Factors influencing antibiotic prescribing for respiratory tract infections in primary care - a comparison of physicians with different antibiotic prescribing rates

BACKGROUND

There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years.

OBJECTIVE

To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors.

DESIGN AND SETTING

A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006-2014. The data were divided into three 3-year periods.

SUBJECTS

The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group.

MAIN OUTCOME MEASURES

For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics.

RESULTS

The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days.

CONCLUSION

Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.

Antibiotic Treatment for Lower Respiratory Tract Infections in Primary Care: A Register-Based Study Examining the Role of Radiographic Imaging

When imaging (i.e., chest-x-ray or computed tomography) is used to differentiate between acute bronchitis and pneumonia, many patients are being prescribed antibiotics despite the absence of radiographic pneumonia signs. This study of lower respiratory tract infections (LRTIs) with negative chest imaging compares cases where antibiotics were prescribed and not prescribed to find characteristics that could explain the prescription. Data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for patients aged 18-79 years diagnosed with acute bronchitis or pneumonia and who had any chest radiologic imaging between 2007-2014. Of 696 cases without evidence of pneumonia on imaging, 55% were prescribed antibiotics. Age, sex, and co-morbidity did not differ between those with or without antibiotics. The median level of C-reactive protein was low in both groups but differed significantly (21 vs. 10 mg/L; p < 0.001). Resident physicians prescribed antibiotics more frequently than interns or specialists (p < 0.001). It is unclear what features prompted the antibiotic prescribing in those with negative imaging indicating overuse of antibiotics for LRTIs.

Use of faecal immunochemical tests common in patients with suspected colorectal cancer but unrelated to travel distance to secondary care: a population-based study from Swedish primary care

BACKGROUND

Evidence is increasing for the use of faecal immunochemical tests (FITs) for occult blood as diagnostic tools when colorectal cancer can be suspected. FITs have been used for this purpose in Swedish primary care since around 2005 despite absence of supporting guidelines. To our knowledge, the extent of this use has not been studied.

OBJECTIVE

To investigate the use of FITs as diagnostic tools, and if the use was related to patient age, sex and travel time from primary care to diagnostic facilities in secondary care.

DESIGN

Population-based retrospective study using data from electronic health records.

SETTING AND SUBJECTS

Patients ≥18 years that provided FITs in primary care in five Swedish health care regions during 2015. Driving times from their primary care centres to secondary care were calculated.

MAIN OUTCOME MEASURES

The proportion of patients that provided FITs was calculated for each region, different age intervals and grouped driving times.

RESULTS

18,913 patients provided FITs. The proportion of listed patients in the five regions that provided FITs increased with age: 0.86-1.2% for ages <65 years, 3.6-4.1% for ages 65-79 years and 3.8-6.1% for ages ≥80 years. Differences between the regions were small. There was no overall correlation between the proportion of patients that provided FITs and driving time to secondary care.

CONCLUSION

FITs were used extensively in Swedish primary care with a higher use in older age groups. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to secondary care.Key PointsEvidence is increasing for the use of faecal immunochemical tests (FITs) as diagnostic tools when colorectal cancer can be suspected. We investigated the use of FITs in Sweden.FITs were used extensively in primary care especially in older age groups.There were small differences in the use of FITs between five studied health care regions.There was no tendency towards a higher use of FITs at primary care centres with longer driving times to diagnostic facilities in secondary care.

Impact of the Covid-19 pandemic on primary care utilization: evidence from Sweden using national register data

Objective

To analyze changes in primary care utilization as a result of the Covid-19 pandemic. Swedish national register data from 2019 to 2020 on utilization of services were used to compare overall utilization levels and across types of contacts and patient groups. A specific objective was to assess the extent to which remote types of patient consultations were able to compensate for any observed fall in on-site visits. Data were stratified by sex and age to investigate any demographic pattern.

Results

Findings show significant reductions in overall utilization of services as the pandemic occurred in the first quarter of 2020. On-site visits fell during the first wave of the pandemic and rebounded thereafter. Patients over 65 years of age appear to have reduced utilization to a larger extent compared with younger groups. Simultaneously, remote contacts increased from around 12% before the pandemic to 17% of the total number of consultations. However, the net effect of changes in service utilization suggests an overall reduction of around 12 percent in the number of primary care consultations as a result of the pandemic. No differences between men and women were observed. Further research will continue to monitor changes in primary care utilization as the pandemic continues.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05839-7.

Seasonal variations in use and outcome of rapid antigen detection tests and cultures in pharyngotonsillitis: a register study in primary care

Background

Diagnosis and treatment of pharyngotonsillitis are commonly focused on group A streptococci (GAS), although the disease is often associated with other pathogens. While the incidence of pharyngotonsillitis is known to vary with season, seasonal variations in the prevalence of potential pathogens are sparsely explored. The aim of this study was to explore any seasonal variations in the use and outcome of rapid antigen detection tests (RADTs) for GAS and throat cultures among patients diagnosed with pharyngotonsillitis in primary care.

Methods

We retrieved and combined retrospective data from the electronic medical record system and the laboratory information system in Kronoberg County, Sweden. Primary care visits resulting in a diagnosis of tonsillitis or pharyngitis were included, covering the period 2013–2016. The monthly rate of visits was measured, along with the use and outcome of RADTs for GAS and throat cultures obtained on the date of diagnosis. The variations between calendar months were then analysed.

Results

We found variations between calendar months, not only in the mean rate of visits resulting in a diagnosis of pharyngotonsillitis (p < 0.001), but in the mean proportion of RADTs being positive for GAS among the diagnosed (p < 0.001), and in the mean proportion of visits associated with a throat culture (p < 0.001). A lower mean rate of visits in August and September coincided with a lower proportion of RADTs being positive for GAS among them, which correlated with a higher proportion of visits associated with a throat culture.

Conclusions

This study suggests that the role of GAS in pharyngotonsillitis in Sweden is less prominent in August and September than during the rest of the year.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06774-5.

Diagnosing colorectal cancer in primary care: cohort study in Sweden of qualitative faecal immunochemical tests, haemoglobin levels, and platelet counts

BACKGROUND

Colorectal cancer (CRC) diagnostics are challenging in primary care and reliable diagnostic aids are desired. Qualitative faecal immunochemical tests (FITs) have been used for suspected CRC in Sweden since the mid-2000s, but evidence regarding their effectiveness is scarce. Anaemia and thrombocytosis are both associated with CRC.

AIM

To evaluate the usefulness of qualitative FITs requested for symptomatic patients in primary care, alone and combined with findings of anaemia and thrombocytosis, in the diagnosis of CRC.

DESIGN AND SETTING

A population-based cohort study using electronic health records and data from the Swedish Cancer Register, covering five Swedish regions.

METHOD

Patients aged ≥18 years in the five regions who had provided FITs requested by primary care practitioners from 1 January 2015 to 31 December 2015 were identified. FIT and blood-count data were registered and all CRC diagnoses made within 2 years were retrieved. Diagnostic measurements were calculated.

RESULTS

In total, 15 789 patients provided FITs (four different brands); of these patients, 304 were later diagnosed with CRC. Haemoglobin levels were available for 13 863 patients, and platelet counts for 10 973 patients. Calculated for the different FIT brands only, the sensitivities for CRC were 81.6%-100%; specificities 65.7%-79.5%; positive predictive values 4.7%-8.1%; and negative predictive values 99.5%-100%. Calculated for the finding of either a positive FIT or anaemia, the sensitivities increased to 88.9-100%. Adding thrombocytosis did not further increase the diagnostic performance.

CONCLUSION

Qualitative FITs requested in primary care seem to be useful as rule-in tests for referral when CRC is suspected. A negative FIT and no anaemia indicate a low risk of CRC.

Different antibiotic regimes in men diagnosed with lower urinary tract infection - a retrospective register-based study

OBJECTIVE

To compare the proportion of therapy failure, recurrence and complications within 30 days after consultation between men diagnosed with lower urinary tract infection (UTI) treated with narrow-spectrum antibiotics (nitrofurantoin or pivmecillinam) and broad-spectrum antibiotics (fluoroquinolones or trimethoprim or trimethoprim/sulfamethoxazole).

DESIGN

A retrospective cohort study based on data derived from electronic medical records between January 2012 and December 2015.

SETTING

Primary health care and hospital care in five different counties in Sweden. Patients: A total of 16,555 men aged between 18 and 79 years diagnosed with lower UTI.

MAIN OUTCOME MEASURES

Treatment with narrow-spectrum antibiotics was compared with broad-spectrum antibiotics regarding therapy failure, recurrence and complications within 30 days.

RESULTS

The median age of included men was 65 IQR (51-72) years. Narrow-spectrum antibiotics were prescribed in 8457 (40%) and broad-spectrum antibiotics in 12,667 (60%) cases, respectively. Therapy failure was registered in 192 (0.9%), recurrence in 1277 (6%) and complications in 121 (0.6%) cases. Therapy failure and recurrence were more common in patients treated with narrow-spectrum antibiotics and trimethoprim (p < 0.001), but no such difference could be detected regarding complications.

CONCLUSION

There was no difference in incidence of complications within 30 days between men treated with narrow- or broad-spectrum antibiotics. Patients prescribed broad-spectrum antibiotics had lower odds of reconsultation because of therapy failure and recurrence. From current data, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men with lower UTI. KEY POINTS Complications such as pyelonephritis and sepsis are uncommon in men diagnosed with lower urinary tract infection treated with antibiotics. There was no difference in incidence of complications among men diagnosed with lower urinary tract infection treated with narrow- or broad-spectrum antibiotics. In spite of higher incidence of therapy failure and recurrence, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men diagnosed with lower UTI.

Diagnosis-linked antibiotic prescribing in Swedish primary care - a comparison between in-hours and out-of-hours

Background

The rise in antibiotic resistance is a global public health concern, and antibiotic overuse needs to be reduced. Earlier studies of out-of-hours care have indicated that antibiotic prescribing is less appropriate than that of in-hours care. However, no study has compared the out-of-hours treatment of infections to in-hours treatment within the same population.

Methods

This retrospective, descriptive study was based on data retrieved from the Kronoberg Infection Database in Primary Care (KIDPC), which consists of all visits to primary care with an infection diagnosis or prescription of antibiotics during 2006–2014. The purpose was to study the trends in antibiotic prescribing and to compare consultations and prescriptions between in-hours and out-of-hours.

Results

The visit rate for all infections was 434 visits per 1000 inhabitants per year. The visit rate was stable during the study period, but the antibiotic prescribing rate decreased from 266 prescriptions per 1000 inhabitants in 2006 to 194 prescriptions in 2014 (mean annual change − 8.5 [95% CI − 11.9 to − 5.2]). For the out-of-hours visits (12% of the total visits), a similar reduction in antibiotic prescribing was seen. The decrease was most apparent among children and in respiratory tract infections.

When antibiotic prescribing during out-of-hours was compared to in-hours, the unadjusted relative risk of antibiotic prescribing was 1.37 (95% CI 1.36 to 1.38), but when adjusted for age, sex, and diagnosis, the relative risk of antibiotic prescribing was 1.09 (95% CI 1.08 to 1.10). The reduction after adjustment was largely explained by a higher visit rate during out-of-hours for infections requiring antibiotics (acute otitis media, pharyngotonsillitis, and lower urinary tract infection). The choices of antibiotics used for common diagnoses were similar.

Conclusions

Although the infection visit rate was unchanged over the study period, there was a significant reduction in antibiotic prescribing, especially to children and for respiratory tract infections. The higher antibiotic prescribing rate during out-of-hours was small when adjusted for age, sex, and diagnosis. No excess prescription of broad-spectrum antibiotics was seen. Therefore, interventions selectively aiming at out-of-hours centres seem to be unmotivated in a low-prescribing context.

Utilization of digital primary care in Sweden: Descriptive analysis of claims data on demographics, socioeconomics, and diagnoses

OBJECTIVE

As digital technologies for health continue to develop, the ability to provide primary care services to patients with new symptoms will grow. In Sweden, two providers of digital primary care have expanded rapidly over the past years giving rise to a heated debate with clear policy implications. The purpose of the study is to present a descriptive review of digital primary care as currently under development in Sweden.

METHODS

Descriptive analysis of national coverage data on the utilization of digital care by sex, age, place of residence, socioeconomic status, and most common diagnoses. The data are compared with samples of corresponding data on traditional, office-based primary care, out-of-hours care, and on non-emergency telephone consultations to obtain a comparative analysis of digital care.

RESULTS

Digital primary care in Sweden has increased rapidly over the past two years. Currently, more than 30,000 digital consultations are made per month, equivalent to around two percent of all physician-led primary care. Digital care differs in some ways to that of traditional care as users are generally younger and seek for different conditions compared with office-based primary care. Digital care is also similar to traditional care as utilization is higher in metropolitan areas compared with rural areas. Similar to general health care use, there is a negative correlation between use of digital care and socioeconomic status. User profiles by age and sex of digital care are also similar to those of out-of-hours care and non-emergency telephone medical consultations.

CONCLUSIONS

By providing a detailed description of the development of digital primary care the study contributes to a growing understanding of the contributions that digital technologies can make to health care. Based on current trends digital primary care is likely to continue to increase in frequency over the coming years. As technologies develop and the public becomes more familiar to interacting with medical providers over the Internet also the scope of digital care is likely to expand. As the provision of digital primary care expands across Europe and beyond, policy makers will need to develop regulating capacities to ensure its safe, effective and equitable integration into existing health systems.