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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Time To talk? patient experiences of waiting for clinical management of knee injuries
Background: People with knee problems face long waits for elective surgery in many parts of the world. However, there is little evidence about the impact of delays in such treatment, especially for patients with mechanical knee injuries. Objective: To conduct a detailed exploration of patient experiences of waits for specialist diagnosis and surgery for knee injuries at one UK centre. Research design: In-depth qualitative paired interviews with a range of patients at baseline and 6 months later. Subjects: Patients awaiting imminent therapeutic arthroscopy of the knee (n = 20) or recently referred from primary care for specialist opinion or imaging for a knee injury (n = 19). Sample stratified to maximise variation by gender and age. Results: 36 patients completed both interviews. Four topic areas were identified. First, problems in the healthcare system were highlighted, including a lack of adequate information, which made it difficult for patients to make decisions about their lives. Second, patients experienced a social and psychological cost of waiting. Third, patients varied in their ability to cope and demonstrated both passive and proactive coping strategies. Fourth, patients described the management effectiveness of clinicians and their ability or otherwise to provide support. Conclusions: A detailed qualitative approach has identified broad physical and psycho-social consequences for patients with knee injuries experiencing delays in clinical management. An overarching theme was the important potential of both systemic and interpersonal communication to improve patient well-being. A managed care pathway which enhanced information provision may provide immediate opportunities for improving patient well-being.
The additional costs of antibiotics and re-consultations for antibiotic-resistant Escherichia coli urinary tract infections managed in general practice
The emergence of antibiotic resistance is a major threat to public health. In the UK, most antibiotics are prescribed in general practice but the extra costs to general practice of resistant infections have not previously been well described. We compared the costs of treating patients presenting with resistant Escherichia coli urinary tract infections (UTIs) (resistant to ampicillin, trimethoprim or at least one antibiotic) with the costs of treating patients with UTIs that were sensitive to all six tested antibiotics (ampicillin, trimethoprim, amoxicillin/clavulanic acid, cefalexin, ciprofloxacin and nitrofurantoin) with regard to re-consultations and antibiotics prescribed. There were significantly higher antibiotic costs (mean extra antibiotic cost £1.19/€1.75), re-consultation costs (£2.42/€3.55) and total costs (£3.62/€5.31) for patients whose infections were resistant to at least one antibiotic compared with those with sensitive infections even after accounting for potentially confounding factors. Although these per-patient costs may appear small, they do not take into account the full additional costs of resistant UTIs in the community and, given the high prevalence of UTIs, the overall costs to the health service are substantial. © 2008 Elsevier B.V. and the International Society of Chemotherapy.
Interventions before consultations to help patients address their information needs by encouraging question asking: systematic review.
OBJECTIVE: To assess the effects on patients, clinicians, and the healthcare system of interventions before consultations to help patients or their representatives gather information in consultations by question asking. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Electronic literature searches of seven databases and hand searching of one journal and bibliographies of relevant articles. Review methods Inclusion criteria included randomised controlled trials. MAIN OUTCOME MEASURES: Primary outcomes were question asking; patients' anxiety, knowledge, and satisfaction; and length of consultation. RESULTS: 33 randomised trials of variable quality involving 8244 patients were identified. A few studies showed positive effects. Meta-analyses showed small and statistically significantly increases in question asking (standardised mean difference 0.27, 95% confidence interval 0.19 to 0.36) and patients' satisfaction (0.09, 0.03 to 0.16). Non-statistically significant changes occurred in patients' anxiety before consultations (weighted mean difference -1.56, -7.10 to 3.97), patients' anxiety after consultations (standardised mean difference -0.08, -0.22 to 0.06), patients' knowledge (-0.34, -0.94 to 0.25), and length of consultation (0.10, -0.05 to 0.25). Interventions comprising written materials had similar effects on question asking, consultation length, and patients' satisfaction as those comprising the coaching of patients. Interventions with additional training of clinicians had little further effect than those targeted at patients alone for patients' satisfaction and consultation length. CONCLUSIONS: Interventions for patients before consultations produce small benefits for patients. This may be because patients and clinicians have established behaviours in consultations that are difficult to change. Alternatively small increases in question asking may not be sufficient to make notable changes to other outcomes.
Developing an 'interactive' booklet on respiratory tract infections in children for use in primary care consultations
Objective: To construct a systematic process for developing an 'interactive' booklet for use in primary care consultations and to use this process to develop a booklet on respiratory tract infections in children. Methods: Booklet development occurred through a number of stages, which included: expert group brainstorming and literature review, professional graphic design, readability assessment, and consultation with users. Consultation was achieved through the use of focus groups and interviews with parents, focus groups and independent booklet review by general practitioners, and booklet review and feedback by paediatricians. Results: All development stages led to meaningful enhancements to the booklet. Consultation with parents demonstrated a desire for more information than anticipated, with a particular emphasis on the interpretation of signs and symptoms, and the recognition of serious illness. General practitioners contributed to the design and clarity of the booklet and helped to ensure that it would be acceptable for use within consultations. Conclusion: Written material needs to be developed in a systematic way and include consultation with the intended users. Focus groups are a valuable tool for consulting with consumers and practitioners in this regard. Practice implications: The process described can be used as a guide for those wishing to develop similar written materials. © 2008 Elsevier Ireland Ltd. All rights reserved.
Antibiotics in the community: A typology of user behaviours
Objectives: To contribute to achieving a deep understanding of lay beliefs about antibiotics and develop a typology of antibiotic user behaviours in the community. Method: Qualitative semi-structured interview study with 32 women and 14 men, selected by both purposive and theoretical sampling, from areas of high, average and low deprivation. Results: Respondents were highly confident about the efficacy and safety of antibiotics. Reported respondent antibiotic user behaviours fell into six types, those that: (1) always took antibiotics as prescribed; (2) could not take doses because of work, child care, or social constraints; (3) frequently forgot doses; (4) believed it made sense to stop taking antibiotics as they started to get better; (5) actively sought to limit antibiotic use because they believed their own bodies became used to them or because antibiotics are 'unnatural'; and (6) deliberately planned to stop early so as to have an antibiotic supply for self use in the future to avoid the challenges of consulting and obtaining antibiotics in primary care. Conclusion: Members of the public are confident about the safety and efficacy of antibiotics. Most report taking antibiotics as prescribed, but there is a range of other unintentional and intentional characteristic non-adherent behaviours that require different solutions. Practice implications: Promoting public engagement in the control of bacterial resistance through adherence to antibiotic regimes requires some interventions that address beliefs, others addressing forgetfulness, and others addressing practical barriers to adherence. © 2008 Elsevier Ireland Ltd. All rights reserved.
GPs' approach to insulin prescribing in older patients: A qualitative study
Background: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. Aim: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. Design of study: Qualitative individual interviews using a grounded theory approach. Setting: Primary care. Method: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. Results: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. Conclusion: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs Intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed. ©British Journal of General Practice.
The effect of using an interactive booklet on childhood respiratory tract infections in consultations: Study protocol for a cluster randomised controlled trial in primary care
Background. 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. Methods/Design. 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. Discussion. 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. Trial registration. Current Controlled Trials ISRCTN46104365. © 2008 Francis et al; licensee BioMed Central Ltd.
General practitioners' perceptions of introducing near-patient testing for common infections into routine primary care: A qualitative study
Objective. 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. Design. Qualitative semi-structured interview study. Interviews were recorded and analysed using thematic content analysis. Setting. General practices in south-east Wales, UK. Subjects. 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. Results. 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. Conclusions. 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. © 2008 Taylor & Francis.
European Surveillance of Antimicrobial Consumption (ESAC): Quality indicators for outpatient antibiotic use in Europe
Background and objective: Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug-specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data. Methods: 27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997-2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA-RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1-6 interval and if there was consensus (number of scores within the 1-3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators-values were updated with 2004 ESAC data. Results: 22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected. Conclusion: 12 of the proposed ESAC-based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.
Public beliefs on antibiotics and respiratory tract infections: An internet-based questionnaire study
Background: Patient expectations are among the strongest predictors of clinicians' antibiotic prescribing decisions. Although public knowledge, beW and experiences of antibiotics contribute to these expectations, little is known about these public views. Aim: To gain insight into pub lic knowledge, beliefs, and experiences of antibiotics and respiratory bad infections. Design of study: Cross-sect ional, internet-based questionnaires study. Setting: Members of the general public aged 16 years and over in the Ne therlands. Methods: Public knowledge, beliefs, and expe-riences of anti biotics 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. Results: Of the participants, 44.6% accurately ident ified 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. Conclusion: 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. © British Journal of General Practice 2007.
Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice
Objective: To determine if a communication skills training program for general practitioners involving context-rich learning experiences and 'peer review' of consultation transcripts results in communication skills acquisition and maintenance, while preserving time-efficiency in consultations. Methods: A pre-test-post-test evaluation of training 20 general practitioners (GPs) in enhanced communication skills. Audio taped consultations with simulated patients in routine practice conducted before, within 2 weeks and again 6 months after communication skills training were analysed and consultation length measured. Transcripts were scored for specific skills to determine differences in short and longer-term competence of GPs for the communication skills. Results: There was good evidence that GPs acquired key communication skills after training and that these were maintained over 6 months. Consultations remained within normal consultation length in primary care. Conclusion: Specific communication skills for acute bronchitis can be successfully acquired by GPs through context-rich communication training with peer review of transcripts with simulated patients, without making consultation length unfeasible. Practice Implications: This approach to skill acquisition is useful for enhancing communication skills competence in general medical practice. © 2007 Elsevier Ireland Ltd. All rights reserved.