Introduction: Antibiotic-associated diarrhea (AAD) is common and frequently more severe in hospitalized elderly adults. It can lead to increased use of healthcare resources. We estimated the cost-effectiveness of a fermented milk (FM) with probiotic in preventing AAD and in particular Clostridium difficile-associated diarrhea (CDAD).
Methods: Clinical effectiveness data and cost information were incorporated in a model to estimate the cost impact of administering a FM containing the probiotic Lactobacillus paracasei ssp paracasei CNCM I-1518 in a hospital setting. Preventing AAD by the consumption of the probiotic was compared to no preventive strategy.
Results: The probiotic intervention to prevent AAD generated estimated mean cost savings of £339 per hospitalized patient over the age of 65 years and treated with antibiotics, compared to no preventive probiotic. Estimated cost savings were sensitive to variation in the incidence of AAD, and to the proportion of patients who develop non-severe/severe AAD. However, probiotics remained cost saving in all sensitivity analyses.
Conclusion: Use of the fermented dairy drink containing the probiotic L. paracasei CNCM I-1518 to prevent AAD in older hospitalized patients treated with antibiotics could lead to substantial cost savings.
antibiotic-associated diarrhea; Clostridium difficile; hospitalized elderly; probiotics; cost effectiveness; nutrition economics
Urinary tract infection (UTI) in children may be associated with long-term complications that could be prevented by prompt treatment.
To determine the prevalence of UTI in acutely ill children ≤ 5 years presenting in general practice and to explore patterns of presenting symptoms and urine sampling strategies.
Design and setting
Prospective observational study with systematic urine sampling, in general practices in Wales, UK.
In total, 1003 children were recruited from 13 general practices between March 2008 and July 2010. The prevalence of UTI was determined and multivariable analysis performed to determine the probability of UTI.
Out of 597 (60.0%) children who provided urine samples within 2 days, the prevalence of UTI was 5.9% (95% confidence interval [CI] = 4.3% to 8.0%) overall, 7.3% in those < 3 years and 3.2% in 3–5 year olds. Neither a history of fever nor the absence of an alternative source of infection was associated with UTI (P = 0.64; P = 0.69, respectively). The probability of UTI in children aged ≥3 years without increased urinary frequency or dysuria was 2%. The probability of UTI was ≥5% in all other groups. Urine sampling based purely on GP suspicion would have missed 80% of UTIs, while a sampling strategy based on current guidelines would have missed 50%.
Approximately 6% of acutely unwell children presenting to UK general practice met the criteria for a laboratory diagnosis of UTI. This higher than previously recognised prior probability of UTI warrants raised awareness of the condition and suggests clinicians should lower their threshold for urine sampling in young children. The absence of fever or presence of an alternative source of infection, as emphasised in current guidelines, may not rule out UTI in young children with adequate certainty.
children; general practice; prevalence; symptoms; urinary tract infections
Outpatients with acute cough who expect, hope for or ask for antibiotics may be more unwell, benefit more from antibiotic treatment, and be more satisfied with care when they are prescribed antibiotics. Clinicians may not accurately identify those patients.
To explore whether patient views (expecting, hoping for or asking for antibiotics) are associated with illness presentation and resolution, whether patient views are accurately perceived by clinicians, and the association of all these factors with antibiotic prescribing and patient satisfaction with care.
Prospective observational study of 3402 adult patients with acute cough presenting in 14 primary care networks. Correlations and associations tested with multilevel logistic regression and McNemar ‘s tests, and Cohen’s Kappa, positive agreement (PA) and negative agreement (NA) calculated as appropriate.
1,213 (45.1%) patients expected, 1,093 (40.6%) hoped for, and 275 (10.2%) asked for antibiotics. Clinicians perceived 840 (31.3%) as wanting to be prescribed antibiotics (McNemar’s test, p<0.05). Their perception agreed modestly with the three patient views (Kappa’s = 0.29, 0.32 and 0.21, PA’s = 0.56, 0.56 and 0.33, NA’s = 0.72, 0.75 and 0.82, respectively). 1,464 (54.4%) patients were prescribed antibiotics. Illness presentation and resolution were similar for patients regardless their views. These associations were not modified by antibiotic treatment. Patient expectation and hope (OR:2.08, 95% CI:[1.48,2.93] and 2.48 [1.73,3.55], respectively), and clinician perception (12.18 [8.31,17.84]) were associated with antibiotic prescribing. 2,354 (92.6%) patients were satisfied. Only those hoping for antibiotics were less satisfied when antibiotics were not prescribed (0.39 [0.17,0.90]).
Patient views about antibiotic treatment were not useful for identifying those who will benefit from antibiotics. Clinician perceptions did not match with patient views, but particularly influenced antibiotic prescribing. Patients were generally satisfied with care, but those hoping for but not prescribed antibiotics were less satisfied. Clinicians need to more effectively elicit and address patient views about antibiotics.
Care home residents, especially those lacking capacity to provide consent for themselves, are frequently excluded from research, thus limiting generalisability of study findings. We set out to explore stakeholders’ views about the ethical and practical challenges associated with recruiting care home residents into research studies.
Qualitative individual interviews with care home residents (n = 14), their relatives (n = 14), and general practitioners (GPs) (n = 10), and focus groups (n = 2) with care home staff. Interviews focused on the issues of older adults consenting to research in care homes, including advanced consent, in general and through reference to a particular study on the use of probiotics to prevent Antibiotic Associated Diarrhoea. Data were analysed using a thematic approach incorporating themes that had been identified in advance, and themes derived from the data. Researchers discussed evidence for themes, and reached consensus on the final themes.
Respondents were generally accepting of low risk observational studies and slightly less accepting of low risk randomised trials of medicinal products. Although respondents identified some practical barriers to informed consent, consenting arrangements were considered workable. Residents and relatives varied in the amount of detail they wanted included in information sheets and consent discussions, but were generally satisfied that an advanced consent model was acceptable and appropriate. Opinions differed about what should happen should residents lose capacity during a research study.
Research staff should be mindful of research guidance and ensure that they have obtained an appropriate level of informed consent without overwhelming the participant with unnecessary detail. For research involving medicinal products, research staff should also be more explicit when recruiting that consent is still valid should an older person lose capacity during a trial provided the individual did not previously state a wish to be withdrawn if they lose capacity, and provided they do not indicate objection or resistance after loss of capacity.
Consent; Older adults; Qualitative research; Mental capacity; Ethics; Recruitment; Common infections
As obesity levels increase, opportunistic behaviour change counselling from primary care clinicians in consultations about healthy eating is ever more important. However, little is known about the approaches clinicians take with patients.
To describe the content of simulated consultations on healthy eating in primary care, and compare this with the content of smoking cessation consultations.
Design and setting
Qualitative study of 23 audiotaped simulated healthy eating and smoking cessation consultations between an actor and primary care clinicians (GPs and nurses) within a randomised controlled trial looking at behaviour change counselling.
Consultations were audiotaped and transcribed verbatim, then analysed inductively using thematic analysis. A thematic framework was developed by all authors and applied to the data. The content of healthy eating consultations was contrasted with that given for smoking cessation.
There was a lack of consistency and clarity when clinicians discussed healthy eating compared with smoking; in smoking cessation consultations, the content was clearer to both the clinician and patient. There was a lack of specificity about what dietary changes should be made, how changes could be achieved, and how progress could be monitored. Barriers to change were addressed in more depth within the smoking cessation consultations than within the healthy eating encounters.
At present, dietary counselling by clinicians in primary care does not typically contain consistent, clear suggestions for specific change, how these could be achieved, and how progress would be monitored. This may contribute to limited uptake and efficacy of dietary counselling in primary care.
communication, behaviour change counselling; commnication; healthy eating; primary care
To describe carers’ perceptions of the development and presentation of community-acquired pneumonia or empyema in their children.
Seven hospitals with paediatric inpatient units in South Wales, UK.
Carers of 79 children aged 6 months to 16 years assessed in hospital between October 2008 and September 2009 with radiographic, community-acquired pneumonia or empyema.
Carers were recruited in hospital and participated in a structured face-to-face or telephone interview about the history and presenting features of their children's illnesses. Responses to open questions were initially coded very finely and then grouped into common themes. Cases were classified into two age groups: 3 or more years and under 3 years.
The reported median duration of illness from onset until the index hospital presentation was 4 days (IQR 2–9 days). Pain in the torso was reported in 84% of cases aged 3 or more years and was the most common cause for carer concern in this age group. According to carer accounts, clinicians sometimes misjudged the origin of this pain. Almost all carers reported something unusual about the index illness that had particularly concerned them—mostly non-specific physical symptoms and behavioural changes.
Pain in the torso and carer concerns about unusual symptoms in their child may provide valuable additional information in a clinician's assessment of the risk of pneumonia in primary care. Further research is needed to confirm the diagnostic value of these features.
Tropical Medicine; Epidemiology; Paediatrics; Paediatric thoracic medicine; Thoracic Medicine; Respiratory infections; Paediatric palliative care; Paediatric infectious disease & immunisation
Near-patient tests are promoted for guiding management of common infections in primary care with a view to enhancing the effectiveness of prescribing decisions and containing antimicrobial resistance. Changes in clinical practice should be based on appraisals of the factors that might influence change, viewed from the perspective of those expected to implement the change. We therefore explored the views of general practitioners concerning the possible introduction of near-patient tests for managing common infections.
Qualitative semi-structured interview study. Interviews were recorded and analysed using thematic content analysis.
General practices in south-east Wales, UK.
A total of 26 general practitioners (GPs) from high fluroquinolone antibiotics prescribing practices and 14 GPs from practices that prescribed fluroquinolones close to the south-east Wales mean.
There was strong enthusiasm for a hypothetical near-patient, finger-prick blood tests that could distinguish viral from bacterial infections. Many GPs emphasized that such tests would be valuable in “selling” decisions not to prescribe antibiotics to patients. Concerns included limited additional useful information to guide prescribing above clinical diagnosis alone, that patients might deteriorate even if the tests correctly identified a viral aetiology, and that GPs would need to be convinced by research evidence supporting uptake. Several indicated that tests would be useful only for a limited number of patients and they were concerned by time pressures, apparatus maintenance and quality control, cost, and possible objections from patients, especially children.
Despite GP enthusiasm for the concept of a rapid test to distinguish viral from bacterial infection, strategies to promote uptake would be enhanced if concerns were addressed regarding the importance and feasibility of such tests in daily practice.
Antibiotics; family practice; near-patient tests; physician views; point of care tests; primary care; qualitative research
Acute respiratory tract infection is the commonest reason for children consulting, and about one-fifth re-consult for the same illness episode. Fifty-nine audiotape recordings from nine general practitioners (GPs) consulting with children with acute respiratory tract infections were examined. Prognosis was mentioned in only 22 consultations, with GPs predicting a brief course in 11, a possibly longer than expected course in six, and with predicted duration not made explicit in five. Carers were invited to re-consult if they were ‘unhappy’ with the child's condition in 11 consultations, and specific triggers to re-consult were provided in 15. A patient information leaflet was given out only once. Providing carers with an evidence-based account of the likely clinical course and communicating specific triggers to re-consult may help them manage more of these illness episodes without re-consulting.
children; infections, upper respiratory; physician–patient relations; prognosis; patient education
Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown.
To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI.
Exploratory, observational study.
Four general practices in South Wales.
A total of 99 sequential attendees with acute illness aged less than five years.
Main outcome measure
UTI defined by >105 organisms/ml on laboratory culture of urine.
Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections.
Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.
Children; diagnosis; prevalence; primary care; urinary tract infection
To compare the frequency and duration of sickness certificates issued by GPs to Polish and Norwegian working adults with acute cough/lower respiratory tract infection (LRTI).
Cross-sectional observational study with clinicians from nine primary care centres in Poland and 11 primary care centres in Norway. GPs filled out a case report form for all patients, including information on antibiotic prescribing, sickness certification, and advice to stay off work.
Primary care research networks in Poland and Norway.
Working adults with a new or worsening cough or clinical presentation suggestive of LRTI.
Main outcome measures
Issuing sickness certificates and advising patients to stay off work.
GPs recorded similar symptoms and signs in patients in the two countries. Antibiotics were prescribed more often in Polish than in Norwegian patients (70.4% vs. 27.1%, p < 0.0001). About half of the patients received a formal sickness certificate (50.5% in Norway and 52.0% in Poland). The proportion of patients advised to stay off work was significantly higher in the Polish sample compared with the Norwegian sample (75.2% vs. 56.1%, p = 0.002). Norwegian GPs less often issued sick certificates for more than seven days (5.6% vs. 36.9%, p < 0.0001).
The overall proportion of sickness certification for acute cough/LRTI was similar in Norwegian and Polish patients. However, in the Polish sample, GPs more often advised patients to take time off work without issuing a sick note. When sickness certificates were issued, duration of longer than seven days was more common in Polish than in Norwegian patients.
Acute cough; adults; GRACE-LRTI; primary care; sickness certification
Respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The value of clinical findings in lower respiratory tract infection (LRTI) is known to be overrated. This study aimed to determine the independent influence of a point of care test (POCT) for C-reactive protein (CRP) on the prescription of antibiotics in patients with acute cough or symptoms suggestive of LRTI, and how symptoms and chest findings influence the decision to prescribe when the test is and is not used.
Prospective observational study of presentation and management of acute cough/LRTI in adults.
Primary care research networks in Norway, Sweden, and Wales.
Adult patients contacting their GP with symptoms of acute cough/LRTI.
Main outcome measures
Predictors of antibiotic prescribing were evaluated in those tested and those not tested with a POCT for CRP using logistic regression and receiver operating characteristic (ROC) curve analysis.
A total of 803 patients were recruited in the three networks. Among the 372 patients tested with a POCT for CRP, the CRP value was the strongest independent predictor of antibiotic prescribing, with an odds ratio (OR) of CRP ≥ 50 mg/L of 98.1. Crackles on auscultation and a patient preference for antibiotics perceived by the GP were the strongest predictors of antibiotic prescribing when the CRP test was not used.
The CRP result is a major influence in the decision whether or not to prescribe antibiotics for acute cough. Clinicians attach less weight to discoloured sputum and abnormal lung sounds when a CRP value is available. CRP testing could prevent undue reliance on clinical features that poorly predict benefit from antibiotic treatment.
Antibiotic prescribing; clinical findings; CRP; LRTI; point of care testing; primary care
Uptake of interventions to improve quality of care by clinicians is variable and is influenced by clinicians' attitudes. The influence of clinicians' experience with an intervention on their preference for adopting interventions is largely unknown.
Thematic analysis of semi-structured interviews exploring views and attitudes towards an illness-focused intervention (specific communication skills training) and a disease-focused intervention (C-reactive protein, or CRP, point-of-care testing) to optimize management of lower respiratory tract infections (LRTI) among general practitioners (GPs) who had used both interventions for two years in a randomised trial (exposed GPs), and GPs without experience of either intervention (non-exposed GPs).
All but two of the ten non-exposed GPs indicated that they would prioritise implementation of the disease-focused intervention of CRP testing over communication skills training, while all but one GP in the exposed group said that they would prioritise the illness-focused approach of communication skills training as it was more widely applicable, whereas CRP testing was confirmatory and useful in a subgroups of patients.
There are differences in attitudes to prioritising contrasting interventions for optimising LRTI management among GPs with and without experience of using the interventions, although GPs in both groups recognised the importance of both approaches to optimise management of acute cough. GPs' experiences with and attitudes towards interventions need to be taken into account when planning rollout of interventions aimed at changing clinical practice.
Objective To establish whether an interactive booklet on respiratory tract infections in children reduces reconsultation for the same illness episode, reduces antibiotic use, and affects future consulting intentions, while maintaining parental satisfaction with care.
Design Pragmatic cluster randomised controlled trial.
Setting 61 general practices in Wales and England.
Participants 558 children (6 months to 14 years) presenting to primary care with an acute respiratory tract infection (7 days or less). Children with suspected pneumonia, asthma or a serious concomitant illness, or needing immediate hospital admission were excluded. Three withdrew and 27 were lost to follow-up, leaving 528 (94.6%) with main outcome data.
Interventions Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during consultations with recruited patients (and provide it as a take home resource). Clinicians in the control group conducted their consultations as usual.
Main outcome measures The proportion of children who attended a face-to-face consultation about the same illness during the two week follow-up period. Secondary outcomes included antibiotic prescribing, antibiotic consumption, future consulting intentions, and parental satisfaction, reassurance, and enablement.
Results Reconsultation occurred in 12.9% of children in the intervention group and 16.2% in the control group (absolute risk reduction 3.3%, 95% confidence interval −2.7% to 9.3%, P=0.29). Using multilevel modelling (at the practice and individual level) to account for clustering, no significant difference in reconsulting was noted (odds ratio 0.75; 0.41 to 1.38). Antibiotics were prescribed at the index consultation to 19.5% of children in the intervention group and 40.8% of children in the control group (absolute risk reduction 21.3%, 95% confidence interval 13.7 to 28.9), P<0.001). A significant difference was still present after adjusting for clustering (odds ratio 0.29; 0.14 to 0.60). There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness (odds ratio 0.34; 0.20 to 0.57). Satisfaction, reassurance, and parental enablement scores were not significantly different between the two groups.
Conclusions Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to consult without reducing satisfaction with care.
Trial registration Current Controlled Trials ISRCTN46104365
Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.
Design Pragmatic, 2×2 factorial, cluster randomised controlled trial.
Setting 20 general practices in the Netherlands.
Participants 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.
Main outcome measures The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement.
Interventions General practitioners’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.
Results General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days’ follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients’ recovery and satisfaction were similar in all study groups.
Conclusion Both general practitioners’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients’ recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.
Trial registration Current Controlled Trials ISRCTN85154857.
After some years of a downward trend, antibiotic prescribing rates in the community have tended to level out in many countries. There is also wide variation in antibiotic prescribing between general practices, and between countries. There are still considerable further gains that could be made in reducing inappropriate antibiotic prescribing, but complex interventions are required. Studies to date have generally evaluated the effect of interventions on antibiotic prescribing in a single consultation and pragmatic evaluations that assess maintenance of new skills are rare. This paper describes the protocol for a pragmatic, randomized evaluation of a complex intervention aimed at reducing antibiotic prescribing by primary care clinicians.
Methods and design
We developed a Social Learning Theory based, blended learning program (on-line learning, a practice based seminar, and context bound learning) called the STAR Educational Program. The 'why of change' is addressed by providing clinicians in general practice with information on antibiotic resistance in urine samples submitted by their practice and their antibiotic prescribing data, and facilitating a practice-based seminar on the implications of this data. The 'how of change' is addressed through context-bound communication skills training and information on antibiotic indication and choice. This intervention will be evaluated in a trial involving 60 general practices, with general practice as the unit of randomization (clinicians from each practice to either receive the STAR Educational Program or not) and analysis. The primary outcome will be the number of antibiotic items dispensed over one year. An economic and process evaluation will also be conducted.
This trial will be the first to evaluate the effectiveness of this type of theory-based, blended learning intervention aimed at reducing antibiotic prescribing by primary care clinicians. Novel aspects include feedback of practice level data on antimicrobial resistance and prescribing, use of principles from motivational interviewing, training in enhanced communication skills that incorporates context-bound experience and reflection, and using antibiotic dispensing over one year (as opposed to antibiotic prescribing in a single consultation) as the main outcome.
Current Controlled Trials ISRCTN63355948.
Patient expectations are among the strongest predictors of clinicians' antibiotic prescribing decisions. Although public knowledge, beliefs, and experiences of antibiotics contribute to these expectations, little is known about these public views.
To gain insight into public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections.
Design of study
Cross-sectional, internet-based questionnaire study.
Members of the general public aged 16 years and over in the Netherlands.
Public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections, as well as predictors of accurate knowledge of antibiotic effectiveness, were measured using 20 questions with sub-items. The questionnaire was given to a Dutch community-based nationwide internet panel of 15 673 individuals. Of these, 1248 eligible responders were invited to participate; 935 responders (75%) completed the questionnaire.
Of the participants, 44.6% accurately identified antibiotics as being effective against bacteria and not viruses. Acute bronchitis was considered to require treatment with antibiotics by nearly 60% of responders. The perceived need for antibiotics for respiratory tract infection-related symptoms ranged from 6.5% for cough with transparent phlegm, to 46.2% for a cough lasting for more than 2 weeks.
Public misconceptions on the effectiveness of, and indications for, antibiotics exist. Nearly half of all responders (47.8%) incorrectly identified antibiotics as being effective in treating viral infections. Doctors should be aware that unnecessary prescribing could facilitate misconceptions regarding antibiotics and respiratory tract infections. Expectations of receiving antibiotics were higher for the disease label ‘acute bronchitis’ than for any of the separate or combined symptoms prominently present in respiratory tract infection. Public beliefs and expectations should be taken into account when developing interventions targeting the public, patients, and physicians to reduce unnecessary prescribing of antibiotics for respiratory tract infections.
antibiotics; community; public beliefs; respiratory tract infections; survey
Delay in the diagnosis of coeliac disease prolongs morbidity and may increase mortality. Little is known about presentations in general practice that may predict a subsequent diagnosis of coeliac disease.
To examine presentations in general practice during the 5 years prior to diagnosis of coeliac disease.
Design of study
A case-control study with each biopsy-proven coeliac disease case matched by age, sex, and general practice to an average of two controls.
Thirty-seven general practices in south-east Wales.
Cases were identified via a secondary care clinic and controls recruited from the general practices of cases. General practice clinical records of both cases and controls were analysed to determine frequency of consultations, presenting symptoms, diagnoses, referrals, and investigations during the 5 years prior to diagnosis.
Cases (n = 68) had an increased number of consultations compared with controls (n = 160) during the 5 years prior to diagnosis (mean difference five consultations, P = 0.001). Three clinical features were independently associated with subsequent diagnosis of coeliac disease: depression and/or anxiety (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.1 to 5.7, P = 0.031); diarrhoea (OR = 4.5, 95% CI = 2.0 to 10.0, P<0.001); and anaemia (OR = 26.3, 95% CI = 5.7 to 120.6, P<0.001). Both diarrhoea and anaemia remained associated even when data for the year prior to diagnosis was excluded from the analysis.
GPs should consider testing for coeliac disease when patients present often, especially with diarrhoea and/or who are discovered to be anaemic. Further research is required to clarify the role of depression and/or anxiety in the diagnosis of coeliac disease.
case-control; coeliac disease; risk factors
Respiratory tract infections in children result in more primary care consultations than any other acute condition, and are the most common reason for prescribing antibiotics (which are largely unnecessary). About a fifth of children consult again for the same illness episode. Providing parents with written information on respiratory tract infections may result in a reduction in re-consultation rates and antibiotic prescribing for these illnesses. Asking clinicians to provide and discuss the information during the consultation may enhance effectiveness. This paper outlines the protocol for a study designed to evaluate the use of a booklet on respiratory tract infections in children within primary care consultations.
This will be a cluster randomised controlled trial. General practices will be randomised to provide parents consulting because their child has an acute respiratory tract infection with either an interactive booklet, or usual care. The booklet provides information on the expected duration of their child's illness, the likely benefits of various treatment options, signs and symptoms that should prompt re-consultation, and symptomatic treatment advice. It has been designed for use within the consultation and aims to enhance communication through the use of specific prompts. Clinicians randomised to using the interactive booklet will receive online training in its use. Outcomes will be assessed via a telephone interview with the parent two weeks after first consulting. The primary outcome will be the proportion of children who re-consult for the same illness episode. Secondary outcomes include: antibiotic use, parental satisfaction and enablement, and illness costs. Consultation rates for respiratory tract infections for the subsequent year will be assessed by a review of practice notes.
Previous studies in adults and children have shown that educational interventions can result in reductions in re-consultation rates and use of antibiotics for respiratory tract infections. This will be the first study to determine whether providing parents with a booklet on respiratory tract infections in children, and discussing it with them during the consultation, reduces re-consultations and antibiotic use for the same illness without reducing satisfaction with care.
Current Controlled Trials ISRCTN46104365
Although tuberculosis (TB) is relatively rare in the UK, its diagnosis is important because diagnostic delays can result in worse outcomes for patients and expose others to the risk of infection. Atypical presentations may be common, and patients' help-seeking behaviour may influence the diagnostic process in primary care. Little is known about the process of diagnosing TB in primary care in developed countries.
To understand the process of diagnosing TB in UK primary care.
Design of study
Qualitative inductive study with paired semi-structured interviews.
Communities and general practices in south-east Wales.
Interviews were conducted with 17 patients diagnosed with TB in the previous 6 months and 16 GPs involved with their care. Data were analysed thematically.
In response to expected classical features, GPs generally ordered specific tests. Both GPs and patients reported atypical presentations, and then the diagnostic and referral net was appropriately widened in most cases. Identified barriers to prompt diagnosis included atypical presentations and low clinical suspicion of TB, lack of continuity of care, workload demands that limit time with patients, and suboptimal clinician–patient communication. GPs recognised the growing problem of TB nationally and the need for improved education among health professionals.
GPs' and patients' accounts about the process of diagnosing TB suggest that delays can occur, although they are not typical. Where diagnosis is clear, GPs generally test specifically and refer appropriately; where diagnosis is less clear, the diagnostic net is cast further. It is only when certain core values of general practice are not applied (including continuity of care, considering context appropriately, and eliciting and responding appropriately to patients' explanatory models) that clinicians and patients identify a suboptimal diagnostic process.
diagnosis; presentation; primary care; qualitative; tuberculosis
Antimicrobial resistance is considered to be one of the major threats to public health. However, the practical implications for patients and workload in primary care are largely unknown.
To determine outcomes for patients managed in primary care with an antibiotic resistant compared to an antibiotic sensitive Escherichia coli (E. coli) urinary tract infection (UTI).
Nested case control study with prospective measurement of outcomes.
Ten general practices in South Wales.
Patients consulting with symptoms suggestive of UTI identified through systematic sampling, and with a laboratory proven E. coli infection, were followed up by interview 1 month after their consultations and by searching of their medical records.
Nine hundred and thirty-two patients were interviewed and had their medical records reviewed. The risk of patients reporting ‘feeling poorly’, ‘frequency or pain on urinating’ and being ‘out of action’ for more than 5 days after consulting was significantly increased for patients with resistant compared to sensitive infections. After adjusting for risk factors, there was an increased risk of ‘frequency or pain on urinating’ and ‘being out of action’ for those infected with a resistant E. coli. The median number of maximum reported days with at least one symptom was 12 days for patients with E. coli infections resistant to trimethoprim, 7 days for infections resistant to ampicillin, 7 days for infections resistant to any antibiotic, and 5 days for infections sensitive to all tested antibiotics. Even if treated with an appropriate antibiotic, infections caused by a resistant strain were symptomatic for longer. For those infected with an organism resistant to at least one antibiotic, the odds ratio (OR) for re-visiting their GP within the next 30 days for the UTI was 1.47 (95% confidence interval [CI] = 1.10 to 1.95). The OR was 1.49 (95% CI = 1.11 to 2.00) for ampicillin resistance and 2.48 (95% CI = 1.70 to 3.59) for trimethoprim resistance.
Resistant E. coli UTIs are symptomatic for longer and cause increased work load in general practice.
anti-bacterial agents; cohort study; drug resistance, bacterial; primary health care; treatment outcomes; urinary tract infections
Most antibiotic prescriptions for acute cough due to lower respiratory tract infections (LRTI) in primary care are not warranted. Diagnostic uncertainty and patient expectations and worries are major drivers of unnecessary antibiotic prescribing. A C-reactive protein (CRP) point of care test may help GPs to better guide antibiotic treatment by ruling out pneumonia in cases of low test results. Alternatively, enhanced communication skills training to help clinicians address patients' expectations and worries could lead to a decrease in antibiotic prescribing, without compromising clinical recovery, while enhancing patient enablement. The aim of this paper is to describe the design and methods of a study to assess two interventions for improving LRTI management in general practice.
This cluster randomised controlled, factorial trial will introduce two interventions in general practice; point of care CRP testing and enhanced communication skills training for LRTI. Twenty general practices with two participating GPs per practice will recruit 400 patients with LRTI during two winter periods. Patients will be followed up for at least 28 days. The primary outcome measure is the antibiotic prescribing rate. Secondary outcomes are clinical recovery, cost-effectiveness, use of other diagnostic tests and medical services (including reconsultation), and patient enablement.
This trial is the first cluster randomised trial to evaluate the influence of point of care CRP testing in the hands of the general practitioner and enhanced communication skills, on the management of LRTI in primary care. The pragmatic nature of the study, which leaves treatment decisions up to the responsible clinicians, will enhance the applicability and generalisability of findings. The factorial design will allow conclusion to be made about the value of CRP testing on its own, communication skills training on its own, and the two combined. Evaluating a biomedical and communication based intervention ('hard' and 'soft' technologies) together in this way makes this trial unique in its field.
Persuading patients to change behaviour that is damaging their health can be difficult. Changing the style of consultation could improve the experience for doctors and patients