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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Llor C, Trapero-Bertran M, Sisó-Almirall A, Monfà R, Abellana R, García-Sangenís A, Moragas A, Morros R. Effects of C-reactive protein rapid testing and communication skills training on antibiotic prescribing for acute cough. A cluster factorial randomised controlled trial. NPJ Prim Care Respir Med 2024; 34:9. [PMID: 38724543 PMCID: PMC11081949 DOI: 10.1038/s41533-024-00368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
This cluster randomised clinical trial carried out in 20 primary care centres in Barcelona was aimed at assessing the effect of a continuous intervention focused on C-reactive protein (CRP) rapid testing and training in enhanced communication skills (ECS) on antibiotic consumption for adults with acute cough due to lower respiratory tract infection (LRTI). The interventions consisted of general practitioners and nurses' use of CRP point-of-care and training in ECS separately and combined, and usual care. The primary outcomes were antibiotic consumption and variation of the quality-adjusted life years during a 6-week follow-up. The difference in the overall antibiotic prescribing between the winter seasons before and after the intervention was calculated. The sample size calculated could not be reached due to the COVID-19 outbreak. A total of 233 patients were recruited. Compared to the usual care group (56.7%) antibiotic consumption among patients assigned to professionals in the ECS group was significantly lower (33.9%, adjusted odds ratio [aOR] 0.38, 95% CI 0.15-0.94, p = 0.037), whereas patients assigned to CRP consumed 43.8% of antibiotics (aOR 0.70, 95% CI 0.29-1.68, p = 0.429) and 38.4% in the combined intervention group (aOR 0.45, 95% CI, 0.17-1.21; p = 0.112). The overall antibiotic prescribing rates in the centres receiving training were lower after the intervention compared to those assigned to usual care, with significant reductions in β-lactam rates. Patient recovery was similar in all groups. Despite the limited power due to the low number of patients included, we observed that continuous training achieved reductions in antibiotic consumption.
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Affiliation(s)
- Carl Llor
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain.
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain.
- Research Unit for General Practice. Department of Public Health. University of Southern Denmark, Odense, Denmark.
| | - Marta Trapero-Bertran
- Department of Economics and Business, Faculty of Law, Economics and Tourism, University of Lleida, Lleida, Spain
| | - Antoni Sisó-Almirall
- Catalan Society of Family Medicine (CAMFiC). Fundació d'Atenció Primària, Barcelona, Spain
| | - Ramon Monfà
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain.
- Plataforma SCReN, UIC IDIAPJGol, Barcelona, Spain.
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.
| | - Rosa Abellana
- Biostatistics, Department of Basic Clinical Practice, University of Barcelona, Barcelona, Spain
| | - Ana García-Sangenís
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana Moragas
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain
- University Rovira i Virgili, Reus, Spain
- Jaume I Health Centre, Institut Català de la Salut, Tarragona, Spain
| | - Rosa Morros
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain
- Plataforma SCReN, UIC IDIAPJGol, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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Ababneh MA, Abujuma H, Altawalbeh S, Al Demour S. Evaluation of Antimicrobial Stewardship Programs and antibiotic prescribing patterns among physicians in ambulatory care settings in Jordan. Expert Rev Pharmacoecon Outcomes Res 2024; 24:405-412. [PMID: 38064312 DOI: 10.1080/14737167.2023.2293197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/28/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Currently, there is an urgent need to implement an Antimicrobial Stewardship Program (ASP) in outpatient settings since nearly half of the antibiotic prescribing is inappropriate or unnecessary. The implementation of ASP should emphasize educational interventions that are more interactive. This study examines the adoption of outpatient ASP by physicians in Jordan. METHODS A cross-sectional study was conducted between 2 March 2022 and 20 May 2022 at major hospitals in Jordan. The survey was distributed randomly among (n = 187) Jordanian physicians. RESULTS It was found that more than half of the physicians were females (51.9%). The participants who reported not including antibiotic stewardship-related duties in position descriptions were (40.1%). While (46.5%) of participants reported writing and displaying public commitments supporting antibiotic stewardship in ambulatory care settings. Physicians' adoption of (action) core elements of ASPs in ambulatory care settings was positive. Almost (24.6%) reported a lack of self-evaluation of their antibiotic-prescribing practices. It was reported that (69.5%) of physicians used effective communication strategies to educate patients about when antibiotics are necessary. CONCLUSION It was fair adoption of the core elements in the ambulatory care settings among Jordanian physicians. Progress necessitates a comprehensive strategy tailored to the needs of the health system.
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Affiliation(s)
- Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Hana Abujuma
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Shoroq Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Saddam Al Demour
- Department of Special Surgery/Division of Urology, The University of Jordan, School of Medicine, Amman, Jordan
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Avent ML, Hall L, van Driel M, Dobson A, Deckx L, Galal M, Plejdrup Hansen M, Gilks C. Reducing antibiotic prescribing in general practice in Australia: a cluster randomised controlled trial of a multimodal intervention. Aust J Prim Health 2024; 30:NULL. [PMID: 37844575 DOI: 10.1071/py23024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The health and economic burden of antimicrobial resistance (in Australia is significant. Interventions that help guide and improve appropriate prescribing for acute respiratory tract infections in the community represent an opportunity to slow the spread of resistant bacteria. Clinicians who work in primary care are potentially the most influential health care professionals to address the problem of antimicrobial resistance, because this is where most antibiotics are prescribed. METHODS A cluster randomised trial was conducted comparing two parallel groups of 27 urban general practices in Queensland, Australia: 13 intervention and 14 control practices, with 56 and 54 general practitioners (GPs), respectively. This study evaluated an integrated, multifaceted evidence-based package of interventions implemented over a 6-month period. The evaluation included quantitative and qualitative components, and an economic analysis. RESULTS A multimodal package of interventions resulted in a reduction of 3.81 prescriptions per GP per month. This equates to 1280.16 prescriptions for the 56GPs in the intervention practices over the 6-month period. The cost per prescription avoided was A$148. The qualitative feedback showed that the interventions were well received by the GPs and did not impact on consultation time. Providing GPs with a choice of tools might enhance their uptake and support for antimicrobial stewardship in the community. CONCLUSIONS A multimodal package of interventions to enhance rational prescribing of antibiotics is effective, feasible and acceptable in general practice. Investment in antimicrobial stewardship strategies in primary care may ultimately provide the important returns for public health into the future.
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Affiliation(s)
- Minyon L Avent
- UQ Centre for Clinical Research, The University of Queensland, Herston, Qld, Australia; and Queensland Statewide Antimicrobial Stewardship Program, Queensland Health, Herston, Qld, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Herston, Qld, Australia
| | - Mieke van Driel
- General Practice, Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Annette Dobson
- School of Public Health, The University of Queensland, Herston, Qld, Australia
| | - Laura Deckx
- General Practice, Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Mahmoud Galal
- School of Public Health, The University of Queensland, Herston, Qld, Australia
| | | | - Charles Gilks
- School of Public Health, The University of Queensland, Herston, Qld, Australia
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AbdEl-Aty MA, Amin MT, Ahmed SM, Elsedfy GO, El-Gazzar AF. Exploring factors for antibiotic over-prescription in children with acute upper respiratory tract infections in Assiut, Egypt: a qualitative study. Antimicrob Resist Infect Control 2024; 13:2. [PMID: 38185690 PMCID: PMC10773027 DOI: 10.1186/s13756-023-01357-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/17/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Over-prescription of antibiotics contributes to antibiotic resistance, which is a global health threat. Egypt has alarmingly high rates of antibiotic over-prescription for acute upper respiratory tract infections (URIs) in children. To effectively address this issue, it is important to understand the various factors that influence prescription behaviors. The Teixeira antibiotic prescription behavioral model (TAPBM) offers a comprehensive framework through which these factors can be explored. This qualitative study sought to investigate the perspectives of key stakeholders involved in pediatric healthcare in Egypt, with the primary goal of identifying the underlying determinants that contributed to this problem. METHODS This qualitative study was conducted in Assiut City, Egypt, between January and March 2023. Purposive sampling was used to select participants, including consultant pediatricians, supervisors of pediatric training programs, and specialists in infection prevention and control. Thirteen semi-structured in-depth interviews (IDIs) were conducted, audio-recorded, and transcribed. Thematic analysis was performed using MAXQDA 2020 software. RESULTS Two main themes emerged from the analysis: intrinsic factors related to physicians, extrinsic factors related to patients, and nonphysician factors. Intrinsic factors encompass personal characteristics and attitudes. Prescribing decisions were influenced by factors such as fear of complications, limited follow-up visits, and competition. Knowledge and education also played a significant role. Moreover, diagnostic uncertainty in distinguishing between bacterial and viral infections posed a challenge. Extrinsic factors included patient and caregiver factors, such as parental expectations and demands for antibiotics, driven by the belief that they produced rapid results. Moreover, patients' demographic factors, including socioeconomic status and living conditions, affected their prescribing behavior. Health system-related factors, such as the type of healthcare institution and the absence of formal national guidelines, were identified as influential factors. Additionally, this study highlighted the influence of the pharmaceutical industry. The potential impact of the COVID-19 pandemic on antibiotic prescriptions was addressed. CONCLUSIONS The study highlights the intricate interplay between intrinsic and extrinsic factors that shape antibiotic prescription decisions, underscoring the significance of addressing these factors in mitigating overprescribing.
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Affiliation(s)
- Mahmoud Attia AbdEl-Aty
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Mariam Taher Amin
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt.
| | - Sabra Mohamed Ahmed
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Ghada Omar Elsedfy
- Department of Pediatrics, Faculty of Medicine, Children's Hospital, Assiut University, Assiut, Egypt
| | - Amira Fathy El-Gazzar
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
- Department of Public Health and Community Medicine, Badr University in Cairo, Badr City, Egypt
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Do NTT, Vu TVD, Greer RC, Dittrich S, Vandendorpe M, Pham NT, Ta DN, Cao HT, Khuong TV, Le TBT, Duong TH, Nguyen TH, Cai NTH, Nguyen TQT, Trinh ST, van Doorn HR, Lubell Y, Lewycka S. Implementation of point-of-care testing of C-reactive protein concentrations to improve antibiotic targeting in respiratory illness in Vietnamese primary care: a pragmatic cluster-randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:1085-1094. [PMID: 37230105 DOI: 10.1016/s1473-3099(23)00125-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND In previous trials, point-of-care testing of C-reactive protein (CRP) concentrations safely reduced antibiotic use in non-severe acute respiratory infections in primary care. However, these trials were done in a research-oriented context with close support from research staff, which could have influenced prescribing practices. To better inform the potential for scaling up point-of-care testing of CRP in respiratory infections, we aimed to do a pragmatic trial of the intervention in a routine care setting. METHODS We did a pragmatic, cluster-randomised controlled trial at 48 commune health centres in Viet Nam between June 1, 2020, and May 12, 2021. Eligible centres served populations of more than 3000 people, handled 10-40 respiratory infections per week, had licensed prescribers on site, and maintained electronic patient databases. Centres were randomly allocated (1:1) to provide point-of-care CRP testing plus routine care or routine care only. Randomisation was stratified by district and by baseline prescription level (ie, the proportion of patients with suspected acute respiratory infections to whom antibiotics were prescribed in 2019). Eligible patients were aged 1-65 years and visiting the commune health centre for a suspected acute respiratory infection with at least one focal sign or symptom and symptoms lasting less than 7 days. The primary endpoint was the proportion of patients prescribed an antibiotic at first attendance in the intention-to-treat population. The per-protocol analysis included only people who underwent CRP testing. Secondary safety outcomes included time to resolution of symptoms and frequency of hospitalisation. This trial is registered with ClinicalTrials.gov, NCT03855215. FINDINGS 48 commune health centres were enrolled and randomly assigned, 24 to the intervention group (n=18 621 patients) and 24 to the control group (n=21 235). 17 345 (93·1%) patients in the intervention group were prescribed antibiotics, compared with 20 860 (98·2%) in the control group (adjusted relative risk 0·83 [95% CI 0·66-0·93]). Only 2606 (14%) of 18 621 patients in the intervention group underwent CRP testing and were included in the per-protocol analysis. When analyses were restricted to this population, larger reductions in prescribing were noted in the intervention group compared with the control group (adjusted relative risk 0·64 [95% CI 0·60-0·70]). Time to resolution of symptoms (hazard ratio 0·70 [95% CI 0·39-1·27]) and frequency of hospitalisation (nine in the intervention group vs 17 in the control group; adjusted relative risk 0·52 [95% CI 0·23-1·17]) did not differ between groups. INTERPRETATION Use of point-of-care CRP testing efficaciously reduced prescription of antibiotics in patients with non-severe acute respiratory infections in primary health care in Viet Nam without compromising patient recovery. The low uptake of CRP testing suggests that barriers to implementation and compliance need to be addressed before scale-up of the intervention. FUNDING Australian Government, UK Government, and the Foundation for Innovative New Diagnostics.
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Affiliation(s)
| | | | - Rachel C Greer
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, Geneva, Switzerland; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | | | - Dieu Ngan Ta
- National Hospital for Tropical Diseases, Hanoi, Viet Nam
| | | | | | | | | | | | | | | | - Son Tung Trinh
- Oxford University Clinical Research Unit, Hanoi, Viet Nam
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Viet Nam; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Sonia Lewycka
- Oxford University Clinical Research Unit, Hanoi, Viet Nam; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open 2023; 13:e065006. [PMID: 37197815 DOI: 10.1136/bmjopen-2022-065006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES This study aimed to identify determinants of inappropriate antibiotic prescription in primary care in developed countries and to construct a framework with the determinants to help understand which actions can best be targeted to counteract development of antimicrobial resistance (AMR). DESIGN A systematic review of peer-reviewed studies reporting determinants of inappropriate antibiotic prescription published through 9 September 2021 in PubMed, Embase, Web of Science and the Cochrane Library was performed. SETTING All studies focusing on primary care in developed countries where general practitioners (GPs) act as gatekeepers for referral to medical specialists and hospital care were included. RESULTS Seventeen studies fulfilled the inclusion criteria and were used for the analysis which identified 45 determinants of inappropriate antibiotic prescription. Important determinants for inappropriate antibiotic prescription were comorbidity, primary care not considered to be responsible for development of AMR and GP perception of patient desire for antibiotics. A framework was constructed with the determinants and provides a broad overview of several domains. The framework can be used to identify several reasons for inappropriate antibiotic prescription in a specific primary care setting and from there, choose the most suitable intervention(s) and assist in implementing them for combatting AMR. CONCLUSIONS The type of infection, comorbidity and the GPs perception of a patient's desire for antibiotics are consistently identified as factors driving inappropriate antibiotic prescription in primary care. A framework with determinants of inappropriate antibiotic prescription may be useful after validation for effective implementation of interventions for decreasing these inappropriate prescriptions. PROSPERO REGISTRATION NUMBER CRD42023396225.
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Affiliation(s)
- Martijn Sijbom
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederike L Büchner
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Nicholas H Saadah
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mark G J de Boer
- Infectious Diseases, Leidsen University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Implementing antibiotic stewardship in high-prescribing English general practices: a mixed-methods study. Br J Gen Pract 2023; 73:e164-e175. [PMID: 36823061 PMCID: PMC9975978 DOI: 10.3399/bjgp.2022.0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. The authors co-developed an implementation intervention to improve use of three AMS strategies: enhanced communication strategies, delayed prescriptions, and point-of-care C-reactive protein tests (POC-CRPTs). AIM To investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing. DESIGN AND SETTING Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an 'antibiotic champion'. METHOD Routinely collected prescribing data were compared between the intervention and the control practices. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention. RESULTS There was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual champions' preconceptions of strategies and the opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPTs; one practice chose all three. POC-CRPTs was used more when allocated to one person. CONCLUSION Clinicians need detailed information on exactly how to adopt AMS strategies. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.
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Lindström AKB, Tängdén T. Introducing the C-reactive protein point-of-care test: A conversation analytic study of primary care consultations for respiratory tract infection. Soc Sci Med 2022; 315:115493. [PMID: 36423539 DOI: 10.1016/j.socscimed.2022.115493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
The C-reactive protein point-of-care test (CRP-POCT) can help distinguish between viral and bacterial infection and has been promoted as a strategy to improve antimicrobial stewardship. The test is widely used in Sweden. National guidelines advocate conservative use in primary care consultations with patients presenting with symptoms of respiratory tract infection (RTI). Previous research suggests low adherence to guidelines. We provide new insights into the communication surrounding the CRP-POCT by documenting how the decision to administer the test is interactionally motivated and organized in Swedish primary care. The data consists of video-recordings of RTI-consultations. A CRP-POCT was performed in nearly two thirds of the consultations and our study is focused on a subset where the test is ordered by a medical doctor. We find that doctors order the test during the transition from or after physical examination, a practice that aligns with national guidelines. Guidelines indicate that pathological findings from physical examination are warrants for ordering the test but we only found one example where this was communicated to the patient. A more prevalent pattern was that doctors ordered the CRP-POCT even though the outcome of the physical examination was assessed as normal. Our analyses of these show that doctors can provide the rationale for ordering the test in subtle ways and that failure to provide a rationale is treated as a noticeable absence. We also find that the CRP-POCT can be used to reconcile the contrast between the normal physical examination and the patient's problem presentation. Doctors can also order the test in ways that position the CRP-POCT as criterial for antibiotic prescription. Consultations where the patients described the symptoms as particularly severe and/or persistent were more likely to engender elaborate accounts than consultations where patients presented their symptoms as less problematic.
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Affiliation(s)
| | - Thomas Tängdén
- Department of Medical Sciences, Infectious Medicine, Uppsala University, Sweden
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10
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Amin MT, Abd El Aty MA, Ahmed SM, Elsedfy GO, Hassanin ES, El-Gazzar AF. Over prescription of antibiotics in children with acute upper respiratory tract infections: A study on the knowledge, attitude and practices of non-specialized physicians in Egypt. PLoS One 2022; 17:e0277308. [PMID: 36327297 PMCID: PMC9632891 DOI: 10.1371/journal.pone.0277308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is currently one of the global public health threats. Increased antibiotic consumption in humans, animals, and agriculture has contributed directly to the spread of AMR. Upper respiratory tract infections (URIs) are one of the most common conditions treated by antibiotics, even if unnecessary as in cases of viral infections and self-limited conditions which represent the most cases of URIs. Investigating physicians' knowledge, attitudes, and practice regarding antibiotic prescriptions in children with acute URIs may reflect the problem of antibiotic over prescription. This study aims to assess the problem in our community and provide information for further planning of appropriate interventions to optimize antibiotic prescriptions. METHODS This is a cross-sectional study for all non-specialized physicians dealing with acute upper respiratory tract infections (URIs) in pediatrics sittings in Assiut district, Egypt. We used a self-administered questionnaire to assess physicians' knowledge, attitudes, and practice. In addition, four clinical vignettes addressing different URI scenarios were included in the questionnaire to assess the patterns of antibiotic prescriptions in common cases. RESULTS Our study included 153 physicians whose mean age was 32.2 ± 8.7, most of whom were pediatric residents in different health institutes in Assiut district. They had good knowledge as out of the 17 knowledge questions,the mean number of correct answers was 12.4 ± 2.9. Regarding their attitudes, mean attitude scores for inappropriate antibiotic prescribing were low. However, of those scores, the responsibility of others had the highest score (3.8 ± 0.61). Prescribing practice in special conditions of URIs showed that 80% of participants prescribed antibiotics if fever continued for more than five days and 61.4% if the child had a yellowish or greenish nasal discharge. Among 612 clinical vignettes, 326 contained antibiotic prescriptions (53.3%), and appropriate antibiotic prescriptions represented only 8.3% overall. CONCLUSIONS Physicians dealing with acute URIs in outpatients' clinics in the Assiut district have good knowledge about antibiotic use and resistance and demonstrate a good attitude toward appropriate antibiotic use. Although the percentage of inappropriate prescriptions in clinical vignettes in high, more research is required to investigate the factors of antibiotic inappropriate prescribing practice and non-adherence to guidelines. Also, it is essential to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems.
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Affiliation(s)
- Mariam Taher Amin
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
| | - Mahmoud Attia Abd El Aty
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
| | - Sabra Mohamed Ahmed
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
| | - Ghada Omar Elsedfy
- Faculty of Medicine, Department of Pediatrics, Children’s Hospital, Assiut University, Assiut, Egypt
| | | | - Amira Fathy El-Gazzar
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
- Badr University, Cairo, Egypt
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11
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Staub MB, Pellegrino R, Gettler E, Johnson MC, Roumie CL, Grijalva CG, Reasoner K, Dittus RS, Hulgan T. Association of antibiotics with veteran visit satisfaction and antibiotic expectations for upper respiratory tract infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e100. [PMID: 36483414 PMCID: PMC9726549 DOI: 10.1017/ash.2022.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Veterans' Affairs (VA) healthcare providers perceive that Veterans expect and base visit satisfaction on receiving antibiotics for upper respiratory tract infections (URIs). No studies have tested this hypothesis. We sought to determine whether receiving and/or expecting antibiotics were associated with Veteran satisfaction with URI visits. METHODS This cross-sectional study included Veterans evaluated for URI January 2018-December 2019 in an 18-clinic ambulatory VA primary-care system. We evaluated Veteran satisfaction via the Patient Satisfaction Questionnaire Short Form (RAND Corporation), an 18-item 5-point Likert scale survey. Additional items assessed Veteran antibiotic expectations. Antibiotic receipt was determined via medical record review. We used multivariable regression to evaluate whether antibiotic receipt and/or Veteran antibiotic expectations were associated with satisfaction. Subgroup analyses focused on Veterans who accurately remembered antibiotic prescribing during their URI visit. RESULTS Of 1,329 eligible Veterans, 432 (33%) participated. Antibiotic receipt was not associated with differences in mean total satisfaction (adjusted score difference, 0.6 points; 95% confidence interval [CI], -2.1 to 3.3). However, mean total satisfaction was lower for Veterans expecting an antibiotic (adjusted score difference -4.4 points; 95% CI -7.2 to -1.6). Among Veterans who accurately remembered the visit and did not receive an antibiotic, those who expected an antibiotic had lower mean satisfaction scores than those who did not (unadjusted score difference, -16.6 points; 95% CI, -24.6 to -8.6). CONCLUSIONS Veteran expectations for antibiotics, not antibiotic receipt, are associated with changes in satisfaction with outpatient URI visits. Future research should further explore patient expectations and development of patient-centered and provider-focused interventions to change patient antibiotic expectations.
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Affiliation(s)
- Milner B. Staub
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachael Pellegrino
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin Gettler
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Morgan C. Johnson
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Christianne L. Roumie
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G. Grijalva
- Division of Pharmacoepidemiology, Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee (Present affiliation: Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina [E.G.])
| | - Kaitlyn Reasoner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S. Dittus
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Hulgan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Infectious Diseases Section, Medical Services, Tennessee Valley Healthcare System, Nashville, Tennessee
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12
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D’Hulster L, Abrams S, Bruyndonckx R, Anthierens S, Adriaenssens N, Butler CC, Verheij T, Goossens H, Little P, Coenen S. Nationwide implementation of online communication skills training to reduce overprescribing of antibiotics: a stepped-wedge cluster randomized trial in general practice. JAC Antimicrob Resist 2022; 4:dlac070. [PMID: 35774072 PMCID: PMC9240414 DOI: 10.1093/jacamr/dlac070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives Primary care is responsible for a large proportion of unnecessary antibiotic use, which is one of the main drivers of antibiotic resistance. Randomized trials have found that online communication skills training for GPs reduces antibiotic prescribing for respiratory infections. This study assesses the real-world effect of implementing online communication skills training in general practice. Methods In a closed cohort stepped-wedge cluster randomized trial all Belgian GPs were invited to participate in online communication skills training courses (TRACE and INTRO) and provided with linked patient information booklets. The primary outcome was the antibiotic prescribing rate per 1000 patient contacts. Intention-to-treat and per protocol analyses were performed. Trial registration at ClinicalTrials.gov: NCT03265028. Results In total, 118 487 observations from 10 375 GPs were included in the analysis. Overall, 299 (2.88%) GPs completed TRACE and 93 (0.90%) completed INTRO, 30 of which completed both. There was no effect of the national implementation of TRACE and INTRO on the population-level antibiotic prescribing rate (prescribing rate ratio [PRR] = 0.99 [95% CI: 0.97-1.02]). GPs who actually completed TRACE prescribed fewer antibiotic prescriptions (PRR = 0.93 [95% CI: 0.90-0.95]). Conclusions Inviting GPs to complete an online communication skills training course and providing them with the linked patient information booklets did not reduce antibiotic prescribing. However, GPs who completed TRACE prescribed 7% fewer antibiotics, especially during winter. This suggests a significant decrease in population-wide antibiotic consumption could be achieved by focusing on increasing the uptake of this intervention by identifying and overcoming barriers to participation.
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Affiliation(s)
- Leon D’Hulster
- National Institute for Health and Disability Insurance, Galileelaan 5/01, 1210 Brussels, Belgium
| | - Steven Abrams
- Global Health Institute, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), UHasselt, Diepenbeek, Belgium
| | - Robin Bruyndonckx
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), UHasselt, Diepenbeek, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Niels Adriaenssens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Theo Verheij
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Primary Care Research Centre, Aldermoor Health Centre, Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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13
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Martínez-González NA, Plate A, Jäger L, Senn O, Neuner-Jehle S. The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners. Antibiotics (Basel) 2022; 11:543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023] Open
Abstract
Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92-98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65-87%). Faced with intermediate CRP results, GPs preferred 3-5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Levy Jäger
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
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14
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Implementing point-of-care CRP testing for better diagnosis of acute respiratory infections. Br J Gen Pract 2022; 72:87-88. [PMID: 35091415 PMCID: PMC8813101 DOI: 10.3399/bjgp22x718517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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15
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Keller SC, Nassery N, Melia MT. The case for curriculum development in antimicrobial stewardship interventions. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e3. [PMID: 36310791 PMCID: PMC9615004 DOI: 10.1017/ash.2021.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 06/16/2023]
Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Najlla Nassery
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael T. Melia
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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16
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Gágyor I, Hay AD. Outcome selection in primary care antimicrobial stewardship research. J Antimicrob Chemother 2021; 77:7-12. [PMID: 34542632 DOI: 10.1093/jac/dkab347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/23/2021] [Indexed: 11/14/2022] Open
Abstract
Clinical and antimicrobial stewardship (AMS) outcomes are highly relevant to pragmatic primary care trials, reflecting aspects, such as persistent symptoms and relapses, or antibiotic use and antimicrobial resistance. Sometimes both can be equally important. We present evidence demonstrating the wide range of outcome measures used in previous primary care trials and observe that there are no agreed standards for their design. We describe AMS interventions and outcomes in terms of intervention types and targets, and we make recommendations for future research designs. Specifically, we argue that: (i) where co-primary outcomes are considered appropriate, investigators should pre-specify interpretation of conflicting results; (ii) intervention evaluation should ensure prescriptions from sources outside of the usual provider are included in any AMS effectiveness measure; (iii) where possible, outcomes should include antimicrobial resistance; (iv) in some contexts, it may be necessary to include the antibiotics used within the intervention as part of the outcome; and (v) patient involvement is needed to establish the principles investigators should use when deciding whether the AMS or clinical outcomes should be prioritized.
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Affiliation(s)
- Ildikó Gágyor
- University Hospital Würzburg, Department of General Practice, Würzburg, Germany
| | - Alastair D Hay
- Centre of Academic Primary Care, Population Health Sciences: Bristol Medical School, Bristol, UK
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17
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Böhmer F, Hornung A, Burmeister U, Köchling A, Altiner A, Lang H, Löffler C. Factors, Perceptions and Beliefs Associated with Inappropriate Antibiotic Prescribing in German Primary Dental Care: A Qualitative Study. Antibiotics (Basel) 2021; 10:987. [PMID: 34439037 PMCID: PMC8389002 DOI: 10.3390/antibiotics10080987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/21/2022] Open
Abstract
Dentists account for up to 10% of all prescribed antibiotics in primary care, with up to 80% being inappropriate. Targeted approaches to change prescription behavior are scarce. This study aimed at identifying specific barriers and facilitators for prudent antibiotic use in German dentistry by using qualitative methods. Nine in-depth interviews and two focus group discussions with another nine dentists were conducted and analyzed thematically. Dentists described being conflicted by the discordance of available treatment time and the necessity of thorough therapy. Lacking the opportunity of follow-up led to uncertainty. Dentists felt a lack of medical competency concerning prophylaxis for infectious endocarditis. A lack of empowerment to make therapeutic decisions interfered with guideline-conformity. The communication with fellow physicians is conflictual and improvement was wished for. In consequence, dentists felt pressure by potential medico-legal liability. Patients demanding quick and easy pain relief put extra strain on the interviewed dentists. Our hypotheses concord with preliminary data, mainly from the UK, but highlighted specifically medico-legal concerns and interprofessional communication as even greater barriers as described before. Tailored interventional concepts based on our findings may have the potential to lower antibiotic prescriptions in German primary dental care.
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Affiliation(s)
- Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany; (A.A.); (C.L.)
| | - Anne Hornung
- Rostock University Library, Rostock University Medical Center, 18059 Rostock, Germany;
| | - Ulrike Burmeister
- Department of Operative Dentistry and Periodontology, Rostock University Medical Center, 18057 Rostock, Germany; (U.B.); (H.L.)
| | - Anna Köchling
- Clinic for Psychosomatic Medicine and Psychotherapy, Rostock University Medical Center, 18147 Rostock, Germany;
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany; (A.A.); (C.L.)
| | - Hermann Lang
- Department of Operative Dentistry and Periodontology, Rostock University Medical Center, 18057 Rostock, Germany; (U.B.); (H.L.)
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany; (A.A.); (C.L.)
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18
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Shishido A, Otake S, Kimura M, Tsuzuki S, Fukuda A, Ishida A, Kasai M, Kusama Y. Effects of a nudge-based antimicrobial stewardship program in a pediatric primary emergency medical center. Eur J Pediatr 2021; 180:1933-1940. [PMID: 33558964 DOI: 10.1007/s00431-021-03979-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
Outpatient medical facilities tend to have high antimicrobial prescription rates and are therefore major targets for antimicrobial stewardship programs (ASPs). Pediatric primary emergency medical centers in Japan have difficulties in implementing conventional ASPs due to the low continuity of stewardship. Accordingly, there is a need to develop effective ASP models for these facilities. We conducted a single-center, quasi-experimental study to evaluate the effects of a nudge-based ASP in reducing unnecessary third-generation cephalosporin (3GC) prescriptions in a pediatric primary emergency care center (PEC). The implemented ASP utilizes monthly newsletters that report current antimicrobial use patterns and prescribing targets. We compared the monthly 3GC prescription numbers and proportions of unnecessary prescriptions before and after the ASP was implemented. The trends in 3GC prescriptions were examined using an interrupted time-series analysis. The numbers of patients before and after ASP implementation were 129,156 and 28,834, respectively. The number of unnecessary 3GC prescriptions decreased by 67.2% in the year after ASP implementation. The interrupted time-series analysis showed that the ASP was significantly associated with a reduction in 3GC prescriptions (regression coefficient - 0.58, P < 0.001).Conclusion: The nudge-based ASP was effective in reducing 3GC use in a Japanese PEC. This simple and inexpensive approach may have applications in other outpatient facilities. What is Known: • Outpatient medical facilities tend to have high antimicrobial prescription rates. Despite the development of several strategies for outpatient antimicrobial stewardship programs, these approaches have not sufficiently reduced antimicrobial use. What is New • Our nudge-based antimicrobial stewardship program using newsletters was shown to be a simple, inexpensive, and feasible method for reducing unnecessary antimicrobial use in a pediatric primary emergency care center. This may represent an effective antimicrobial stewardship strategy in Japanese outpatient facilities.
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Affiliation(s)
- Ayumi Shishido
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Shogo Otake
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Makoto Kimura
- Department of Pharmacy, Kobe Children's Primary Emergency Medical Center, 1-4-1, Wakinohama-Kaigandori, Tyuo-ku, Kobe, Hyogo, 651-0073, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, 1-21-1 Toyama Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Akiko Fukuda
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, 1-4-1, Wakinohama-Kaigandori, Tyuo-ku, Kobe, Hyogo, 651-0073, Japan
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Yoshiki Kusama
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, 1-21-1 Toyama Shinjuku-ku, Tokyo, 162-8655, Japan.
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Thi Thuy Do N, Greer RC, Lubell Y, Dittrich S, Vandendorpe M, Nguyen VA, Ngoc Thach P, Thi Dieu Ngan T, Van Kinh N, Hung Thai C, Dung LTK, Nguyen Thi Cam T, Nguyen TH, Nadjm B, van Doorn HR, Lewycka S. Implementation of C-reactive protein point of care testing to improve antibiotic targeting in respiratory illness in Vietnamese primary care (ICAT): a study protocol for a cluster randomised controlled trial. BMJ Open 2020; 10:e040977. [PMID: 33361164 PMCID: PMC7759760 DOI: 10.1136/bmjopen-2020-040977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION C-reactive protein (CRP), a biomarker of infection, has been used widely in high-income settings to guide antibiotic treatment in patients presenting with respiratory illnesses in primary care. Recent trials in low- and middle-income countries showed that CRP testing could safely reduce antibiotic use in patients with non-severe acute respiratory infections (ARIs) and fever in primary care. The studies, however, were conducted in a research-oriented context, with research staff closely monitoring healthcare behaviour thus potentially influencing healthcare workers' prescribing practices. For policy-makers to consider wide-scale roll-out, a pragmatic implementation study of the impact of CRP point of care (POC) testing in routine care is needed. METHODS AND ANALYSIS A pragmatic, cluster-randomised controlled trial, with two study arms, consisting of 24 commune health centres (CHC) in the intervention arm (provision of CRP tests with additional healthcare worker guidance) and 24 facilities acting as controls (routine care). Comparison between the treatment arms will be through logistic regression, with the treatment assignment as a fixed effect, and the CHC as a random effect. With 48 clusters, an average of 10 consultations per facility per week will result in approximately 520 over 1 year, and 24 960 in total (12 480 per arm). We will be able to detect a reduction of 12% to 23% or more in immediate antibiotic prescription as a result of the CRP POC intervention. The primary endpoint is the proportion of patient consultations for ARI resulting in immediate antibiotic prescription. Secondary endpoints include the proportion of all patients receiving an antibiotic prescription regardless of ARI diagnosis, frequency of re-consultation, subsequent antibiotic use when antibiotics are not prescribed, referral and hospitalisation. ETHICS AND DISSEMINATION The study protocol was approved by the Oxford University Tropical Research Ethics Committee (OxTREC, Reference: 53-18), and the ethical committee of the National Hospital for Tropical Diseases in Vietnam (Reference:07/HDDD-NDTW/2019). Results from this study will be disseminated via meetings with stakeholders, conferences and publications in peer-reviewed journals. Authorship and reporting of this work will follow international guidelines. TRIAL REGISTRATION DETAILS NCT03855215; Pre-results.
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Affiliation(s)
| | - Rachel Claire Greer
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabine Dittrich
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Malaria/Fever Program, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Maida Vandendorpe
- Malaria/Fever Program, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Van Anh Nguyen
- Foundation for Innovative New Diagnostics (FIND), Hanoi, Vietnam
| | | | | | | | - Cao Hung Thai
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | - Le Thi Kim Dung
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | | | | | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- Clinical Services Department, MRC Unit The Gambia at The London School of Hygiene, Banjul, Gambia
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sonia Lewycka
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University of Auckland, Auckland, New Zealand
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20
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Eley CV, Sharma A, Lee H, Charlett A, Owens R, McNulty CAM. Effects of primary care C-reactive protein point-of-care testing on antibiotic prescribing by general practice staff: pragmatic randomised controlled trial, England, 2016 and 2017. ACTA ACUST UNITED AC 2020; 25. [PMID: 33153517 PMCID: PMC7645970 DOI: 10.2807/1560-7917.es.2020.25.44.1900408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background C-reactive protein (CRP) testing can be used as a point-of-care test (POCT) to guide antibiotic use for acute cough. Aim We wanted to determine feasibility and effect of introducing CRP POCT in general practices in an area with high antibiotic prescribing for patients with acute cough and to evaluate patients’ views of the test. Methods We used a McNulty–Zelen cluster pragmatic randomised controlled trial design in general practices in Northern England. Eight intervention practices accepted CRP testing and eight control practices maintained usual practice. Data collection included process evaluation, patient questionnaires, practice audit and antibiotic prescribing data. Results Eight practices with over 47,000 patient population undertook 268 CRP tests over 6 months: 78% of patients had a CRP < 20 mg/L, 20% CRP 20–100 mg/L and 2% CRP > 100 mg/L, where 90%, 22% and 100%, respectively, followed National Institute for Health and Care Excellence (NICE) antibiotic prescribing guidance. Patients reported that CRP testing was comfortable (88%), convenient (84%), useful (92%) and explained well (85%). Patients believed CRP POCT aided clinical diagnosis, provided quick results and reduced unnecessary antibiotic use. Intervention practices had an estimated 21% reduction (95% confidence interval: 0.46–1.35) in the odds of prescribing for cough compared with the controls, a non-significant but clinically relevant reduction. Conclusions In routine general practice, CRP POCT use was variable. Non-significant reductions in antibiotic prescribing may reflect small sample size due to non-use of tests. While CRP POCT may be useful, primary care staff need clearer CRP guidance and action planning according to NICE guidance.
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Affiliation(s)
| | - Anita Sharma
- An NHS Clinical Commissioning Group, Greater Manchester, United Kingdom
| | - Hazel Lee
- An NHS Clinical Commissioning Group, Greater Manchester, United Kingdom
| | - Andre Charlett
- Statistics Unit, Public Health England, London, United Kingdom
| | - Rebecca Owens
- Primary Care Unit, Public Health England, Gloucester, United Kingdom
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Martínez-González NA, Keizer E, Plate A, Coenen S, Valeri F, Verbakel JYJ, Rosemann T, Neuner-Jehle S, Senn O. Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials. Antibiotics (Basel) 2020; 9:antibiotics9090610. [PMID: 32948060 PMCID: PMC7559694 DOI: 10.3390/antibiotics9090610] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/16/2022] Open
Abstract
C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, PO Box 4466, CH-6002 Lucerne, Switzerland
- Correspondence:
| | - Ellen Keizer
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp-Campus Drie Eiken, Doornstraat 331, 2610 Antwerp (Wilrijk), Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp-Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp (Wilrijk), Belgium
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Jan Yvan Jos Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Kapucijnenvoer 33, 3000 Leuven, Belgium;
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
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22
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Avent ML, Cosgrove SE, Price-Haywood EG, van Driel ML. Antimicrobial stewardship in the primary care setting: from dream to reality? BMC FAMILY PRACTICE 2020; 21:134. [PMID: 32641063 PMCID: PMC7346425 DOI: 10.1186/s12875-020-01191-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.
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Affiliation(s)
- M L Avent
- Statewide Antimicrobial Stewardship Program, Queensland Health, Brisbane, Australia.
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Australia.
| | - S E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E G Price-Haywood
- Ochsner Health System, Center for Outcomes and Health Services Research, New Orleans, Louisiana, USA
- Ochnser Clinical School, The University of Queensland, New Orleans, Louisiana, USA
| | - M L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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23
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Haverfield MC, Tierney A, Schwartz R, Bass MB, Brown-Johnson C, Zionts DL, Safaeinili N, Fischer M, Shaw JG, Thadaney S, Piccininni G, Lorenz KA, Asch SM, Verghese A, Zulman DM. Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. J Gen Intern Med 2020; 35:2107-2117. [PMID: 31919725 PMCID: PMC7351919 DOI: 10.1007/s11606-019-05525-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 10/16/2019] [Accepted: 10/25/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience). METHODS We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes. RESULTS Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands. DISCUSSION Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.
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Affiliation(s)
- Marie C Haverfield
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA. .,Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Research and Policy (CHRP), Stanford, CA, USA.
| | - Aaron Tierney
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Rachel Schwartz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Research and Policy (CHRP), Stanford, CA, USA
| | | | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Dani L Zionts
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Nadia Safaeinili
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Meredith Fischer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sonoo Thadaney
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Karl A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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24
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Lee C, Jafari M, Brownbridge R, Phillips C, Vanstone JR. The viral prescription pad - a mixed methods study to determine the need for and utility of an educational tool for antimicrobial stewardship in primary health care. BMC FAMILY PRACTICE 2020; 21:42. [PMID: 32087685 PMCID: PMC7035666 DOI: 10.1186/s12875-020-01114-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/18/2020] [Indexed: 12/17/2022]
Abstract
Background In order to combat rising rates of antimicrobial resistant infections, it is vital that antimicrobial stewardship become embedded in primary health care (PHC). Despite the high use of antimicrobials in PHC settings, there is a lack of data regarding the integration of antimicrobial stewardship programs (ASP) in non-hospital settings. Our research aimed to determine which antimicrobial stewardship interventions are optimal to introduce into PHC clinics beginning to engage with an ASP, as well as how to optimize those interventions. This work became focused specifically around management of viral upper respiratory tract infections (URTIs), as these infections are one of the main sources of inappropriate antibiotic use. Methods This mixed methods study of sequential explanatory design was developed through three research projects over 3 years in Regina, Saskatchewan, Canada. First, a survey of PHC providers was performed to determine their perceived needs from a PHC-based ASP. From this work, a “viral prescription pad” was developed to provide a tool to help PHC providers engage in patient education regarding appropriate antimicrobial use, specifically for URTIs. Next, interviews were performed with family physicians to discuss their perceived utility of this tool. Finally, we performed a public survey to determine preferences for the medium by which information is received regarding symptom management for viral URTIs. Results The majority of PHC providers responding to the initial survey indicated they were improperly equipped with tools to aid in promoting conversations with patients and providing education about the appropriate use of antimicrobials. Following dissemination of the viral prescription pad and semi-structured interviews with family physicians, the viral prescription pad was deemed to be a useful educational tool. However, about half of the physicians interviewed indicated they did not actually provide a viral prescription to patients when providing advice on symptom management for viral URTIs. When asked about their preferences, 76% of respondents to the public survey indicated they would prefer to receive written or a combination of verbal and written information in this circumstance. Conclusions PHC providers indicated a need for educational tools to promote conversations with patients and provide education about the appropriate use of antimicrobials. Viral prescription pads were regarded by family physicians and patients as useful tools in facilitating discussion on the appropriate use of antimicrobials. PHC providers should exercise caution in opting out of providing written forms of information, as many respondents to the general public survey indicated their preference in receiving both verbal and written information.
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Affiliation(s)
- Christine Lee
- College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK, S7N 2Z4, Canada
| | - Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, 3401B Pasqua St., Regina, SK, S4S 7K9, Canada
| | - Regan Brownbridge
- College of Medicine, University of Saskatchewan, 107 Wiggins Rd., Saskatoon, SK, S7N 5E5, Canada
| | - Casey Phillips
- Antimicrobial Stewardship Program, Saskatchewan Health Authority - Regina Area, 4B35, 1440 - 14th Ave., Regina, SK, S4P 0W5, Canada
| | - Jason R Vanstone
- Stewardship and Clinical Appropriateness, Saskatchewan Health Authority - Regina Area, 4B35, 1440 - 14th Ave., Regina, SK, S4P 0W5, Canada.
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25
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Llor C, Bjerrum L, Molero JM, Moragas A, González López-Valcárcel B, Monedero MJ, Gómez M, Cid M, Alcántara JDD, Cots JM, Ribas JM, García G, Ortega J, Pineda V, Guerra G, Munuera S. Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections. J Antimicrob Chemother 2019; 73:2215-2222. [PMID: 29718420 DOI: 10.1093/jac/dky137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/20/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives Few studies have evaluated the long-term effects of educational interventions on antibiotic prescription and the results are controversial. This study was aimed at assessing the effect of a multifaceted practice-based intervention carried out 6 years earlier on current antibiotic prescription for respiratory tract infections (RTIs). Methods The 210 general practitioners (GPs) who completed the first two registrations in 2008 and 2009 were invited to participate in a third registration. The intervention held before the second registration consisted of discussion about the first registration of results, appropriate use of antibiotics for RTIs, patient brochures, a workshop and the provision of rapid tests. As in the previous registrations, GPs were instructed to complete a template for all the patients with RTIs during 15 working days in 2015. A new group of GPs from the same areas was also invited to participate and acted as controls. A multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable. Results A total of 121 GPs included in the 2009 intervention (57.6%) and 117 control GPs registered 22 247 RTIs. On adjustment for covariables, compared with the antibiotic prescription observed just after the intervention, GPs assigned to intervention prescribed slightly more antibiotics 6 years later albeit without statistically significant differences (OR 1.08, 95% CI 0.89-1.31, P = 0.46), while GPs in the control group prescribed significantly more antibiotics (OR 2.74, 95% CI 2.09-3.59, P < 0.001). Conclusions This study shows that a single multifaceted intervention continues to reduce antibiotic prescribing 6 years later.
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Affiliation(s)
- Carl Llor
- Via Roma Health Centre, Barcelona, Spain
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Ana Moragas
- University Rovira i Virgili, Jaume I Health Centre, Tarragona, Spain
| | | | | | | | | | | | - Josep M Cots
- University of Barcelona, La Marina Health Centre, Barcelona, Spain
| | | | | | | | | | - Gloria Guerra
- Escaleritas Health Centre, Las Palmas de Gran Canaria, Spain
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26
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Butler CC, Gillespie D, White P, Bates J, Lowe R, Thomas-Jones E, Wootton M, Hood K, Phillips R, Melbye H, Llor C, Cals JWL, Naik G, Kirby N, Gal M, Riga E, Francis NA. C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations. N Engl J Med 2019; 381:111-120. [PMID: 31291514 DOI: 10.1056/nejmoa1803185] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). RESULTS A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was -0.19 points (two-sided 90% CI, -0.33 to -0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation. CONCLUSIONS CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473.).
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Affiliation(s)
- Christopher C Butler
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - David Gillespie
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Patrick White
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Janine Bates
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Rachel Lowe
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Emma Thomas-Jones
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Mandy Wootton
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Kerenza Hood
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Rhiannon Phillips
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Hasse Melbye
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Carl Llor
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Jochen W L Cals
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Gurudutt Naik
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Nigel Kirby
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Micaela Gal
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Evgenia Riga
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
| | - Nick A Francis
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King's College, London (P.W.) - all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø-the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.)
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27
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Rowe TA, Linder JA. Novel approaches to decrease inappropriate ambulatory antibiotic use. Expert Rev Anti Infect Ther 2019; 17:511-521. [DOI: 10.1080/14787210.2019.1635455] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Theresa A. Rowe
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A. Linder
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
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28
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Molero JM, Moragas A, González López-Valcárcel B, Bjerrum L, Cots JM, Llor C. Reducing antibiotic prescribing for lower respiratory tract infections 6 years after a multifaceted intervention. Int J Clin Pract 2019; 73:e13312. [PMID: 30664320 DOI: 10.1111/ijcp.13312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/21/2018] [Accepted: 01/18/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS Few studies have evaluated the long-term impact of interventions on antibiotic prescription for lower respiratory tract infections (LRTI). This study was aimed at evaluating the use of antibiotics prescribed for LRTIs by general practitioners (GP) who underwent a multifaceted intervention carried out 6 years earlier. METHODS General practitioners who had completed two registrations in 2008 and 2009 were again invited to participate in a third audit-based study in 2015. A multifaceted intervention was held 1-3 months before the second registration. A new group of GPs with no previous training on the rational use of antibiotics were also invited to participate and acted as controls. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable. RESULTS A total of 121 GPs of the 210 who underwent the intervention (57.6%) and 117 control GPs registered 4333 episodes of LRTIs. On adjustment for covariables, compared with the antibiotic prescription for LRTIs observed just after the intervention, antibiotic prescription slightly increased 6 years later among GPs who had undergone the intervention (OR 1.17, 95% CI 0.95-1.43), while control GPs prescribed significantly more antibiotics (OR 2.31, 95% CI 1.62-3.29). However, withholding antibiotic prescribing with C-reactive protein (CRP) values <10 mg/L was more frequently observed just after the intervention compared 6 years later (12.7% vs 32.2%; P < 0.01). CONCLUSIONS Antibiotic prescribing for LRTIs remains low 6 years after an intervention, although GPs are less confident to withhold antibiotic therapy in patients with low CRP levels.
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Affiliation(s)
- José M Molero
- San Andrés Primary Health Centre, Department Preventive Medicine, University Rey Juan Carlos, Madrid, Spain
| | - Ana Moragas
- Jaume I Health Centre, University Rovira i Virgili, Tarragona, Spain
| | - Beatriz González López-Valcárcel
- Department of Quantitative Methods for Economics and Management, University of Las Palmas, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josep M Cots
- La Marina Health Centre, University of Barcelona, Barcelona, Spain
| | - Carl Llor
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Via Roma Health Centre, University Institute in Primary Care Research Jordi Gol, Barcelona, Spain
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29
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Little P, Stuart B, Francis N, Douglas E, Tonkin-Crine S, Anthierens S, Cals JWL, Melbye H, Santer M, Moore M, Coenen S, Butler CC, Hood K, Kelson M, Godycki-Cwirko M, Mierzecki A, Torres A, Llor C, Davies M, Mullee M, O'Reilly G, van der Velden A, Geraghty AWA, Goossens H, Verheij T, Yardley L. Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial. Ann Fam Med 2019; 17:125-132. [PMID: 30858255 PMCID: PMC6411389 DOI: 10.1370/afm.2356] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial. METHODS A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months. RESULTS Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively). CONCLUSIONS Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye).
| | - Beth Stuart
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Nick Francis
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Elaine Douglas
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Sarah Tonkin-Crine
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Sibyl Anthierens
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Jochen W L Cals
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Hasse Melbye
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Miriam Santer
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Samuel Coenen
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Chris C Butler
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Kerenza Hood
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Mark Kelson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Maciek Godycki-Cwirko
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Artur Mierzecki
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Antoni Torres
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Carl Llor
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Melanie Davies
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Gilly O'Reilly
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Alike van der Velden
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Adam W A Geraghty
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Herman Goossens
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Theo Verheij
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Lucy Yardley
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
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Haenssgen MJ, Charoenboon N, Do NTT, Althaus T, Khine Zaw Y, Wertheim HFL, Lubell Y. How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions. Trials 2019; 20:111. [PMID: 30736818 PMCID: PMC6368827 DOI: 10.1186/s13063-019-3215-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 01/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, “Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?” Methods We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients’ and healthcare workers’ adherence to the biomarker test results, and patient exclusion to gauge the potential “impact” of CRP point-of-care testing on the population level. Results We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system. Conclusions Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment. Trial registration ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013. Electronic supplementary material The online version of this article (10.1186/s13063-019-3215-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco J Haenssgen
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK. .,CABDyN Complexity Centre, Saïd Business School, University of Oxford, Park End Street, Oxford, OX1 1HP, UK. .,Global Sustainable Development, University of Warwick, Ramphal Building, Coventry, CV4 7AM, UK. .,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Nga T T Do
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Yuzana Khine Zaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Heiman F L Wertheim
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam.,Medical Microbiology Department, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, 6525, Netherlands
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
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31
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Wei X, Zhang Z, Hicks JP, Walley JD, King R, Newell JN, Yin J, Zeng J, Guo Y, Lin M, Upshur REG, Sun Q. Long-term outcomes of an educational intervention to reduce antibiotic prescribing for childhood upper respiratory tract infections in rural China: Follow-up of a cluster-randomised controlled trial. PLoS Med 2019; 16:e1002733. [PMID: 30721234 PMCID: PMC6363140 DOI: 10.1371/journal.pmed.1002733] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing causes widespread serious health problems. To reduce prescribing of antibiotics in Chinese primary care to children with upper respiratory tract infections (URTIs), we developed an intervention comprising clinical guidelines, monthly prescribing review meetings, doctor-patient communication skills training, and education materials for caregivers. We previously evaluated our intervention using an unblinded cluster-randomised controlled trial (cRCT) in 25 primary care facilities across two rural counties. When our trial ended at the 6-month follow-up period, we found that the intervention had reduced antibiotic prescribing for childhood URTIs by 29 percentage points (pp) (95% CI -42 to -16). METHODS AND FINDINGS In this long-term follow-up study, we collected our trial outcomes from the one county (14 facilities and 1:1 cluster randomisation ratio) that had electronic records available 12 months after the trial ended, at the 18-month follow-up period. Our primary outcome was the antibiotic prescription rate (APR)-the percentage of outpatient prescriptions containing any antibiotic(s) for children aged 2 to 14 years who had a primary diagnosis of a URTI and had no other illness requiring antibiotics. We also conducted 15 in-depth interviews to understand how interventions were sustained. In intervention facilities, the APR was 84% (1,171 out of 1,400) at baseline, 37% (515 out of 1,380) at 6 months, and 54% (2,748 out of 5,084) at 18 months, and in control facilities, it was 76% (1,063 out of 1,400), 77% (1,084 out of 1,400), and 75% (2,772 out of 3,685), respectively. After adjusting for patient and prescribing doctor covariates, compared to the baseline intervention-control difference, the difference at 6 months represented a 6-month intervention-arm reduction in the APR of -49 pp (95% CI -63 to -35; P < 0.0001), and compared to the baseline difference, the difference at 18 months represented an 18-month intervention-arm reduction in the APR of -36 pp (95% CI -55 to -17; P < 0.0001). Compared to the 6-month intervention-control difference, the difference at 18 months represented no change in the APR: 13 pp (95% CI -7 to 33; P = 0.21). Factors reported to sustain reductions in antibiotic prescribing included doctors' improved knowledge and communication skills and focused prescription review meetings, whereas lack of supervision and monitoring may be associated with relapse. Key limitations were not including all clusters from the trial and not collecting returned visits or sepsis cases. CONCLUSIONS Our intervention was associated with sustained and substantial reductions in antibiotic prescribing at the end of the intervention period and 12 months later. Our intervention may be adapted to similar resource-poor settings. TRIAL REGISTRATION ISRCTN registry ISRCTN14340536.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Joseph P. Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - John D. Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - James N. Newell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Jia Yin
- School of Health Care Management, Shandong University, Jinan, China
- Key Laboratory of Health Economics and Policy Research, National Health Commission, Jinan, China
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Yan Guo
- School of Public Health, Peking University, Beijing, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Ross E. G. Upshur
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Qiang Sun
- School of Health Care Management, Shandong University, Jinan, China
- Key Laboratory of Health Economics and Policy Research, National Health Commission, Jinan, China
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Verbakel JY, Lee JJ, Goyder C, Tan PS, Ananthakumar T, Turner PJ, Hayward G, Van den Bruel A. Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis. BMJ Open 2019; 9:e025036. [PMID: 30782747 PMCID: PMC6361331 DOI: 10.1136/bmjopen-2018-025036] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/12/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care. DESIGN This was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied. DATA EXTRACTION Data were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool. RESULTS 11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission. CONCLUSIONS Performing a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes. PROSPERO REGISTRATION NUMBER CRD42016035426; Results.
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Affiliation(s)
- Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Clare Goyder
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Thanusha Ananthakumar
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Philip J Turner
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
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Petel D, Winters N, Gore GC, Papenburg J, Beltempo M, Lacroix J, Fontela PS. Use of C-reactive protein to tailor antibiotic use: a systematic review and meta-analysis. BMJ Open 2018; 8:e022133. [PMID: 30580258 PMCID: PMC6318522 DOI: 10.1136/bmjopen-2018-022133] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES C-reactive protein (CRP) has been proposed to guide the use of antibiotics. However, study results are controversial regarding the benefits of such a strategy. We synthesised the evidence of CRP-based algorithms on antibiotic treatment initiation and on antibiotic treatment duration in adults, children and neonates, as well as their safety profile. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, EMBASE, CENTRAL and CINAHL from inception to 20 July 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included randomised controlled trials (RCTs), non-RCTs and cohort studies (prospective or retrospective) investigating CRP-guided antibiotic use in adults, children and neonates with bacterial infection. DATA EXTRACTION AND SYNTHESIS Two researchers independently screened all identified studies and retrieved the data. Outcomes were duration of antibiotic use, antibiotic initiation, mortality, infection relapse and hospitalisation. We assessed the quality of the included studies using the Cochrane Collaboration's tool (RCTs), and A Cochrane Risk Of Bias Assessment Tool: for Non-Randomized Studies of Interventions and the Newcastle-Ottawa scale (non-RCTs). We analysed our results using descriptive statistics and random effects models. RESULTS Of 11 165 studies screened, 15 were included. In five RCTs in adult outpatients, the risk difference for antibiotic treatment initiation in the CRP group was -7% (95% CI: -10% to -4%), with no difference in hospitalisation rate. In neonates, CRP-based algorithms shortened antibiotic treatment duration by -1.45 days (95% CI -2.61 to -0.28) in two RCTs, and by -1.15 days (95% CI -2.06 to -0.24) in two cohort studies, with no differences in mortality or infection relapse. CONCLUSION The use of CRP-based algorithms seems to reduce antibiotic treatment duration in neonates, as well as to decrease antibiotic treatment initiation in adult outpatients. However, further high-quality studies are still needed to assess safety, particularly in children outside the neonatal period. PROSPERO REGISTRATION NUMBER CRD42016038622.
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Affiliation(s)
- Dara Petel
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Nicholas Winters
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Genevieve C Gore
- Schulich Library of Physical Sciences, Life Sciences and Engineering, Montreal, Canada
| | - Jesse Papenburg
- Division of Pediatric Infectious Diseases, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Marc Beltempo
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Patricia S Fontela
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Abstract
The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.
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Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
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Poole NM. Judicious antibiotic prescribing in ambulatory pediatrics: Communication is key. Curr Probl Pediatr Adolesc Health Care 2018; 48:306-317. [PMID: 30389361 DOI: 10.1016/j.cppeds.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Children in outpatient clinics are prescribed over 15 million courses of unnecessary antibiotics annually. Clinicians have identified parent pressure for antibiotics, parent satisfaction, and time constraints as the primary drivers of unnecessary antibiotic prescribing. Over the past decade, parents have become more aware that antibiotics only treat bacterial infections, yet continue to report an expectation for antibiotics in 50-65% of acute care visits. Parental expectations for antibiotics stem from parental concerns about symptom severity and a desire to alleviate symptoms. Clinicians can address parental concerns when they assess the severity of illness through a physical exam, provide a clear explanation for the symptoms, recommend ways to alleviate the symptoms, and provide council on when to be concerned. When clinicians fail to address parental concerns, parents are more likely to challenge the diagnosis or treatment recommendations, clinicians are more likely to perceive that parent as expecting an antibiotic, and antibiotics are significantly more likely to be prescribed. Parents that expect antibiotics are more likely to communicate using a 'candidate diagnosis' (e.g., "Johnny has strep throat.") and resist the diagnosis or treatment given. Clinicians can recognize these parental communication patterns and use specific communication practices shown to decrease unnecessary antibiotic prescribing. When parents expect antibiotics, clinicians should (1) review physical exam findings using 'no problem' commentary (e.g., "This ear is just a little red."), (2) deliver a specific diagnosis (e.g., avoid 'a virus'), (3) use a two-part negative/positive treatment recommendation (e.g., "On the one hand, antibiotics will not help. On the other hand, ibuprofen can help with pain."), and (4) provide a contingency plan. Clinicians should feel comfortable discussing the risks and benefits of antibiotics. Effective communication between parents and clinicians in outpatient clinics leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.
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Affiliation(s)
- Nicole M Poole
- Seattle Children's Research Institute, Seattle, WA, United States; University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States.
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Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts. Pediatrics 2018; 141:peds.2017-4124. [PMID: 29793986 DOI: 10.1542/peds.2017-4124] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Brian A Smith
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
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Keller SC, Tamma PD, Cosgrove SE, Miller MA, Sateia H, Szymczak J, Gurses AP, Linder JA. Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review. J Am Board Fam Med 2018; 31:417-430. [PMID: 29743225 PMCID: PMC6013839 DOI: 10.3122/jabfm.2018.03.170225] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/28/2017] [Accepted: 01/04/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. METHODS We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. RESULTS Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. CONCLUSIONS A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS.
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Affiliation(s)
- Sara C Keller
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL).
| | - Pranita D Tamma
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Sara E Cosgrove
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Melissa A Miller
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Heather Sateia
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Julie Szymczak
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Ayse P Gurses
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Jeffrey A Linder
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
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Köchling A, Löffler C, Reinsch S, Hornung A, Böhmer F, Altiner A, Chenot JF. Reduction of antibiotic prescriptions for acute respiratory tract infections in primary care: a systematic review. Implement Sci 2018; 13:47. [PMID: 29554972 PMCID: PMC5859410 DOI: 10.1186/s13012-018-0732-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 02/27/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although most respiratory tract infections (RTIs) are due to viral infections, they cause the majority of antibiotic (Abx) prescriptions in primary care. This systematic review summarises the evidence on the effectiveness of interventions in primary care aiming to reduce Abx prescriptions in patients ≥ 13 years for acute RTI. METHODS We searched the databases "MEDLINE/PubMed" and "Cochrane Library" for the period from January 1, 2005, to August 31, 2016, for randomised controlled trials (RCTs) in primary care aiming at the reduction of Abx prescriptions for patients suffering from RTI. Out of 690 search results, 67 publications were retrieved and 17 RCTs were included. We assumed an absolute change of 10% as minimal important change. RESULTS Twelve out of 17 included RCTs showed statistically significant lower Abx prescription rates in the intervention groups, but only six of them reported a clinically relevant reduction according to our definition. Communication skills training (CST) and point-of-care testing (POCT) were the most effective interventions. Pre-intervention Abx prescription rates varied between 13.5% and 80% and observed reductions ranged from 1.5 to 23.3%. Studies with post-intervention rates lower than 20% had no significant effects. Post-intervention observation periods ranged from 2 weeks up to 3.5 years. The design of the trials was heterogeneous precluding calculation of pooled effect size. The reporting of many RCTs was poor. CONCLUSIONS CST and POCT alone or as adjunct can reduce antibiotic prescriptions for RTI. Eleven out of 17 trials were not successfully reducing Abx prescription rates according to our definition of minimal important change. However, five of them reported a statistically significant reduction. Trials with initially lower prescription rates were less likely to be successful. Future trials should investigate sustainability of intervention effects for a longer time period. The generalisability of findings was limited due to heterogeneous designs and outcome measures. Therefore, a consensus of designing and reporting of studies aiming at reducing antibiotic prescriptions is urgently needed to generate meaningful evidence.
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Affiliation(s)
- Anna Köchling
- Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Center, Rostock, Germany
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Christin Löffler
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Stefan Reinsch
- Department of Pediatric Pneumology, Immunology & Intensive Care Medicine Charité, University Medical Center Berlin, Berlin, Germany
| | - Anne Hornung
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University Medical Center Rostock, Rostock, Germany
| | - Femke Böhmer
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Attila Altiner
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Jean-François Chenot
- Institute for Community Medicine—Department of Family Medicine, University Greifswald, Greifswald, Germany
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Odermatt J, Friedli N, Kutz A, Briel M, Bucher HC, Christ-Crain M, Burkhardt O, Welte T, Mueller B, Schuetz P. Effects of procalcitonin testing on antibiotic use and clinical outcomes in patients with upper respiratory tract infections. An individual patient data meta-analysis. Clin Chem Lab Med 2017; 56:170-177. [PMID: 28665787 DOI: 10.1515/cclm-2017-0252] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Several trials found procalcitonin (PCT) helpful for guiding antibiotic treatment in patients with lower respiratory tract infections and sepsis. We aimed to perform an individual patient data meta-analysis on the effects of PCT guided antibiotic therapy in upper respiratory tract infections (URTI). METHODS A comprehensive search of the literature was conducted using PubMed (MEDLINE) and Cochrane Library to identify relevant studies published until September 2016. We reanalysed individual data of adult URTI patients with a clinical diagnosis of URTI. Data of two trials were used based on PRISMA-IPD guidelines. Safety outcomes were (1) treatment failure defined as death, hospitalization, ARI-specific complications, recurrent or worsening infection at 28 days follow-up; and (2) restricted activity within a 14-day follow-up. Secondary endpoints were initiation of antibiotic therapy, and total days of antibiotic exposure. RESULTS In total, 644 patients with a follow up of 28 days had a final diagnosis of URTI and were thus included in this analysis. There was no difference in treatment failure (33.1% vs. 34.0%, OR 1.0, 95% CI 0.7-1.4; p=0.896) and days with restricted activity between groups (8.0 vs. 8.0 days, regression coefficient 0.2 (95% CI -0.4 to 0.9), p=0.465). However, PCT guided antibiotic therapy resulted in lower antibiotic prescription (17.8% vs. 51.0%, OR 0.2, 95% CI 0.1-0.3; p<0.001) and in a 2.4 day (95% CI -2.9 to -1.9; p<0.001) shorter antibiotic exposure compared to control patients. CONCLUSIONS PCT guided antibiotic therapy in the primary care setting was associated with reduced antibiotic exposure in URTI patients without compromising outcomes.
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Saliba-Gustafsson EA, Borg MA, Rosales-Klintz S, Nyberg A, StålsbyLundborg C. Maltese Antibiotic Stewardship Programme in the Community (MASPIC): protocol of a prospective quasiexperimental social marketing intervention. BMJ Open 2017; 7:e017992. [PMID: 28947463 PMCID: PMC5623537 DOI: 10.1136/bmjopen-2017-017992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/18/2017] [Accepted: 08/03/2017] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Antibiotic misuse is a key driver of antibiotic resistance. In 2015/2016, Maltese respondents reported the highest proportions of antibiotic consumption in Europe. Since antibiotics are prescription-only medicines in Malta, research on effective strategies targeting general practitioners' (GPs) knowledge and behaviour is needed. Multifaceted behaviour change (BC) interventions are likely to be effective. Social marketing (SM) can provide the tools to promote sustained BC; however, its utilisation in Europe is limited. This paper aims to describe the design and methods of a multifaceted SM intervention aimed at changing Maltese GPs' antibiotic prescribing behaviour for patients with acute respiratory tract infections (aRTIs). METHODS AND ANALYSIS This 4-year quasiexperimental intervention study will be carried out in Malta and includes three phases: preintervention, intervention and postintervention. The preintervention phase intends to gain insight into the practices and attitudes of GPs, pharmacists and parents through interviews, focus group discussions and antibiotic prescribing surveillance. A 6-month intervention targeting GPs will be implemented following assessment of their prescribing intention and readiness for BC. The intervention will likely comprise: prescribing guidelines, patient educational materials, delayed antibiotic prescriptions and GP education. Outcomes will be evaluated in the postintervention phase through questionnaires based on the theory of planned behaviour and stages-of-change theory, as well as postintervention surveillance. The primary outcome will be the antibiotic prescribing rate for all patients with aRTIs. Secondary outcomes will include the proportion of diagnosis-specific antibiotic prescription and symptomatic relief medication prescribed, and the change in GPs stage-of-change and their intention to prescribe antibiotics. ETHICS AND DISSEMINATION The project received ethical approval from the University of Malta's Research Ethics Committee. Should this intervention successfully decrease antibiotic prescribing, it may be scaled up locally and transferred to similar settings. TRIAL REGISTRATION NUMBER NCT03218930; Pre-results.
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Affiliation(s)
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | | | - Anna Nyberg
- Department of Marketing and Strategy, Stockholm School of Economics, Stockholm, Sweden
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Tonkin‐Crine SKG, Tan PS, van Hecke O, Wang K, Roberts NW, McCullough A, Hansen MP, Butler CC, Del Mar CB. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD012252. [PMID: 28881002 PMCID: PMC6483738 DOI: 10.1002/14651858.cd012252.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials. OBJECTIVES To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care. METHODS We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview. MAIN RESULTS We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications. AUTHORS' CONCLUSIONS We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.
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Affiliation(s)
- Sarah KG Tonkin‐Crine
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Pui San Tan
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Oliver van Hecke
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Kay Wang
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | | | - Christopher C Butler
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
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Gifford J, Vaeth E, Richards K, Siddiqui T, Gill C, Wilson L, DeLisle S. Decision support during electronic prescription to stem antibiotic overuse for acute respiratory infections: a long-term, quasi-experimental study. BMC Infect Dis 2017; 17:528. [PMID: 28760143 PMCID: PMC5537944 DOI: 10.1186/s12879-017-2602-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 07/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to support decision-making can reduce inappropriate antibiotic use for acute respiratory infections (ARI), but they may not be sustainable. The objective of the study is to evaluate the long-term effectiveness of a clinical decision-support system (CDSS) interposed at the time of electronic (e-) prescriptions for selected antibiotics. METHODS This is a retrospective, observational intervention study, conducted within a large, statewide Veterans Affairs health system. Participants are outpatients with an initial visit for ARI. A CDSS was deployed upon e-prescription of selected antibiotics during the study period. From 01/2004 to 05/2006 (pre-withdrawal period), the CDSS targeted azithromycin and the fluoroquinolone gatifloxacin. From 05/2006 to 12/2011 (post-withdrawal period), the CDSS was retained for azithromycin but withdrawn for the fluoroquinolone. A manual record review was conducted to determine concordance of antibiotic prescription with ARI treatment guidelines. RESULTS Of 1131 included ARI visits, 380 (33.6%) were guideline-concordant. For azithromycin, concordance did not change between the pre- and post-withdrawal periods, and adjusted odds of concordance was 8.8 for the full study period, compared to unrestricted antibiotics. For fluoroquinolones, guideline concordance decreased from 88.6% (39 of 44 visits) to 51.3% (59 of 115 visits), pre- vs. post-withdrawal periods (p < 0.005). The adjusted odds of concordance compared to "All Other Antibiotics" visits decreased from 24.4 (95% CI 9.0-66.3) pre-withdrawal to 5.5 (95% CI 3.5-8.8) post-withdrawal (p = .008). Concordance did not change between those same time periods for antibiotics that were never subjected to the intervention ("All Other Antibiotics"). CONCLUSIONS A CDSS interposed at the time of e-prescription of selected antibiotics can shift their use toward ARI treatment guidelines, and this effect can be maintained over the long term as long as the CDSS remains in place. Removal of the CDSS after 3.5 years of implementation resulted in a rise in guideline-discordant antibiotic use.
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Affiliation(s)
- Jeneen Gifford
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.,School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Elisabeth Vaeth
- Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | | | - Tariq Siddiqui
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.,School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Christine Gill
- School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | - Sylvain DeLisle
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA. .,School of Medicine, University of Maryland, Baltimore, MD, USA. .,Professor of Medicine and Clinical Sciences, University of Texas Southwestern, 8B, Building 2, Dallas VA Medical Center, 4500 S Lancaster Rd, Dallas, TX, 75216, USA.
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Verbal and non-verbal behaviour and patient perception of communication in primary care: an observational study. Br J Gen Pract 2016; 65:e357-65. [PMID: 26009530 DOI: 10.3399/bjgp15x685249] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Few studies have assessed the importance of a broad range of verbal and non-verbal consultation behaviours. AIM To explore the relationship of observer ratings of behaviours of videotaped consultations with patients' perceptions. DESIGN AND SETTING Observational study in general practices close to Southampton, Southern England. METHOD Verbal and non-verbal behaviour was rated by independent observers blind to outcome. Patients competed the Medical Interview Satisfaction Scale (MISS; primary outcome) and questionnaires addressing other communication domains. RESULTS In total, 275/360 consultations from 25 GPs had useable videotapes. Higher MISS scores were associated with slight forward lean (an 0.02 increase for each degree of lean, 95% confidence interval [CI] = 0.002 to 0.03), the number of gestures (0.08, 95% CI = 0.01 to 0.15), 'back-channelling' (for example, saying 'mmm') (0.11, 95% CI = 0.02 to 0.2), and social talk (0.29, 95% CI = 0.4 to 0.54). Starting the consultation with professional coolness ('aloof') was helpful and optimism unhelpful. Finishing with non-verbal 'cut-offs' (for example, looking away), being professionally cool ('aloof'), or patronising, ('infantilising') resulted in poorer ratings. Physical contact was also important, but not traditional verbal communication. CONCLUSION These exploratory results require confirmation, but suggest that patients may be responding to several non-verbal behaviours and non-specific verbal behaviours, such as social talk and back-channelling, more than traditional verbal behaviours. A changing consultation dynamic may also help, from professional 'coolness' at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end.
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Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016; 65:1-12. [PMID: 27832047 DOI: 10.15585/mmwr.rr6506a1] [Citation(s) in RCA: 358] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings. In 2014 and 2015, respectively, CDC released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management. The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic prescribing practices. Clinicians and leaders of outpatient clinics and health care systems can track antibiotic prescribing practices and regularly report these data back to clinicians. Clinicians can provide educational resources to patients and families on appropriate antibiotic use. Finally, leaders of outpatient clinics and health systems can provide clinicians with education aimed at improving antibiotic prescribing and with access to persons with expertise in antibiotic stewardship. Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings.
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Fleming-Dutra KE, Mangione-Smith R, Hicks LA. How to Prescribe Fewer Unnecessary Antibiotics: Talking Points That Work with Patients and Their Families. Am Fam Physician 2016; 94:200-202. [PMID: 27479620 PMCID: PMC6338216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Rita Mangione-Smith
- University of Washington and Seattle Children's Research Institute, Seattle, WA, USA
| | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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Lemme F, van Breukelen GJP, Berger MPF. Efficient treatment allocation in 2 × 2 cluster randomized trials, when costs and variances are heterogeneous. Stat Med 2016; 35:4320-4334. [PMID: 27271007 DOI: 10.1002/sim.7003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 04/29/2016] [Accepted: 05/09/2016] [Indexed: 11/05/2022]
Abstract
Typically, clusters and individuals in cluster randomized trials are allocated across treatment conditions in a balanced fashion. This is optimal under homogeneous costs and outcome variances. However, both the costs and the variances may be heterogeneous. Then, an unbalanced allocation is more efficient but impractical as the outcome variance is unknown in the design stage of a study. A practical alternative to the balanced design could be a design optimal for known and possibly heterogeneous costs and homogeneous variances. However, when costs and variances are heterogeneous, both designs suffer from loss of efficiency, compared with the optimal design. Focusing on cluster randomized trials with a 2 × 2 design, the relative efficiency of the balanced design and of the design optimal for heterogeneous costs and homogeneous variances is evaluated, relative to the optimal design. We consider two heterogeneous scenarios (two treatment arms with small, and two with large, costs or variances, or one small, two intermediate, and one large costs or variances) at each design level (cluster, individual, and both). Within these scenarios, we compute the relative efficiency of the two designs as a function of the extents of heterogeneity of the costs and variances, and the congruence (the cheapest treatment has the smallest variance) and incongruence (the cheapest treatment has the largest variance) between costs and variances. We find that the design optimal for heterogeneous costs and homogeneous variances is generally more efficient than the balanced design and we illustrate this theory on a trial that examines methods to reduce radiological referrals from general practices. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Francesca Lemme
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands.
| | | | - Martijn P F Berger
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
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Zou G, Wei X, Hicks JP, Hu Y, Walley J, Zeng J, Elsey H, King R, Zhang Z, Deng S, Huang Y, Blacklock C, Yin J, Sun Q, Lin M. Protocol for a pragmatic cluster randomised controlled trial for reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China. BMJ Open 2016; 6:e010544. [PMID: 27235297 PMCID: PMC4885273 DOI: 10.1136/bmjopen-2015-010544] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Irrational use of antibiotics is a serious issue within China and internationally. In 2012, the Chinese Ministry of Health issued a regulation for antibiotic prescriptions limiting them to <20% of all prescriptions for outpatients, but no operational details have been issued regarding policy implementation. This study aims to test the effectiveness of a multidimensional intervention designed to reduce the use of antibiotics among children (aged 2-14 years old) with acute upper respiratory infections in rural primary care settings in China, through changing doctors' prescribing behaviours and educating parents/caregivers. METHODS AND ANALYSIS This is a pragmatic, parallel-group, controlled, cluster-randomised superiority trial, with blinded evaluation of outcomes and data analysis, and un-blinded treatment. From two counties in Guangxi Province, 12 township hospitals will be randomised to the intervention arm and 13 to the control arm. In the control arm, the management of antibiotics prescriptions will continue through usual care via clinical consultations. In the intervention arm, a provider and patient/caregiver focused intervention will be embedded within routine primary care practice. The provider intervention includes operational guidelines, systematic training, peer review of antibiotic prescribing and provision of health education to patient caregivers. We will also provide printed educational materials and educational videos to patients' caregivers. The primary outcome is the proportion of all prescriptions issued by providers for upper respiratory infections in children aged 2-14 years old, which include at least one antibiotic. ETHICS AND DISSEMINATION The trial has received ethical approval from the Ethics Committee of Guangxi Provincial Centre for Disease Control and Prevention, China. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION NUMBER ISRCTN14340536; Pre-results.
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Affiliation(s)
- Guanyang Zou
- China Global Health Research and Development, Shenzhen, China
| | - Xiaolin Wei
- China Global Health Research and Development, Shenzhen, China
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Yanhong Hu
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Helen Elsey
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Yuanyuan Huang
- China Global Health Research and Development, Shenzhen, China
| | - Claire Blacklock
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jia Yin
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Qiang Sun
- Centre for Health Management and Policy, Shandong University, Jinan, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
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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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Avent ML, Hansen MP, Gilks C, Del Mar C, Halton K, Sidjabat H, Hall L, Dobson A, Paterson DL, van Driel ML. General Practitioner Antimicrobial Stewardship Programme Study (GAPS): protocol for a cluster randomised controlled trial. BMC FAMILY PRACTICE 2016; 17:48. [PMID: 27098971 PMCID: PMC4839086 DOI: 10.1186/s12875-016-0446-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/14/2016] [Indexed: 12/13/2022]
Abstract
Background There is a strong link between antibiotic consumption and the rate of antibiotic resistance. In Australia, the vast majority of antibiotics are prescribed by general practitioners, and the most common indication is for acute respiratory infections. The aim of this study is to assess if implementing a package of integrated, multifaceted interventions reduces antibiotic prescribing for acute respiratory infections in general practice. Methods/design This is a cluster randomised trial comparing two parallel groups of general practitioners in 28 urban general practices in Queensland, Australia: 14 intervention and 14 control practices. The protocol was peer-reviewed by content experts who were nominated by the funding organization. This study evaluates an integrated, multifaceted evidence-based package of interventions implemented over a six month period. The included interventions, which have previously been demonstrated to be effective at reducing antibiotic prescribing for acute respiratory infections, are: delayed prescribing; patient decision aids; communication training; commitment to a practice prescribing policy for antibiotics; patient information leaflet; and near patient testing with C-reactive protein. In addition, two sub-studies are nested in the main study: (1) point prevalence estimation carriage of bacterial upper respiratory pathogens in practice staff and asymptomatic patients; (2) feasibility of direct measures of antibiotic resistance by nose/throat swabbing. The main outcome data are from Australia’s national health insurance scheme, Medicare, which will be accessed after the completion of the intervention phase. They include the number of antibiotic prescriptions and the number of patient visits per general practitioner for periods before and during the intervention. The incidence of antibiotic prescriptions will be modelled using the numbers of patients as the denominator and seasonal and other factors as explanatory variables. Results will compare the change in prescription rates before and during the intervention in the two groups of practices. Semi-structured interviews will be conducted with the general practitioners and practice staff (practice nurse and/or practice manager) from the intervention practices on conclusion of the intervention phase to assess the feasibility and uptake of the interventions. An economic evaluation will be conducted to estimate the costs of implementing the package, and its cost-effectiveness in terms of cost per unit reduction in prescribing. Discussion The results on the effectiveness, cost-effectiveness, acceptability and feasibility of this package of interventions will inform the policy for any national implementation. Trial registration The GAPS trial is registered under the Australian New Zealand Clinical Trials Register, reference number: ACTRN12615001128583 (registered 26/10/2015).
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Affiliation(s)
- Minyon L Avent
- The University of Queensland, School of Public Health, Herston, QLD, 4006, Australia. .,The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4006, Australia.
| | - Malene Plejdrup Hansen
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4226, Australia
| | - Charles Gilks
- The University of Queensland, School of Public Health, Herston, QLD, 4006, Australia
| | - Chris Del Mar
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4226, Australia
| | - Kate Halton
- Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Kelvin Grove, QLD, 4059, Australia
| | - Hanna Sidjabat
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4006, Australia
| | - Lisa Hall
- Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Kelvin Grove, QLD, 4059, Australia
| | - Annette Dobson
- The University of Queensland, School of Public Health, Herston, QLD, 4006, Australia
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4006, Australia
| | - Mieke L van Driel
- The University of Queensland, Discipline of General Practice, School of Medicine, Herston, QLD, 4006, Australia
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Ferrat E, Le Breton J, Guéry E, Adeline F, Audureau E, Montagne O, Roudot-Thoraval F, Attali C, Le Corvoisier P, Renard V. Effects 4.5 years after an interactive GP educational seminar on antibiotic therapy for respiratory tract infections: a randomized controlled trial. Fam Pract 2016; 33:192-9. [PMID: 26797464 DOI: 10.1093/fampra/cmv107] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The few studies assessing long-term effects of educational interventions on antibiotic prescription have produced conflicting results. OBJECTIVES Our aim was to assess the effects after 4.5 years of an interactive educational seminar designed for GPs and focused on antibiotic therapy in respiratory tract infections (RTIs). The seminar was expected to decrease antibiotic prescriptions for any diagnosis. METHODS We conducted a randomized controlled parallel-group trial in a Paris suburb (France), with GPs as the randomization unit and prescriptions as the analysis unit. The intervention occurred in September 2004 and the final assessment in March 2009. Among 203 randomized GPs, 168 completed the study, 70 in the intervention group and 98 in the control group. Intervention GPs were randomized to attending only a 2-day interactive educational seminar on evidence-based guidelines about managing RTIs or also 1 day of problem-solving training. The primary outcome was the percentage of change in the proportion of prescriptions containing an antibiotic for any diagnosis in 2009 versus 2004. An intention-to-treat sensitivity analysis was performed using multiple imputation. RESULTS After 4.5 years, absolute changes in the primary outcome measure were -1.1% (95% confidence interval: -2.2 to 0.0) in the intervention group and +1.4% (0.3-2.6) in the control group, yielding an adjusted between-group difference of -2.2% (-2.7 to -1.7; P < 0.001). Both intervention modalities had significant effects, and multiple imputation produced similar results. CONCLUSIONS A single, standardized and interactive educational seminar targeting GPs significantly decreased antibiotic use for RTIs after 4.5 years.
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Affiliation(s)
- E Ferrat
- Department of General Practice, School of Medicine, Université Paris Est Créteil (UPEC), Creteil F-94000, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, A-TVB DHU, IMRB, Université Paris Est Créteil (UPEC), Créteil F-94010,
| | - J Le Breton
- Department of General Practice, School of Medicine, Université Paris Est Créteil (UPEC), Creteil F-94000, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, A-TVB DHU, IMRB, Université Paris Est Créteil (UPEC), Créteil F-94010
| | - E Guéry
- Department of General Practice, School of Medicine, Université Paris Est Créteil (UPEC), Creteil F-94000, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, A-TVB DHU, IMRB, Université Paris Est Créteil (UPEC), Créteil F-94010, Department of Public Health, AP-HP, Henri Mondor Hospital, Creteil F-94000
| | - F Adeline
- Department of General Practice, School of Medicine, Université Paris Est Créteil (UPEC), Creteil F-94000
| | - E Audureau
- CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, A-TVB DHU, IMRB, Université Paris Est Créteil (UPEC), Créteil F-94010, Department of Public Health, AP-HP, Henri Mondor Hospital, Creteil F-94000
| | - O Montagne
- INSERM, Clinical Investigation Centre 1430, Paris-Est University, Creteil F-94000 and
| | - F Roudot-Thoraval
- Department of Public Health, AP-HP, Henri Mondor Hospital, Creteil F-94000
| | - C Attali
- Department of General Practice, School of Medicine, Université Paris Est Créteil (UPEC), Creteil F-94000, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, A-TVB DHU, IMRB, Université Paris Est Créteil (UPEC), Créteil F-94010
| | - P Le Corvoisier
- INSERM, Clinical Investigation Centre 1430, Paris-Est University, Creteil F-94000 and
| | - V Renard
- Department of General Practice, School of Medicine, Université Paris Est Créteil (UPEC), Creteil F-94000, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, A-TVB DHU, IMRB, Université Paris Est Créteil (UPEC), Créteil F-94010
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