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1.  Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women 
Background
Dipsticks are one of the most commonly used near-patient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed.
Aim
To confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI).
Design of study
Validation study.
Setting
Primary care.
Method
A total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines.
Results
Sixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule — based on presence of nitrite, or both leucocytes and blood — was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features.
Conclusion
A clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.
doi:10.3399/bjgp10X514747
PMCID: PMC2894378  PMID: 20594439
algorithms, clinical scoring; diagnosis, urinary tract infection; primary care; urinalysis
2.  Effect of antibiotic prescribing strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection 
Background
Limited evidence suggests that delayed prescribing may influence future consultation behaviour.
Aim
To assess the effects of antibiotic prescribing strategy on reconsultation in the year following presentation with acute lower respiratory tract infection (LRTI).
Design of study
Balanced factorial randomised trial.
Setting
Primary care.
Method
Eight hundred and seven subjects, aged ≥3 years, had acute illness presenting with cough as the main symptom, plus at least one symptom or sign from sputum, chest pain, dyspnoea or wheeze. The subjects were randomised to one of three prescribing strategies (antibiotics, delayed antibiotic, no antibiotic) and a leaflet. Prior antibiotic use and reconsultation were assessed by medical record review.
Results
Patients who had been prescribed antibiotic for cough in the previous 2 years were much more likely to reconsult (incidence rate ratio [IRR] = 2.55, 95% confidence interval [CI] = 1.62 to 4.01) and use of a delayed prescription strategy is associated with reduced reconsultation in this group. In those with prior antibiotic exposure, there was a 34% reduction in consultation rate in the no antibiotic group (IRR = 0.66, 0.30 to 1.44, P = 0.295) and a 78% reduction for the delayed antibiotic group (IRR = 0.22, 0.10 to 0.49, P<0.001) when compared with those given immediate antibiotics. This effect was not observed in patients who had not been prescribed antibiotics in the previous 2 years; there was no reduction in consultations in the no antibiotic group (IRR = 1.23, 0.79 to 1.92, P = 0.358) or the delayed antibiotic group (1.19, 0.78 to 1.80, P = 0.426). There was an increase in consultation rate with an information leaflet (IRR = 1.27, 0.86 to 1.87, P = 0.229). Past attendance with cough, or past attendance with other respiratory illness and smoking, also predicted reconsultation with cough.
Conclusion
Delayed antibiotic prescribing for LRTI appears effective in modifying reconsultation behaviour, particularly in those with a prior history of antibiotic prescription for LRTI.
doi:10.3399/bjgp09X472601
PMCID: PMC2751917  PMID: 19843421
anti-bacterial agents; primary health care; referral and consultation; respiratory tract infections
3.  Predicting the duration of symptoms in lower respiratory tract infection 
Background
Acute lower respiratory tract infection (LRTI) presenting in primary care has a long natural history. Antibiotic treatment makes little or no difference to the duration of cough. Limited information is currently available regarding predictors of illness duration.
Aim
To determine predictors of illness duration in acute LRTI in primary care.
Design of study
Secondary analysis of trial data to identify independent predictors of illness severity and duration.
Setting
Primary care.
Method
Eight-hundred and seven patients aged 3 years and over with acute illness (21 days or less) presenting with cough as the main symptom plus at least one symptom or sign from sputum, chest pain, dyspnoea, or wheeze were recruited to the study. Main outcomes were duration of symptoms (rated at least a slight problem) and more severe symptoms (rated at least moderately bad).
Results
The average duration of cough (rated at least a slight problem) was 11.7 days and was shorter among children (duration −1.72 days; 95% confidence interval [CI] = −3.02 to −0.41) or in individuals with a history of fever (−1.22 days; 95% CI = −0.18 to 2.27). The duration of cough was longer among those with restricted activities on the day they saw the doctor (+0.69 days for each point of a 7-point scale). The duration of more severe symptoms was longer in those with a longer duration of symptoms prior to consultation, with a more severe cough on the day of seeing the doctor, and restriction of activities on the day of seeing the doctor.
Conclusion
Illness duration may be predicted from a limited number of clinical symptoms and from prior history. These findings should be subjected to validation in a separate population. To minimise expectation about rapid resolution of illness, adults who have restricted activities could be advised that they are likely to experience symptoms for longer.
doi:10.3399/bjgp08X264045
PMCID: PMC2233957  PMID: 18307851
bronchitis; cough; prognosis; respiratory tract infections
4.  Developing clinical rules to predict urinary tract infection in primary care settings: sensitivity and specificity of near patient tests (dipsticks) and clinical scores 
Background
Suspected urinary tract infection (UTI) is one of the most common presentations in primary care. Systematic reviews have not documented any adequately powered studies in primary care that assess independent predictors of laboratory diagnosis.
Aim
To estimate independent clinical and dipstick predictors of infection and to develop clinical decision rules.
Design of study
Validation study of clinical and dipstick findings compared with laboratory testing.
Setting
General practices in the south of England.
Method
Laboratory diagnosis of 427 women with suspected UTI was assessed using European urinalysis guidelines. Independent clinical and dipstick predictors of diagnosis were estimated.
Results
UTI was confirmed in 62.5% of women with suspected UTI. Only nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) independently predicted diagnosis (adjusted odds ratios 6.36, 4.52, 2.23 respectively). A dipstick decision rule, based on having nitrite, or both leucocytes and blood, was moderately sensitive (77%) and specific (70%); positive predictive value (PPV) was 81% and negative predictive value (NPV) was 65%. Predictive values were improved by varying the cut-off point: NPV was 73% for all three dipstick results being negative, and PPV was 92% for having nitrite and either blood or leucocyte esterase. A clinical decision rule, based on having two of the following: urine cloudiness, offensive smell, and dysuria and/or nocturia of moderate severity, was less sensitive (65%) (specificity 69%; PPV 77%, NPV 54%). NPV was 71% for none of the four clinical features, and the PPV was 84% for three or more features.
Conclusions
Simple decision rules could improve targeting of investigation and treatment. Strategies to use such rules need to take into account limited negative predictive value, which is lower than expected from previous research.
PMCID: PMC1874525  PMID: 16882379
clinical scoring algorithms; diagnosis, urinary tract infection; dipsticks
5.  Longer term outcomes from a randomised trial of prescribing strategies in otitis media 
Background
There are limited data about the longer-term outcomes in acute otitis media (AOM) when comparing the realistic alternatives of immediate prescription of antibiotics and a ‘wait and see’ or delayed prescribing policy.
Aim
The aim was to assess the medium and longer term outcomes of two prescribing strategies for otitis media.
Design of study
Follow-up of a randomised controlled trial cohort.
Setting
Primary care.
Method
Three-hundred and fifteen children aged 6 months to 10 years presenting with AOM were randomised to immediate antibiotics, or antibiotics delayed at the parents discretion 72 hours if the child still had significant otalgia or fever, or was not improving. Episodes of earache since study entry were documented, and a poor score (of 9 or more — the top 20%) on a reliable six-item functional rating scale (Cronbach's α = 0.75).
Results
The delayed prescribing strategy did not significantly increase reported episodes of earache in the 3 months since randomisation (odds ratio [OR] = 0.89; 95% confidence interval [CI] = 0.48 to 1.65) or over 1 year (OR = 1.03; 95% CI = 0.60 to 1.78) nor of poor scores on the function scale at 3 months (OR = 1.16; 95% CI = 0.61 to 2.22) or 1 year (OR = 1.12; 95% CI = 0.57 to 2.19), and controlling for subsequent antibiotic use after the randomised episode did not alter these estimates. The number of prior episodes of AOM documented in the doctor's notes predicted episodes of earache reported (0, 1, ≥2 episodes, respectively; OR = 1, 2.42, 2.61; χ2 for trend 8.04; P<0.01). There was weaker evidence that prior episodes also predicted poor function at 1 year (OR = 1, 1.86, 2.28; χ2 for trend 5.49; P = 0.019). For children with recurrent AOM (two or more previous episodes documented in the doctor's notes, n = 43) there was possible evidence of fewer episodes of earache in the 3 months since study entry in the immediate antibiotic group (10% compared to 39% in the delayed group, χ2 4.8, P = 0.029), but no effect from randomisation to 1 year.
Conclusions
For most children, delayed prescribing is not likely to have adverse longer-term consequences. Children with recurrent AOM are more likely to have poorer outcomes. Secondary analysis should be treated with caution and requires confirmation, but suggests that treating such children with antibiotics immediately may not alter longer-term outcomes.
PMCID: PMC1828260  PMID: 16536957
antibiotics; otitis media; prescribing strategies; randomised controlled trial
7.  Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study 
BMJ : British Medical Journal  2004;328(7437):444.
Objective To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.
Design Observational study nested within a randomised controlled trial.
Setting Five general practices in three settings in the United Kingdom.
Participants 847 consecutive patients, aged 16-80 years.
Main outcomes measures Patient preferences and doctors' perception of patient pressure and medical need.
Results Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences.
Conclusions Doctors' behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor to be slightly needed or not needed at all, and perceived patient pressure is a strong independent predictor of all doctor behaviours. To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations.
doi:10.1136/bmj.38013.644086.7C
PMCID: PMC344266  PMID: 14966079
8.  Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care 
BMJ : British Medical Journal  2004;328(7437):441.
Objective To assess the impact of leaflets encouraging patients to raise concerns and to discuss symptoms or other health related issues in the consultation.
Design Randomised controlled trial.
Setting Five general practices in three settings in the United Kingdom.
Participants 636 consecutive patients, aged 16-80 years, randomised to receive a general leaflet, a depression leaflet, both, or neither.
Main outcomes Mean item score on the medical interview satisfaction scale, consultation time, prescribing, referral, and investigation.
Results The general leaflet increased patient satisfaction and was more effective with shorter consultations (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both -0.045, -0.08 to—0.009), with similar results for subscales related to the different aspects of communication. Thus for a 10 minute consultation the leaflet increased satisfaction by 7% (seven centile points) and for a five minute consultation by 14%. The leaflet overall caused a small non-significant increase in consultation time (0.36 minutes, -0.54 to 1.26). Although there was no change in prescribing or referral, a general leaflet increased the numbers of investigations (odds ratio 1.43, 1.00 to 2.05), which persisted when controlling for the major potential confounders of perceived medical need and patient preference (1.87, 1.10 to 3.19). Most of excess investigations were not thought strongly needed by the doctor or the patient. The depression leaflet had no significant effect on any outcome.
Conclusions Encouraging patients to raise issues and to discuss symptoms and other health related issues in the consultation improves their satisfaction and perceptions of communication, particularly in short consultations. Doctors do, however, need to elicit expectations to prevent needless investigations.
doi:10.1136/bmj.37999.716157.44
PMCID: PMC344265  PMID: 14966078
10.  Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial 
BMJ : British Medical Journal  2002;325(7354):22.
Objectives
To identify which children with acute otitis media are at risk of poor outcome and to assess benefit from antibiotics in these children.
Design
Secondary analysis of randomised controlled trial cohort.
Setting
Primary care.
Participants
315 children aged 6 months to 10 years.
Intervention
Immediate or delayed (taken after 72 hours if necessary) antibiotics.
Main outcome measure
Predictors of short term outcome: an episode of distress or night disturbance three days after child saw doctor.
Results
Distress by day three was more likely in children with high temperature (adjusted odds ratio 4.5, 95% confidence interval 2.3 to 9.0), vomiting (2.6,1.3 to 5.0), and cough (2.0, 1.1 to 3.8) on day one. Night disturbance by day three was more likely with high temperature 2.4 (1.2 to 4.8), vomiting (2.1,1.1 to 4.0), cough (2.3,1.3 to 4.2), and ear discharge (2.1, 1.2 to 3.9). Among the children with high temperature or vomiting, distress by day three was less likely with immediate antibiotics (32% for immediate v 53% for delayed, χ2=4.0; P=0.045, number needed to treat 5) as was night disturbance (26% v 59%, χ2=9.3; P=0.002; number needed to treat 3). In children without higher temperature or vomiting, immediate antibiotics made little difference to distress by day three (15% v 19%, χ2=0.74; P=0.39) or night disturbance (20% v 27%, χ2=1.6; P=0.20). Addition of cough did not significantly improve prediction of benefit.
Conclusion
In children with otitis media but without fever and vomiting antibiotic treatment has little benefit and a poor outcome is unlikely.
What is already known on this topicMost children with otitis media will not benefit symptomatically from immediate use of antibioticsIt is unclear which children are more likely to benefit from antibiotics and which features predict poor outcomeWhat this study addsChildren with high temperature or vomiting were more likely to be distressed or have night disturbance three days after seeing the doctorChildren with high temperature or vomiting were more likely to benefit from antibiotics, although it is still reasonable to wait 24-48 hours as many children will settle anywayChildren without high temperature or vomiting were unlikely to have poor outcome and unlikely to benefit from immediate antibiotics
PMCID: PMC116668  PMID: 12098725
11.  Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations 
BMJ : British Medical Journal  2001;323(7318):908-911.
Objective
To measure patients' perceptions of patient centredness and the relation of these perceptions to outcomes.
Design
Observational study using questionnaires.
Setting
Three general practices.
Participants
865 consecutive patients attending the practices.
Main outcome measures
Patients' enablement, satisfaction, and burden of symptoms.
Results
Factor analysis identified five components. These were communication and partnership (a sympathetic doctor interested in patients' worries and expectations and who discusses and agrees the problem and treatment, Cronbach's α=0.96); personal relationship (a doctor who knows the patient and their emotional needs, α=0.89); health promotion (α=0.87); positive approach (being definite about the problem and when it would settle, α=0.84); and interest in effect on patient's life (α=0.89). Satisfaction was related to communication and partnership (adjusted β=19.1; 95% confidence interval 17.7 to 20.7) and a positive approach (4.28; 2.96 to 5.60). Enablement was greater with interest in the effect on life (0.55; 0.25 to 0.86), health promotion (0.57; 0.30 to 0.85), and a positive approach (0.82; 0.52 to 1.11). A positive approach was also associated with reduced symptom burden at one month (β=−0.25; −0.41 to −0.10). Referrals were fewer if patients felt they had a personal relationship with their doctor (odds ratio 0.70; 0.54 to 0.90).
Conclusions
Components of patients' perceptions can be measured reliably and predict different outcomes. If doctors don't provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and higher rates of referral.
What is already known on this topicPreliminary evidence suggests that patients' perceptions of patient centredness predict outcomes better than analysing what the doctor says in a consultationWhat this study addsThere are five distinct components of patients' perceptions that can be measured reliably: communication and partnership, personal relationship, health promotion, positive approach to diagnosis and prognosis, and interest in the effect on lifeEach component predicts different consultation outcomesIf doctors don't provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and use more health service resources
PMCID: PMC58543  PMID: 11668137
12.  Randomised controlled trial of self management leaflets and booklets for minor illness provided by post 
BMJ : British Medical Journal  2001;322(7296):1214.
Objective
To assess the effectiveness of providing information by post about managing minor illnesses.
Design
Randomised controlled trial.
Setting
Six general practices.
Participants
Random sample of 4002 patients from the practice registers.
Intervention
Patients were randomised to receive one of three kinds of leaflet or booklet endorsed by their general practitioner: control (surgery access times), booklet, or summary card.
Main outcome measures
Attendance with the 42 minor illnesses listed in the booklet. Perceived usefulness of leaflets or booklets, confidence in managing illness, and willingness to wait before seeing the doctor.
Results
238 (6%) patients did not receive the intervention as allocated. Of the remaining 3764 patients, 2965 (79%) had notes available for review after one year. Compared with the control group, fewer patients attended commonly with the minor illnesses in the booklet group (⩾2 consultations a year: odds ratio 0.81, 95% confidence interval 0.67 to 0.99) and the summary card group (0.83; 0.72 to 0.96). Among patients who had attended with respiratory tract infections in the past year there was a reduction in those attending in the booklet group (0.81; 0.62 to 1.07) and summary card group (0.67; 0.51 to 0.89) compared with the control group. The incidence of contacts with minor illness fell slightly compared with the previous year in the booklet (incidence ratio 0.97; 0.84 to 1.13) and summary card groups (0.93; 0.80 to 1.07). More patients in the intervention groups felt greater confidence in managing illness (booklet 32%, card 34%, control 12%, P<0.001), but there was no difference in willingness to wait score (all groups mean=32, P=0.67).
Conclusion
Most patients find information about minor illness provided by post useful, and it helps their confidence in managing illness. Information may reduce the number attending commonly with minor illness, but the effect on overall contacts is likely to be modest. These data suggest that posting detailed information booklets about minor illness to the general population would have a limited effect.
What is already known on this topicIncreasing attendance for minor illness in primary care is a threat to consultation time and quality of careFew recent studies have examined the effect of providing patients with information on self management of minor illnessWhat this study addsMost patients find information about minor illness provided by post useful, and it helps their confidence in managing illnessInformation booklets and leaflets reduced the number attending frequently with minor illness, but the effect on overall contacts was not significantInformation booklets on minor illness provided by post may have a limited role in the NHS
PMCID: PMC31621  PMID: 11358775
13.  Preferences of patients for patient centred approach to consultation in primary care: observational study 
BMJ : British Medical Journal  2001;322(7284):468.
Objective
To identify patient's preferences for patient centred consultation in general practice.
Design
Questionnaire study.
Setting
Consecutive patients in the waiting room of three doctors' surgeries.
Main outcome measures
Key domains of patient centredness from the patient perspective. Predictors of preferences for patient centredness, a prescription, and examination.
Results
865 patients participated: 824 (95%) returned the pre-consultation questionnaire and were similar in demographic characteristic to national samples. Factor analysis identified three domains of patient preferences: communication (agreed with by 88-99%), partnership (77-87%), and health promotion (85-89%). Fewer wanted an examination (63%), and only a quarter wanted a prescription. As desire for a prescription was modestly associated with desire for good communication (odds ratio 1.20; 95% confidence interval 0.85 to 1.69), partnership (1.46; 1.01 to 2.09), and health promotion (1.61; 1.12 to 2.31) this study may have underestimated preferences for patient centredness compared with populations with stronger preferences for a prescription. Patients who strongly wanted good communication were more likely to feel unwell (very, moderately, and slightly unwell; odds ratios 1, 0.56, 0.39 respectively, z trend P<0.001), be high attenders (1.70; 1.18 to 2.44), and have no paid work (1.84; 1.21 to 2.79). Strongly wanting partnership was also related to feeling unwell, worrying about the problem, high attendance, and no paid work; and health promotion to high attendance and worry.
Conclusion
Patients in primary care strongly want a patient centred approach, with communication, partnership, and health promotion. Doctors should be sensitive to patients who have a strong preference for patient centredness—those vulnerable either psychosocially or because they are feeling unwell.
PMCID: PMC26564  PMID: 11222423
14.  Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media 
BMJ : British Medical Journal  2001;322(7282):336-342.
Objective
To compare immediate with delayed prescribing of antibiotics for acute otitis media.
Design
Open randomised controlled trial.
Setting
General practices in south west England.
Participants
315 children aged between 6 months and 10 years presenting with acute otitis media.
Interventions
Two treatment strategies, supported by standardised advice sheets—immediate antibiotics or delayed antibiotics (antibiotic prescription to be collected at parents' discretion after 72 hours if child still not improving).
Main outcome measures
Symptom resolution, absence from school or nursery, paracetamol consumption.
Results
On average, symptoms resolved after 3 days. Children prescribed antibiotics immediately had shorter illness (−1.1 days (95% confidence interval −0.54 to −1.48)), fewer nights disturbed (−0.72 (−0.30 to −1.13)), and slightly less paracetamol consumption (−0.52 spoons/day (−0.26 to −0.79)). There was no difference in school absence or pain or distress scores since benefits of antibiotics occurred mainly after the first 24 hours—when distress was less severe. Parents of 36/150 of the children given delayed prescriptions used antibiotics, and 77% were very satisfied. Fewer children in the delayed group had diarrhoea (14/150 (9%) v 25/135 (19%), χ2=5.2, P=0.02). Fewer parents in the delayed group believed in the effectiveness of antibiotics and in the need to see the doctor with future episodes.
Conclusion
Immediate antibiotic prescription provided symptomatic benefit mainly after first 24 hours, when symptoms were already resolving. For children who are not very unwell systemically, a wait and see approach seems feasible and acceptable to parents and should substantially reduce the use of antibiotics for acute otitis media.
PMCID: PMC26576  PMID: 11159657

Results 1-14 (14)