36 research outputs found
The overlooked challenges facing Out-of-Hours primary care in the NHS:a missed opportunity in policy
No full text[No abstract
Inequality in uptake of bowel cancer screening by deprivation, ethnicity and smoking status: cross-sectional study in 86 850 citizens
No full textBackgroundSurvival from colorectal cancer depends on stage at detection. In England, bowel cancer mortality has historically been highest in deprived areas. During the initial stages of the COVID-19 pandemic, it was necessary to temporarily halt many screening programmes, which may have led to inequalities in uptake since screening restarted.MethodsCross-sectional data from the Bristol, North Somerset and South Gloucestershire Systemwide Dataset were analyzed. Associations of baseline characteristics with uptake of bowel screening were examined using logistic regression.ResultsAmongst 86 850 eligible adults aged 60–74 years, 5261 had no screening record. There was little evidence of association between no screening and sex (adjusted odds ratio 0.95 (95% confidence interval 0.90, 1.02)). Absence of screening record was associated with deprivation (1.26 (1.14, 1.40) for the most compared with the least deprived groups), smoking (1.11 (1.04, 1.18)) compared with no smoking record and black (1.36 (1.09, 1.70)) and mixed (1.08 (1.01, 1.15)) ethnicity compared with white ethnicity.ConclusionsIn a data set covering a whole NHS Integrated Care Board, there was evidence of lower uptake of bowel cancer screening in adults living in more deprived areas, of minority ethnic groups and who smoked. These findings may help focus community engagement work and inform research aimed at reducing inequalities
Protocol for an ‘efficient design’ cluster randomised controlled trial to evaluate a complex intervention to improve antibiotic prescribing for CHIldren presenting to primary care with acute COugh and respiratory tract infection:the CHICO study
No full textIntroduction Respiratory tract infections (RTIs) in children are common and present major resource implications for primary care. Unnecessary use of antibiotics is associated with the development and proliferation of antimicrobial resistance. In 2016, the National Institute for Health Research (NIHR)-funded ‘TARGET’ programme developed a prognostic algorithm to identify children with acute cough and RTI at very low risk of 30-day hospitalisation and unlikely to need antibiotics. The intervention includes: (1) explicit elicitation of parental concerns, (2) the results of the prognostic algorithm accompanied by prescribing guidance and (3) provision of a printout for carers including safety netting advice. The CHIldren’s COugh feasibility study suggested differential recruitment of healthier patients in control practices. This phase III ‘efficiently designed’ trial uses routinely collected data at the practice level, thus avoiding individual patient consent. The aim is to assess whether embedding a multifaceted intervention into general practitioner (GP) practice Information Technology (IT) systems will result in reductions of antibiotic prescribing without impacting on hospital attendance for RTI.Methods and analysis The coprimary outcomes are (1) practice rate of dispensed amoxicillin and macrolide antibiotics, (2) hospital admission rate for RTI using routinely collected data by Clinical Commissioning Groups (CCGs). Data will be collected for children aged 0–9 years registered at 310 practices (155 intervention, 155 usual care) over a 12-month period. Recruitment and randomisation of practices (using the Egton Medical Information Systems web data management system) is conducted via each CCG stratified for children registered and baseline dispensing rates of each practice. Secondary outcomes will explore intervention effect modifiers. Qualitative interviews will explore intervention usage. The economic evaluation will be limited to a between-arm comparison in a cost–consequence analysis.Ethics and dissemination Research ethics approval was given by London-Camden and Kings Cross Research Ethics Committee (ref:18/LO/0345). This manuscript refers to protocol V.4.0. Results will be disseminated through peer-reviewed journals and international conferences.Trial registration number ISRCTN11405239
Can primary care research be conducted more efficiently using routinely reported practice-level data: a cluster randomised controlled trial conducted in England?
No full textObjectives Conducting randomised controlled trials (RCTs) in primary care is challenging; recruiting patients during time-limited or remote consultations can increase selection bias and physical access to patients’ notes is costly and time-consuming. We investigated barriers and facilitators to running a more efficient design.
Design An RCT aiming to reduce antibiotic prescribing among children presenting with acute cough and a respiratory tract infection (RTI) with a clinician-focused intervention, embedded at the practice level. By using aggregate level, routinely collected data for the coprimary outcomes, we removed the need to recruit individual participants.
Setting Primary care.
Participants Baseline data from general practitioner practices and interviews with individuals from Clinical Research Networks (CRNs) in England who helped recruit practices and Clinical Commission Groups (CCGs) who collected outcome data.
Intervention The intervention included: (1) explicit elicitation of parental concerns, (2) a prognostic algorithm to identify children at low risk of hospitalisation and (3) provision of a printout for carers including safety-netting advice.
Coprimary outcomes For 0–9 years old—(1) Dispensing data for amoxicillin and macrolide antibiotics and (2) hospital admission rate for RTI.
Results We recruited 294 of the intended 310 practices (95%) representing 336 496 registered 0–9 years old (5% of all 0–9 years old children). Included practices were slightly larger, had slightly lower baseline prescribing rates and were located in more deprived areas reflecting the national distribution. Engagement with CCGs and their understanding of their role in this research was variable. Engagement with CRNs and installation of the intervention was straight-forward although the impact of updates to practice IT systems and lack of familiarity required extended support in some practices. Data on the coprimary outcomes were almost 100%.
Conclusions The infrastructure for trials at the practice level using routinely collected data for primary outcomes is viable in England and should be promoted for primary care research where appropriate.
Trial registration number ISRCTN11405239
Some like it hot: medical student views on choosing the emotional level of a simulation
No full textThis study aimed to determine the impact of giving junior medical students control over the level of emotion expressed by a simulated patient (SP) in a teaching session designed to prepare students to handle emotions when interviewing real patients on placements
A multifaceted intervention to reduce antibiotic prescribing among CHIldren with acute COugh and respiratory tract infection: the CHICO cluster RCT
No full textBACKGROUND: Clinical uncertainty in primary care regarding the prognosis of children with respiratory tract infections contributes to the unnecessary use of antibiotics. Improved identification of children at low risk of future hospitalisation might reduce clinical uncertainty. A National Institute for Health and Care Research-funded 5-year programme (RP-PG-0608-10018) was used to develop and feasibility test an intervention.OBJECTIVES: The aim of the children with acute cough randomised controlled trial was to reduce antibiotic prescribing among children presenting with acute cough and respiratory tract infection without increasing hospital admission.DESIGN: An efficient, pragmatic open-label, two-arm trial (with embedded qualitative and health economic analyses) using practice-level randomisation using routinely collected data as the primary outcome.SETTING: General practitioner practices in England.PARTICIPANTS: General practitioner practices using the Egton Medical Information Systems
® patient-record system for children aged 0-9 years presenting with a cough or upper respiratory tract infection. Recruited by Clinical Research Networks and Clinical Commissioning Groups.
INTERVENTION: Comprised: (1) elicitation of parental concerns during consultation; (2) a clinician-focused prognostic algorithm to identify children with acute cough and respiratory tract infection at low, average or elevated risk of hospitalisation in the next 30 days accompanied by prescribing guidance, (3) provision of a printout for carers including safety-netting advice.MAIN OUTCOME MEASURES: Co-primaries using the practice list-size for children aged 0-9 years as the denominator: rate of dispensed amoxicillin and macrolide items at each practice (superiority comparison) from
NHS Business Services Authority ePACT2 and rate of hospital admission for respiratory tract infection (non-inferiority comparison) from Clinical Commissioning Groups, both routinely collected over 12 months.
RESULTS: Of the 310 practices required, 294 (95%) were recruited (144 intervention and 150 controls) with 336,496 registered 0-9-year-olds (5% of all 0-9-year-old children in England) from 47 Clinical Commissioning Groups. Included practices were slightly larger than those not included, had slightly lower baseline dispensing rates and were located in more deprived areas (reflecting the distribution for practice postcodes nationally). Twelve practices (4%) subsequently withdrew (six related to the pandemic). The median number of times the intervention was used was 70 per practice (by a median of 9 clinicians) over 12 months. There was no evidence that the antibiotic dispensing rate in the intervention practices [0.155 (95% confidence interval 0.135 to 0.179)] differed to controls [0.154 (95% confidence interval 0.130 to 0.182), relative risk= 1.011 (95% confidence interval 0.992 to 1.029);
p = 0.253]. There was, overall, a reduction in dispensing levels and intervention usage during the pandemic. The rate of hospitalisation for respiratory tract infection in the intervention practices [0.019 (95% confidence interval 0.014 to 0.026)] compared to the controls [0.021 (95% confidence interval 0.014 to 0.029)] was non-inferior [relative risk = 0.952 (95% confidence interval 0.905 to 1.003)]. The qualitative evaluation found the clinicians liked the intervention, used it as a supportive aid, especially with borderline cases but that it, did not always integrate well within the consultation flow and was used less over time. The economic evaluation found no evidence of a difference in mean National Health Service costs between arms; mean difference -£1999 (95% confidence interval -£6627 to 2630).
CONCLUSIONS: The intervention was feasible and subjectively useful to practitioners, with no evidence of harm in terms of hospitalisations, but did not impact on antibiotic prescribing rates.FUTURE WORK AND LIMITATIONS: Although the intervention does not appear to change prescribing behaviour, elements of the approach may be used in the design of future interventions.TRIAL REGISTRATION: This trial is registered as ISRCTN11405239 (date assigned 20 April 2018) at www.controlled-trials.com (accessed 5 September 2022). Version 4.0 of the protocol is available at: https://www.journalslibrary.nihr.ac.uk/ (accessed 5 September 2022).FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (NIHR award ref: 16/31/98) programme and is published in full in
Health Technology Assessment; Vol. 27, No. 32. See the NIHR Funding and Awards website for further award information.
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A multi-faceted intervention to improve management of antibiotics for CHIldren presenting to primary care with acute COugh and respiratory tract infection (CHICO): an efficient cluster randomised controlled trial
No full textObjectives: Unnecessary use of antibiotics needlessly contributes to antimicrobial resistance. Our aim was to assess whether an easy-to-use multifaceted intervention for children presenting to primary care with respiratory tract infections (RTI) would reduce antibiotic dispensing, without increasing hospital admissions for RTI.
Design: A two-arm randomised controlled trial clustered by GP practice, using routine outcome data, with qualitative and economic evaluations.
Setting: English GP practices using the EMIS® electronic medical record system.
Participants: Children aged 0-9 years with RTI, before and during the COVID-19 pandemic.
Intervention: Three components: i) elicitation of parental concerns during consultation; ii) a clinician-focussed prognostic algorithm to identify children at very low, normal or elevated 30-day hospitalisation risk accompanied by antibiotic prescribing guidance; and iii) a leaflet for carers including safety-netting advice.
Main outcome measures: Rate of dispensed amoxicillin and macrolide antibiotics (superiority comparison) and hospital admissions for RTI (non-inferiority comparison) for children aged
0-9 years over 12 months (same-age practice list-size as denominator).
Results: Of 310 practices required, 294 (95%) were randomised (144 intervention and 150 controls) representing 5% of all registered 0-9 year-olds in England. Of these, 12 (4%) subsequently withdrew (6 related to the pandemic). Median intervention use per practice was 70 (by a median of 9 clinicians). There was no evidence that antibiotic dispensing in intervention practices (155 items per year, per 1000 children [95% CI: 138 to 174]) differed from control practices (157 items per year, per 1000 children [95% CI: 140 to 176]); rate ratio(RR)=1.011 [95% CI:0.992 to 1.029]; p=0.253). Pre-specified subgroup analyses suggested reduced dispensing in intervention practices with fewer prescribing nurses, in single site (compared with multi-site) practices, and located in areas of lower socioeconomic deprivation; although these analyses were underpowered. Pre-specified sensitivity analysis suggested reduced dispensing amongst older children in the intervention arm (p=0.03). A post-hoc sensitivity analyses suggested there was less dispensing in intervention practices pre-pandemic (RR=0.967 [95% CI:0.946 to 0.989];p=0.003). The rate of hospitalisation for RTI in the intervention practices (13 hospitalisations per 1000 children [95% CI:10 to 18)] was non-inferior compared with control practices (15 hospitalisations per 1000 children [95% CI: 12 to 20]); RR=0.952 [95% CI:0.905 to 1.003].
Conclusions: This multifaceted antibiotic stewardship intervention for children with RTIs did not reduce overall antibiotic dispensing nor increase RTI-related hospital admissions. There were some subgroups and situations (e.g. under non-pandemic conditions) where the intervention slightly reduced prescribing rates but not in a clinically meaningful way
Impact of remote vital sign monitoring on health outcomes in acute respiratory infection and exacerbation of chronic respiratory conditions:systematic review and meta-analysis
No full textBackground Our aim was to investigate the effectiveness of virtual wards on health outcomes in patients with acute respiratory infection.Methods We searched four electronic databases from January 2000–March 2021 for randomised controlled trials (RCTs). We included studies in people with acute respiratory illness or an acute exacerbation of a chronic respiratory illness, where a patient or carer measured vital signs (oximetry, blood pressure, pulse) for initial diagnosis and/or asynchronous monitoring, in a person living in private housing or a care home. We performed random effects meta-analysis for mortality.Results We reviewed 5834 abstracts, 107 full texts, and judged nine RCTs relevant for inclusion in which sample sizes ranged from 37–389 (total=1627), mean ages between 61 and 77 years, and five judged to be at low risk of bias. Five RCTs had fewer hospital admissions in the intervention (monitoring) group, out of which two studies reported a significant difference. Two studies reported more admissions in the intervention group, with one reporting a significant difference. We were unable to perform a meta-analysis on healthcare utilisation and hospitalisation data due to lack of outcome definition in the primary studies and variable outcome measurements. We judged two studies to be at low risk of bias. The pooled summary risk ratio for mortality was 0.90 (95% CI 0.55 to 1.48).Conclusion The limited literature for remote monitoring of vital signs in acute respiratory illness provides weak evidence that these interventions have a variable impact on hospitalisations and healthcare utilisation, and may reduce mortality
