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Wilson JA, Fouweather T, Stocken DD, Homer T, Haighton C, Rousseau N, O'Hara J, Vale L, Wilson R, Carnell S, Wilkes S, Morrison J, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Lindley L, MacKenzie K, McSweeney L, Mehanna H, Raine C, Whelan RS, Sullivan F, von Wilamowitz-Moellendorff A, Teare D. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess 2023; 27:1-195. [PMID: 38204203 PMCID: PMC11017150 DOI: 10.3310/ykur3660] [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] [Indexed: 01/12/2024] Open
Abstract
Background The place of tonsillectomy in the management of sore throat in adults remains uncertain. Objectives To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways. Design This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation. Setting The study took place at 27 NHS secondary care hospitals in Great Britain. Participants A total of 453 eligible participants with recurrent sore throats were recruited to the main trial. Interventions Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity. Main outcome measures The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms. Results There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it. Limitations The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial. Conclusions The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective. Trial registration This trial is registered as ISRCTN55284102. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Haighton
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Wilson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | | | - Kim Ah-See
- Department of Otolaryngology Head and Neck Surgery, NHS Grampian, Aberdeen, UK
| | - Sean Carrie
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Hopkins
- Ear, Nose and Throat and Head and Neck Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Kenneth MacKenzie
- Department of Ear, Nose and Throat Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lorraine McSweeney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Christopher Raine
- Ear, Nose and Throat Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ruby Smith Whelan
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Frank Sullivan
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Use of antibiotics for acute sore throat and tonsillitis in primary care. Br J Gen Pract 2022; 72:136-137. [PMID: 35210250 PMCID: PMC8884437 DOI: 10.3399/bjgp22x718793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/15/2021] [Indexed: 10/31/2022] Open
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Estrela M, Roque F, Silva TM, Zapata-Cachafeiro M, Figueiras A, Herdeiro MT. Validation of the eHealthResp online course for pharmacists and physicians: A Delphi method approach. Biomed Pharmacother 2021; 140:111739. [PMID: 34020245 DOI: 10.1016/j.biopha.2021.111739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022] Open
Abstract
FRAMEWORK The inappropriate use of antibiotics for respiratory tract infections is dispersed worldwide, thus being a strong contributor to antibiotic resistances. As the use of educational interventions among health practitioners is shown to have an impact on judicious antibiotic use, an online course (eHealthResp) has been developed, especially targeted to pharmacists and physicians. Thus, the main goal of this study is to validate the contents of the online course eHealthResp. METHODS This two-round Delphi study involved the recruitment of a multidisciplinary panel (n = 19), to which the questionnaires of the first round were sent. After the first round, a report summing up the results has been forwarded to the panel, along with a new, reformulated version of the questionnaire. RESULTS After the two rounds of the Delphi process, consensus was evaluated. Six clinical cases and fifty-one treatments obtained minor consensus [60-75%] or full consensus (≥75%). The question on antibiotic practice has obtained a consensus >90% on both rounds. CONCLUSIONS The validation of the contents based on experts' consensus has been an essential approach to improve eHealthResp's online course, as valuable feedback has been provided by the panel on both rounds.
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Affiliation(s)
- Marta Estrela
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal.
| | - Fátima Roque
- Research Unit for Inland Development, Guarda Polytechnic Institute (UDI-IPG), Guarda, Portugal; Health Sciences Research Center, University of Beira Interior (CICS-UBI), Covilhã, Portugal
| | - Tânia Magalhães Silva
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Maruxa Zapata-Cachafeiro
- Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Spain; Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Madrid, Spain
| | - Adolfo Figueiras
- Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Spain; Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Madrid, Spain
| | - Maria Teresa Herdeiro
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
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Stuart B, Hounkpatin H, Becque T, Yao G, Zhu S, Alonso-Coello P, Altiner A, Arroll B, Böhning D, Bostock J, Bucher HC, Chao J, de la Poza M, Francis N, Gillespie D, Hay AD, Kenealy T, Löffler C, McCormick DP, Mas-Dalmau G, Muñoz L, Samuel K, Moore M, Little P. Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis. BMJ 2021; 373:n808. [PMID: 33910882 PMCID: PMC8080136 DOI: 10.1136/bmj.n808] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect. DESIGN Systematic review and individual patient data meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science. ELIGIBILITY CRITERIA FOR STUDY SELECTION Randomised controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing. MAIN OUTCOME MEASURES The primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale. RESULTS Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference -0.003, 95% confidence interval -0.12 to 0.11) or delayed versus no antibiotics (0.02, -0.11 to 0.15). Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13). A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group. CONCLUSIONS Delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children. STUDY REGISTRATION PROSPERO CRD42018079400.
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Affiliation(s)
- Beth Stuart
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hilda Hounkpatin
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Taeko Becque
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Shihua Zhu
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Dankmar Böhning
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Jennifer Bostock
- Division of Health and Social Care Research, King's College London, London, UK
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel and University of Basel, Switzerland
| | - Jennifer Chao
- Pediatric Emergency Medicine, State University of New York Downstate, Brooklyn, New York, USA
| | - Mariam de la Poza
- Institut Català de la Salut, CAP Doctor Carles Ribas, Foc 112, Barcelona, Spain
| | - Nick Francis
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - David Gillespie
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Timothy Kenealy
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - David P McCormick
- Department of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Gemma Mas-Dalmau
- Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Laura Muñoz
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
| | - Kirsty Samuel
- ASPIRE PPI Panel, Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Michael Moore
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
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Implementing a guideline for acute tonsillitis using an ambulatory medical unit. The Journal of Laryngology & Otology 2019; 133:386-389. [PMID: 30967160 DOI: 10.1017/s0022215119000380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission. METHODS A retrospective review of 48 patients' notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions. RESULTS The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase. CONCLUSION The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.
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O'Connor R, O'Doherty J, O'Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci 2018; 187:969-986. [PMID: 29532292 PMCID: PMC6209023 DOI: 10.1007/s11845-018-1774-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections. AIMS To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions. METHODS Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review. RESULTS Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education. CONCLUSION There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.
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Affiliation(s)
- Ray O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland.
| | - Jane O'Doherty
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Andrew O'Regan
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
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Influence of the duration of penicillin prescriptions on outcomes for acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e623-e633. [PMID: 28808076 DOI: 10.3399/bjgp17x692333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Guidelines recommend 10-day treatment courses for acute sore throat, but shorter courses may be used in practice. AIM To determine whether antibiotic duration predicts adverse outcome of acute sore throat in adults in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study of 12 829 adults presenting in UK general practice with acute sore throat. METHOD A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcomes were collected by notes review, a sample also completed a symptom diary. The primary outcome was re-consultation with new/non-resolving symptoms within 1 month. The secondary outcome was 'global' poorer symptom control (longer than the median duration or higher than median severity). RESULTS Antibiotics were prescribed for 62% (7872/12 677) of participants. The most commonly prescribed antibiotic was phenoxymethylpenicillin (76%, 5656/7474) and prescription durations were largely for 5 (20%), 7 (57%), or 10 (22%) days. Compared with 5-day courses, those receiving longer courses were less likely to re-consult with new or non-resolving symptoms (5 days 15.3%, 7 days 13.9%, 10 days 12.2%, 7-day course adjusted risk ratio (RR) 0.92 [95% confidence interval [CI] = 0.76 to 1.11] and 10-days RR 0.86 [95% CI = 0.59 to 1.23]) but these differences did not reach statistical significance. CONCLUSION In adults prescribed antibiotics for sore throat, the authors cannot rule out a small advantage in terms of reduced re-consultation for a 10-day course of penicillin, but the effect is likely to be small.
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