michael J Abramson
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Juliet L Brown
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - John R Goddard
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Rayleen V Bowman
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Kwun M Fong
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Ian A Yang
- 1 School of Medicine, The University of Queensland, Brisbane, Australia ; 2 Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia ; 3 Lung Foundation Australia, Brisbane, Australia ; 4 Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
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McDermott L, Yardley L, Little P, van Staa T, Dregan A, McCann G, Ashworth M, Gulliford M. Process evaluation of a point-of-care cluster randomised trial using a computer-delivered intervention to reduce antibiotic prescribing in primary care. BMC Health Serv Res 2014; 14:594. [PMID: 25700144 PMCID: PMC4260184 DOI: 10.1186/s12913-014-0594-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 11/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The study aimed to conduct a process evaluation for a cluster randomised trial of a computer-delivered, point-of-care intervention to reduce antibiotic prescribing in primary care. The study aimed to evaluate both the intervention and implementation of the trial. METHODS The intervention comprised a set of electronic educational and decision support tools that were remotely installed and activated during consultations with patients with acute respiratory infections over a 12 month intervention period. A mixed method evaluation was conducted with 103 general practitioners (GPs) who participated in the trial. Semi-structured telephone interviews were conducted with 20 GPs who had been in the intervention group of the trial and 4 members of the implementation staff. Questionnaires, consisting of both intervention evaluation and theory-based measures, were self-administered to 83 GPs (56 control group and 27 intervention group). RESULTS Interviews suggested that a key factor influencing GPs' use of the intervention appeared to be their awareness of the implementation of the system into their practice. GPs who were aware of the implementation of the intervention reported feeling confident in using it if they chose to and understood the purpose of the intervention screens. However, GPs who were unaware that the intervention would be appearing often reported feeling confused when they saw the messages appear on the screen and not fully understanding what they were for or how they could be used. Intervention evaluation questionnaires indicated that GPs were satisfied with the usability of the prompts, and theory-based measures revealed that intervention group GPs reported higher levels of self-efficacy in managing RTI patients according to recommended guidelines compared to GPs in the control group. CONCLUSIONS Remote installation of a computer-delivered intervention for use at the point-of-care was feasible and acceptable. Additional measures to promote awareness of the intervention may be required to promote health care professionals' utilisation of the intervention and these might sometimes compromise the pragmatic intention of a trial. TRIAL REGISTRATION ISRCTN47558792 (registered on 17 March 2010).
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Affiliation(s)
- Lisa McDermott
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Lucy Yardley
- />Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK
| | - Paul Little
- />Aldermoor Health Centre, School of Primary Care and Population Sciences, University of Southampton, Aldermoor Close, Southampton, UK
| | - Tjeerd van Staa
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
| | - Alex Dregan
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Gerard McCann
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
| | - Mark Ashworth
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Martin Gulliford
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - The eCRT research team
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
- />Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK
- />Aldermoor Health Centre, School of Primary Care and Population Sciences, University of Southampton, Aldermoor Close, Southampton, UK
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
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Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, Lasseter G, Cheng MYE, Leydon G, McDermott L, Turner D, Pinedo-Villanueva R, Raftery J, Glasziou P, Mullee M. PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess 2014; 18:vii-xxv, 1-101. [PMID: 24467988 DOI: 10.3310/hta18060] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. OBJECTIVE This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. DESIGN The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. SETTING The setting was UK primary care general practices. PARTICIPANTS Participants were patients aged ≥ 3 years with acute sore throat. INTERVENTIONS An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. MAIN OUTCOME MEASURES The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). RESULTS The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. CONCLUSIONS Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN32027234. SOURCE OF FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - F D Richard Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian Williamson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - Gemma Lasseter
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - M Y Edith Cheng
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lisa McDermott
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Turner
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | | | - James Raftery
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Paul Glasziou
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
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Kastner M, Sawka AM, Hamid J, Chen M, Thorpe K, Chignell M, Ewusie J, Marquez C, Newton D, Straus SE. A knowledge translation tool improved osteoporosis disease management in primary care: an interrupted time series analysis. Implement Sci 2014; 9:109. [PMID: 25252858 PMCID: PMC4182792 DOI: 10.1186/s13012-014-0109-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 08/11/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems, yet gaps in management still exist. In response, we developed a multi-component osteoporosis knowledge translation (Op-KT) tool involving a patient-initiated risk assessment questionnaire (RAQ), which generates individualized best practice recommendations for physicians and customized education for patients at the point of care. The objective of this study was to evaluate the effectiveness of the Op-KT tool for appropriate disease management by physicians. METHODS The Op-KT tool was evaluated using an interrupted time series design. This involved multiple assessments of the outcomes 12 months before (baseline) and 12 months after tool implementation (52 data points in total). Inclusion criteria were family physicians and their patients at risk for osteoporosis (women aged ≥ 50 years, men aged ≥ 65 years). Primary outcomes were the initiation of appropriate osteoporosis screening and treatment. Analyses included segmented linear regression modeling and analysis of variance. RESULTS The Op-KT tool was implemented in three family practices in Ontario, Canada representing 5 family physicians with 2840 age eligible patients (mean age 67 years; 76% women). Time series regression models showed an overall increase from baseline in the initiation of screening (3.4%; P < 0.001), any osteoporosis medications (0.5%; P = 0.006), and calcium or vitamin D (1.2%; P = 0.001). Improvements were also observed at site level for all the three sites considered, but these results varied across the sites. Of 351 patients who completed the RAQ unprompted (mean age 64 years, 77% women), the mean time for completing the RAQ was 3.43 minutes, and 56% had any disease management addressed by their physician. Study limitations included the inherent susceptibility of our design compared with a randomized trial. CONCLUSIONS The multicomponent Op-KT tool significantly increased osteoporosis investigations in three family practices, and highlights its potential to facilitate patient self-management. Next steps include wider implementation and evaluation of the tool in primary care.
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Gulliford MC, van Staa T, Dregan A, McDermott L, McCann G, Ashworth M, Charlton J, Little P, Moore MV, Yardley L. Electronic health records for intervention research: a cluster randomized trial to reduce antibiotic prescribing in primary care (eCRT study). Ann Fam Med 2014; 12:344-51. [PMID: 25024243 PMCID: PMC4096472 DOI: 10.1370/afm.1659] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/04/2014] [Accepted: 03/29/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study aimed to implement a point-of-care cluster randomized trial using electronic health records. We evaluated the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in primary care. METHODS Family practices from England and Scotland participating in the Clinical Practice Research Datalink (CPRD) were included in the trial; 53 family practices were allocated to intervention and 51 practices were allocated to usual care. Patients aged 18 to 59 years consulting for respiratory tract infections were eligible. The intervention was through remotely installed, computer-delivered decision support tools accessed during the consultations. Control practices provided usual care. The primary outcome was the proportion of consultations for respiratory tract infections with an antibiotic prescribed based on electronic health records. Family practice-specific proportions were included in a cluster-level analysis. RESULTS Data were analyzed for 603,409 patients: 317,717 at intervention practices and 285,692 at control practices. Use of the intervention was less than anticipated, varying among practices. There was a reduction in proportion of consultations with antibiotics prescribed of 1.85% (95% CI, 0.10%-3.59%, P=.038) and in the rate of antibiotic prescribing for respiratory tract infections (9.69%; 95% CI, 0.75%-18.63%, fewer prescriptions per 1,000 patient-years, P=.034). There were no adverse events. CONCLUSIONS Cluster randomized trials may be implemented efficiently in large samples from routine care settings by using primary care electronic health records. Future studies should develop and test multicomponent methods for remotely delivered intervention.
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Affiliation(s)
- Martin C Gulliford
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Tjeerd van Staa
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, United Kingdom London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alex Dregan
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Lisa McDermott
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Gerard McCann
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
| | - Mark Ashworth
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Judith Charlton
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Paul Little
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Michael V Moore
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Lucy Yardley
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
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Gulliford MC, van Staa TP, McDermott L, McCann G, Charlton J, Dregan A. Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study). Trials 2014; 15:220. [PMID: 24919485 PMCID: PMC4062282 DOI: 10.1186/1745-6215-15-220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/22/2014] [Indexed: 11/10/2022] Open
Abstract
Background There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Methods Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. Results We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Conclusions Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Trial registration Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).
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Affiliation(s)
- Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, Capital House, 42 Weston St, London SE1 3QD, UK.
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Dregan A, van Staa TP, McDermott L, McCann G, Ashworth M, Charlton J, Wolfe CDA, Rudd A, Yardley L, Gulliford MC, Trial Steering Committee. Point-of-care cluster randomized trial in stroke secondary prevention using electronic health records. Stroke 2014; 45:2066-71. [PMID: 24903985 DOI: 10.1161/strokeaha.114.005713] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to evaluate whether the remote introduction of electronic decision support tools into family practices improves risk factor control after first stroke. This study also aimed to develop methods to implement cluster randomized trials in stroke using electronic health records. METHODS Family practices were recruited from the UK Clinical Practice Research Datalink and allocated to intervention and control trial arms by minimization. Remotely installed, electronic decision support tools promoted intensified secondary prevention for 12 months with last measure of systolic blood pressure as the primary outcome. Outcome data from electronic health records were analyzed using marginal models. RESULTS There were 106 Clinical Practice Research Datalink family practices allocated (intervention, 53; control, 53), with 11 391 (control, 5516; intervention, 5875) participants with acute stroke ever diagnosed. Participants at trial practices had similar characteristics as 47,887 patients with stroke at nontrial practices. During the intervention period, blood pressure values were recorded in the electronic health records for 90% and cholesterol values for 84% of participants. After intervention, the latest mean systolic blood pressure was 131.7 (SD, 16.8) mm Hg in the control trial arm and 131.4 (16.7) mm Hg in the intervention trial arm, and adjusted mean difference was -0.56 mm Hg (95% confidence interval, -1.38 to 0.26; P=0.183). The financial cost of the trial was approximately US $22 per participant, or US $2400 per family practice allocated. CONCLUSIONS Large pragmatic intervention studies may be implemented at low cost by using electronic health records. The intervention used in this trial was not found to be effective, and further research is needed to develop more effective intervention strategies. CLINICAL TRIAL REGISTRATION URL http://www.controlled-trials.com. Current Controlled Trials identifier: ISRCTN35701810.
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Affiliation(s)
- Alex Dregan
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Tjeerd P van Staa
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Lisa McDermott
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Gerard McCann
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Mark Ashworth
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Judith Charlton
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Charles D A Wolfe
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Anthony Rudd
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Lucy Yardley
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Martin C Gulliford
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.).
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Demonchy E, Dufour JC, Gaudart J, Cervetti E, Michelet P, Poussard N, Levraut J, Pulcini C. Impact of a computerized decision support system on compliance with guidelines on antibiotics prescribed for urinary tract infections in emergency departments: a multicentre prospective before-and-after controlled interventional study. J Antimicrob Chemother 2014; 69:2857-63. [DOI: 10.1093/jac/dku191] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Cornu P, Steurbaut S, De Beukeleer M, Putman K, van de Velde R, Dupont AG. Physician's expectations regarding prescribing clinical decision support systems in a Belgian hospital. Acta Clin Belg 2014; 69:157-64. [PMID: 24820921 DOI: 10.1179/2295333714y.0000000015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Developing and implementing clinical decision support systems (CDSSs) is time-consuming and costly. Therefore, prioritization of the most relevant systems is warranted. The physician's perceived usefulness has been identified as a decisive reason for using CDSSs. The objective of this study was to investigate the physician's perceived usefulness of different types of CDSSs and to identify the user needs and expectations regarding future CDSSs. METHODS Cross-sectional single-centre survey among physicians with a clinical assignment in a university hospital. Physicians were questioned about their current experiences with drug prescribing and the perceived usefulness and desired features of future CDSSs. RESULTS One hundred and sixty-four physicians completed the survey (52·6%). The majority acknowledged that it is very difficult to take all relevant information into account when prescribing drugs. Drug-drug interaction checking, drug-allergy checking, and dosing guidance were considered as most useful. Automated clinical guidelines and adverse drug event monitoring were considered as least useful. The user-friendliness of the systems, clinical relevance of the alerts, and prevention of alert fatigue were perceived as important aspects for a successful implementation. CONCLUSIONS From the physicians' perspective drug-drug interaction checking, drug-allergy checking, and dosing guidance should receive the highest priority for development and implementation. Because the perceived usefulness has been identified as a decisive reason for using CDSSs, it seems feasible to take into account this prioritization when developing and implementing CDSSs. In order to overcome the physicians' perceived disadvantages, attention should go to the development of user-friendly systems that deliver clinical relevant alerts.
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Doerr M, Edelman E, Gabitzsch E, Eng C, Teng K. Formative evaluation of clinician experience with integrating family history-based clinical decision support into clinical practice. J Pers Med 2014; 4:115-36. [PMID: 25563219 PMCID: PMC4263968 DOI: 10.3390/jpm4020115] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/01/2014] [Accepted: 03/03/2014] [Indexed: 11/16/2022] Open
Abstract
Family health history is a leading predictor of disease risk. Nonetheless, it is underutilized to guide care and, therefore, is ripe for health information technology intervention. To fill the family health history practice gap, Cleveland Clinic has developed a family health history collection and clinical decision support tool, MyFamily. This report describes the impact and process of implementing MyFamily into primary care, cancer survivorship and cancer genetics clinics. Ten providers participated in semi-structured interviews that were analyzed to identify opportunities for process improvement. Participants universally noted positive effects on patient care, including increases in quality, personalization of care and patient engagement. The impact on clinical workflow varied by practice setting, with differences observed in the ease of integration and the use of specific report elements. Tension between the length of the report and desired detail was appreciated. Barriers and facilitators to the process of implementation were noted, dominated by the theme of increased integration with the electronic medical record. These results fed real-time improvement cycles to reinforce clinician use. This model will be applied in future institutional efforts to integrate clinical genomic applications into practice and may be useful for other institutions considering the implementation of tools for personalizing medical management.
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Affiliation(s)
- Megan Doerr
- Center for Personalized Healthcare, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA.
| | - Emily Edelman
- Genomics Education, the Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609-1500, USA.
| | - Emily Gabitzsch
- Center for Personalized Healthcare, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA.
| | - Charis Eng
- Genomic Medicine Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA.
| | - Kathryn Teng
- Center for Personalized Healthcare, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, 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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Leydon GM, McDermott L, Moore M, Williamson I, Hobbs FDR, Lambton T, Cooper R, Henderson H, Little P. A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: 'swamped with sore throats?'. BMJ Open 2013; 3:e002460. [PMID: 23558734 PMCID: PMC3641470 DOI: 10.1136/bmjopen-2012-002460] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 02/05/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore patient and healthcare professionals' (HCP) views of clinical scores and rapid streptococcal antigen detection tests (RADTs) for acute sore throat. DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS General practitioners (GPs), nurse practitioners (NPs) and patients from general practices across Hampshire, Oxfordshire and the West Midlands who were participating in the Primary Care Streptococcal Management (PRISM) study. METHOD Semistructured, face-to-face and phone interviews were conducted with GPs, NPs and patients from general practices across Hampshire, Oxfordshire and the West Midlands. RESULTS 51 participants took part in the study. Of these, 42 were HCPs (29 GPs and 13 NPs) and 9 were patients. HCPs could see a positive role for RADTs in terms of reassurance, as an educational tool for patients, and for aiding inexperienced practitioners, but also had major concerns about RADT use in clinical practice. Particular concerns included the validity of the tests (the role of other bacteria, and carrier states), the tension and possible disconnect with clinical assessment and intuition, the issues of time and resource use and the potential for medicalisation of self-limiting illness. In contrast, however, experience of using RADTs over time seemed to make some participants more positive about using the tests. Moreover, patients were much more positive about the place of RADTs in providing reassurance and in limiting their antibiotic use. CONCLUSIONS It is unlikely that RADTs will have a (comfortable) place in clinical practice in the near future until health professionals' concerns are met, and they have direct experience of using them. The routine use of clinical scoring systems for acute upper respiratory illness also face important barriers related to clinicians' perceptions of their utility in the face of clinician experience and intuition.
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Affiliation(s)
- Gerry M Leydon
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Kortteisto T, Komulainen J, Mäkelä M, Kunnamo I, Kaila M. Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care. BMC Health Serv Res 2012; 12:349. [PMID: 23039113 PMCID: PMC3508894 DOI: 10.1186/1472-6963-12-349] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 10/05/2012] [Indexed: 11/28/2022] Open
Abstract
Background Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals. Methods The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics. Results The content of the guidance is a significant feature of the primary care professional’s intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use. Conclusions Primary care professionals have to perceive eCDS guidance useful for their work before they use it.
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Affiliation(s)
- Tiina Kortteisto
- School of Health Sciences, University of Tampere, Tampere, 33014, Finland.
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Dregan A, van Staa T, McDermott L, McCann G, Ashworth M, Charlton J, Wolfe C, Rudd A, Yardley L, Gulliford M. Cluster randomized trial in the general practice research database: 2. Secondary prevention after first stroke (eCRT study): study protocol for a randomized controlled trial. Trials 2012; 13:181. [PMID: 23034059 PMCID: PMC3570277 DOI: 10.1186/1745-6215-13-181] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/26/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this research is to develop and evaluate methods for conducting pragmatic cluster randomized trials in a primary care electronic database. The proposal describes one application, in a less frequent chronic condition of public health importance, secondary prevention of stroke. A related protocol in antibiotic prescribing was reported previously. METHODS/DESIGN The study aims to implement a cluster randomized trial (CRT) using the electronic patient records of the General Practice Research Database (GPRD) as a sampling frame and data source. The specific objective of the trial is to evaluate the effectiveness of a computer-delivered intervention at enhancing the delivery of stroke secondary prevention in primary care. GPRD family practices will be allocated to the intervention or usual care. The intervention promotes the use of electronic prompts to support adherence with the recommendations of the UK Intercollegiate Stroke Working Party and NICE guidelines for the secondary prevention of stroke in primary care. Primary outcome measure will be the difference in systolic blood pressure between intervention and control trial arms at 12-month follow-up. Secondary outcomes will be differences in serum cholesterol, prescribing of antihypertensive drugs, statins, and antiplatelet therapy. The intervention will continue for 12 months. Information on the utilization of the decision-support tools will also be analyzed. DISCUSSION The CRT will investigate the effectiveness of using a computer-delivered intervention to reduce the risk of stroke recurrence following a first stroke event. The study will provide methodological guidance on the implementation of CRTs in electronic databases in primary care. TRIAL REGISTRATION Current Controlled Trials ISRCTN35701810.
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Affiliation(s)
- Alex Dregan
- Department of Primary Care and Public Health Sciences, King's College, London, UK.
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Michie S, Brown J, Geraghty AWA, Miller S, Yardley L, Gardner B, Shahab L, McEwen A, Stapleton JA, West R. Development of StopAdvisor: A theory-based interactive internet-based smoking cessation intervention. Transl Behav Med 2012; 2:263-75. [PMID: 24073123 PMCID: PMC3717907 DOI: 10.1007/s13142-012-0135-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Reviews of internet-based behaviour-change interventions have shown that they can be effective but there is considerable heterogeneity and effect sizes are generally small. In order to advance science and technology in this area, it is essential to be able to build on principles and evidence of behaviour change in an incremental manner. We report the development of an interactive smoking cessation website, StopAdvisor, designed to be attractive and effective across the social spectrum. It was informed by a broad motivational theory (PRIME), empirical evidence, web-design expertise, and user-testing. The intervention was developed using an open-source web-development platform, 'LifeGuide', designed to facilitate optimisation and collaboration. We identified 19 theoretical propositions, 33 evidence- or theory-based behaviour change techniques, 26 web-design principles and nine principles from user-testing. These were synthesised to create the website, 'StopAdvisor' (see http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The systematic and transparent application of theory, evidence, web-design expertise and user-testing within an open-source development platform can provide a basis for multi-phase optimisation contributing to an 'incremental technology' of behaviour change.
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Affiliation(s)
- Susan Michie
- />UCL Medical School and Division of Psychology and Language Sciences, University College London, London, UK
- />NHS Centre for Smoking Cessation and Training, London, UK
| | - Jamie Brown
- />Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | | | - Sascha Miller
- />School of Psychology, University of Southampton, Southampton, UK
| | - Lucy Yardley
- />School of Psychology, University of Southampton, Southampton, UK
| | - Benjamin Gardner
- />Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Lion Shahab
- />Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Andy McEwen
- />NHS Centre for Smoking Cessation and Training, London, UK
- />Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - John A Stapleton
- />Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Robert West
- />NHS Centre for Smoking Cessation and Training, London, UK
- />Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
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Hirsch O, Keller H, Krones T, Donner-Banzhoff N. Arriba-lib: evaluation of an electronic library of decision aids in primary care physicians. BMC Med Inform Decis Mak 2012; 12:48. [PMID: 22672414 PMCID: PMC3461416 DOI: 10.1186/1472-6947-12-48] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 05/21/2012] [Indexed: 11/29/2022] Open
Abstract
Background The successful implementation of decision aids in clinical practice initially depends on how clinicians perceive them. Relatively little is known about the acceptance of decision aids by physicians and factors influencing the implementation of decision aids from their point of view. Our electronic library of decision aids (arriba-lib) is to be used within the encounter and has a modular structure containing evidence-based decision aids for the following topics: cardiovascular prevention, atrial fibrillation, coronary heart disease, oral antidiabetics, conventional and intensified insulin therapy, and unipolar depression. The aim of our study was to evaluate the acceptance of arriba-lib in primary care physicians. Methods We conducted an evaluation study in which 29 primary care physicians included 192 patients. The physician questionnaire contained information on which module was used, how extensive steps of the shared decision making process were discussed, who made the decision, and a subjective appraisal of consultation length. We used generalised estimation equations to measure associations within patient variables and traditional crosstab analyses. Results Only a minority of consultations (8.9%) was considered to be unacceptably extended. In 90.6% of consultations, physicians said that a decision could be made. A shared decision was perceived by physicians in 57.1% of consultations. Physicians said that a decision was more likely to be made when therapeutic options were discussed “detailed”. Prior experience with decision aids was not a critical variable for implementation within our sample of primary care physicians. Conclusions Our study showed that it might be feasible to apply our electronic library of decision aids (arriba-lib) in the primary care context. Evidence-based decision aids offer support for physicians in the management of medical information. Future studies should monitor the long-term adoption of arriba-lib in primary care physicians.
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Affiliation(s)
- Oliver Hirsch
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany.
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Høye S, Frich JC, Lindbæk M. Use and feasibility of delayed prescribing for respiratory tract infections: a questionnaire survey. BMC FAMILY PRACTICE 2011; 12:34. [PMID: 21592334 PMCID: PMC3114766 DOI: 10.1186/1471-2296-12-34] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 05/18/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives. METHODS Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method. RESULTS 304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002). CONCLUSION Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses.
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Affiliation(s)
- Sigurd Høye
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, PO Box 1130 Blindern, N-0318 Oslo, Norway.
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Gulliford MC, van Staa T, McDermott L, Dregan A, McCann G, Ashworth M, Charlton J, Grieve AP, Little P, Moore MV, Yardley L. Cluster randomised trial in the General Practice Research Database: 1. Electronic decision support to reduce antibiotic prescribing in primary care (eCRT study). Trials 2011; 12:115. [PMID: 21569237 PMCID: PMC3101122 DOI: 10.1186/1745-6215-12-115] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 05/10/2011] [Indexed: 01/17/2023] Open
Abstract
Background The purpose of this research is to develop and evaluate methods for conducting cluster randomised trials in a primary care database that contains electronic patient records for large numbers of family practices. Cluster randomised trials are trials in which the units allocated represent groups of individuals, in this case family practices and their registered patients. Cluster randomised trials often suffer from the limitation that they include too few clusters, leading to problems of insufficient power and only imprecise estimation of the intraclass correlation coefficient, a key design parameter. This difficulty might be overcome by utilising databases that already hold electronic patient records for large numbers of practices. The protocol describes one application: a study of antibiotic prescribing for acute respiratory infection; a second protocol outlines an intervention in a less frequent chronic condition of public health importance, stroke. Methods/Design The objective of the study is to implement a cluster randomised trial to test the effectiveness of an electronic record-based intervention at achieving a reduction in antibiotic prescribing at consultations for respiratory illness in patients aged 18 and 59 years old in intervention family practices as compared with controls. Family practices will be recruited from the practices that presently contribute data to the UK General Practice Research Database (GPRD). Following randomisation, electronic prompts will be installed remotely at intervention practices to promote adherence with evidence-based standards of medical practice. The intervention was developed through qualitative research at non-intervention practices. Data for outcome assessment will be obtained from anonymised electronic patient records that are routinely collected into GPRD. This protocol outlines the proposed study designs, data sources, sample size requirements, analysis methods and dissemination plans. Ethical issues are also discussed. Discussion Results from this study will provide methodological evidence concerning the use of electronic patient records and databases for implementing cluster randomised trials in primary care. The study will also provide substantive findings in respect of electronic record-based interventions to reduce antibiotic prescribing in primary care. Trial Registration Current Controlled Trials ISRCTN 47558792.
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Dregan A, Toschke MA, Wolfe CD, Rudd A, Ashworth M, Gulliford MC. Utility of electronic patient records in primary care for stroke secondary prevention trials. BMC Public Health 2011; 11:86. [PMID: 21299872 PMCID: PMC3041663 DOI: 10.1186/1471-2458-11-86] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 02/07/2011] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records (EPRs) as potential outcome measures. The study also evaluated achievement of recommended standards of care; variation between family practices; and changes in risk factor values from before to after stroke. METHODS Data from the UK General Practice Research Database (GPRD) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practices. For each subject, the EPR was evaluated for the 12 months before and after stroke. Measures relevant to stroke secondary prevention were analysed including blood pressure (BP), cholesterol, smoking, alcohol use, body mass index (BMI), atrial fibrillation, utilisation of antihypertensive, antiplatelet and cholesterol lowering drugs. Intraclass correlation coefficients (ICC) were estimated by family practice. Random effects models were fitted to evaluate changes in risk factor values over time. RESULTS In the 12 months following stroke, BP was recorded for 90%, cholesterol for 70% and body mass index (BMI) for 47%. ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol. For subjects with records available both before and after stroke, the mean reductions from before to after stroke were: mean systolic BP, 6.02 mm Hg; diastolic BP, 2.78 mm Hg; total cholesterol, 0.60 mmol/l; BMI, 0.34 Kg/m2. There was an absolute reduction in smokers of 5% and heavy drinkers of 4%. The proportion of stroke patients within the recommended guidelines varied from less than a third (29%) for systolic BP, just over half for BMI (54%), and over 90% (92%) on alcohol consumption. CONCLUSIONS Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention. Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke. Better recording of lifestyle factors in the GPRD has the potential to expand the scope of the GPRD for health care research and practice.
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Affiliation(s)
- Alex Dregan
- Division of Health and Social Care Research, King's College London, Capital House, Weston Street, London, UK.
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