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J Wood, C C Butler,
K Hood,
M J Kelly,
T Verheij,
P Little,
A Torres,
F Blasi,
T Schaberg,
H Goossens,
J Nuttall,
S Coenen
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ABSTRACT: European guidelines for treating acute cough/lower respiratory tract infection (LRTI) aim to reduce nonevidence-based variation in prescribing, and better target and increase the use of first-line antibiotics. However, their application in primary care is unknown. We explored congruence of both antibiotic prescribing and antibiotic choice with European Respiratory Society (ERS)/European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for managing LRTI. The present study was an analysis of prospective observational data from patients presenting to primary care with acute cough/LRTI. Clinicians recorded symptoms on presentation, and their examination and management. Patients were followed up with self-complete diaries. 1,776 (52.7%) patients were prescribed antibiotics. Given patients' clinical presentation, clinicians could have justified an antibiotic prescription for 1,915 (71.2%) patients according to the ERS/ESCMID guidelines. 761 (42.8%) of those who were prescribed antibiotics received a first-choice antibiotic (i.e. tetracycline or amoxicillin). Ciprofloxacin was prescribed for 37 (2.1%) and cephalosporins for 117 (6.6%). A lack of specificity in definitions in the ERS/ESCMID guidelines could have enabled clinicians to justify a higher rate of antibiotic prescription. More studies are needed to produce specific clinical definitions and indications for treatment. First-choice antibiotics were prescribed to the minority of patients who received an antibiotic prescription.
European Respiratory Journal 01/2011; 38(1):112-8. · 5.89 Impact Factor
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ABSTRACT: Otitis media with effusion (OME) is the most common cause of acquired hearing loss in childhood and has been associated with delayed language development and behavioural problems. This condition has a point-prevalence of about 20% at the age of two years, a time of rapid language development. It is most often asymptomatic. Effective treatment exists for clearing effusions. Some have argued, therefore, that children should be screened and treated early if found to have clinically important OME. However, there is a high rate of spontaneous resolution of effusions and, for some children, effusions may represent a physiological response that does not reduce hearing significantly or impact negatively on language development or behaviour. Previous reviews of the effect of screening and treatment have included studies using non-randomised designs.
The aim of this review was to assess evidence from randomised controlled trials about the effect, on language and behavioural outcomes, of screening and treating children with clinically important OME in the first four years of their life. The focus was on the first four years of life because this is the time of most rapid language development. The consequences of hearing loss are likely to be most serious during this time. In addition, children of this age are least likely to be able to report or seek help for impaired hearing, particularly if these problems have a slow onset and are subtle.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006) in February 2002, and again in January 2006, and the reference lists of all studies. We also contacted the first authors of the studies we included in the original review.
1. Randomised controlled trials evaluating interventions for OME among children with OME identified through screening.2. Comparison of outcomes for children randomised to be screened for OME and outcomes for children who were not randomised to be screened for OME.
Four authors independently extracted data and assessed trial quality, two in the original review and two for the update.
We identified no trials comparing outcomes for children randomised to be screened for OME with outcomes for children who were not randomised to be screened for OME. We identified three trials evaluating interventions for OME among children with OME identified through screening, one of which generated three published studies. These were trials of treatment in children identified through screening rather than trials of treatment programs. From these trials, we found no evidence of clinically important benefit in language development from screening and treating children with clinically important OME.
The identified randomised trials do not show an important benefit on language development and behaviour from screening of the general population of asymptomatic children in the first four years of life for OME. However, these trials were all conducted in developed countries. Evidence generated in the developed world, where children may enjoy better nutrition, better living conditions and less severe and different infections may not be applicable to children in developing countries. The screening aspect of some of these studies was aimed primarily at identifying suitable children in whom to evaluate the effects of treatment, rather than to evaluate the effects of screening programs. Younger children and children with milder disease may have been included in these treatment trials compared to children who are offered treatment in pragmatic settings.
Cochrane database of systematic reviews (Online) 02/2007; · 5.72 Impact Factor
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ABSTRACT: Patients often do not get the information they require from doctors and nurses. To address this problem, interventions directed at patients to help them gather information in their healthcare consultations have been proposed and tested.
To assess the effects on patients, clinicians and the healthcare system of interventions which are delivered before consultations, and which have been designed to help patients (and/or their representatives) address their information needs within consultations.
We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library (issue 3 2006); MEDLINE (1966 to September 2006); EMBASE (1980 to September 2006); PsycINFO (1985 to September 2006); and other databases, with no language restriction. We also searched reference lists of articles and related reviews, and handsearched Patient Education and Counseling (1986 to September 2006).
Randomised controlled trials of interventions before consultations designed to encourage question asking and information gathering by the patient.
Two researchers assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of five outcomes.
We identified 33 randomised controlled trials, from 6 countries and in a range of settings. A total of 8244 patients was randomised and entered into studies. The most common interventions were question checklists and patient coaching. Most interventions were delivered immediately before the consultations.Commonly-occurring outcomes were: question asking, patient participation, patient anxiety, knowledge, satisfaction and consultation length. A minority of studies showed positive effects for these outcomes. Meta-analyses, however, showed small and statistically significant increases for question asking (standardised mean difference (SMD) 0.27 (95% confidence interval (CI) 0.19 to 0.36)) and patient satisfaction (SMD 0.09 (95% CI 0.03 to 0.16)). There was a notable but not statistically significant decrease in patient anxiety before consultations (weighted mean difference (WMD) -1.56 (95% CI -7.10 to 3.97)). There were small and not statistically significant changes in patient anxiety after consultations (reduced) (SMD -0.08 (95%CI -0.22 to 0.06)), patient knowledge (reduced) (SMD -0.34 (95% CI -0.94 to 0.25)), and consultation length (increased) (SMD 0.10 (95% CI -0.05 to 0.25)). Further analyses showed that both coaching and written materials produced similar effects on question asking but that coaching produced a smaller increase in consultation length and a larger increase in patient satisfaction. Interventions immediately before consultations led to a small and statistically significant increase in consultation length, whereas those implemented some time before the consultation had no effect. Both interventions immediately before the consultation and those some time before it led to small increases in patient satisfaction, but this was only statistically significant for those immediately before the consultation. There appear to be no clear benefits from clinician training in addition to patient interventions, although the evidence is limited.
Interventions before consultations designed to help patients address their information needs within consultations produce limited benefits to patients. Further research could explore whether the quality of questions is increased, whether anxiety before consultations is reduced, the effects on other outcomes and the impact of training and the timing of interventions. More studies need to consider the timing of interventions and possibly the type of training provided to clinicians.
Cochrane database of systematic reviews (Online) 02/2007; · 5.72 Impact Factor
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ABSTRACT: The aims of this study were to examine how GPs manage the consultation for upper resiratory tract infections (URTIs) and the prescribing of antibiotics, to understand what skills and strategies are used in managing URTIs without antibiotics, and to note evidence of pressure on doctors to prescribe and whether there are signs of overt disagreement about prescribing in the consultation.
A qualitative analysis of audiotaped consultations was carried out. The setting was a general practice in South Wales and the subjects were five GPs and 29 parents presenting children with URTIs over a 2-week period. The main outcome measures were skills and strategies identified from audiotapes of consultations.
This group of GPs used a set of readily identifiable consulting skills for managing the consultation without prescribing. Their consultations had a highly routinized quality. There was little evidence of either conflict or overt pressure from parents to prescribe. The word 'antibiotics' was seldom mentioned. Clinicians did not elicit patient expectations for receiving antibiotics.
Doctors use a set of readily identifiable skills in managing the URTI consultation. Avoiding the prescribing of antibiotics is not necessarily a simple and straightforward matter. Since patients apparently want antibiotics less than anticipated, eliciting expectations might be a way of reducing prescribing and broadening the approach to meeting patient needs. Whether doctors can adjust their routinized consulting patterns in the time-limited context of general practice remains an open question.
Family Practice 11/2001; 18(5):506-10. · 1.50 Impact Factor
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C Butler
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ABSTRACT: Research strongly supports the view that pregnancy termination is seldom associated with adverse psychological sequelae in the short to medium term, but experience shows that there is a small group of women who experience long and intense suffering. This is a report of the cases of two women who presented with psychological problems associated with a termination 19 and 5 years earlier.
The Journal of family practice 11/1996; 43(4):396-401. · 0.61 Impact Factor
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ABSTRACT: Patients grouped together in practices may share characteristics that cause them to have similar responses to an intervention. Sampling from such groups means that the power of a trial is less than when subjects are selected from the population at random. Knowledge of likely variation in outcome at the practice level is necessary to calculate the extent to which sample size would need to be inflated to maintain statistical power in the face of 'cluster effects'.
To plan sample size and precision requirements of a clinical trial, we examined reports of primary care smoking cessation trials for information on outcomes at the level of clusters, and found them unhelpful. We therefore constructed hypothetical scenarios to quantity the potential importance of this effect.
Scenarios of moderate and large inter cluster variation were compared with a sample where there was no difference in effect size at the level of practices.
A study with 80% power to detect a difference of 20% versus 10% at a 5% significance level would need 200 patients in each arm in the absence of cluster effects. With moderate variation in outcome between clusters, over a thousand patients would be needed in the study to maintain this precision. With larger inter-cluster variation, close to 4000 subjects would be required.
In the absence of detailed data from previous studies, hypothetical models can give insight into the statistical implications of possible cluster effects on study design and analysis. With even moderate inter-cluster variation, sample size will have to be inflated considerably to maintain the same statistical precision. Workers in this field will greatly assist those planning future research if they publish details of variation in outcome at the level of clusters.
Family Practice 09/1996; 13(4):402-7. · 1.50 Impact Factor
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ABSTRACT: Despite the explosion of research into the effect of medical advice on patient behaviour, only about 50% of patients comply with long-term drug regimens. And when it comes to changes in lifestyle, the percentage of patients who comply with medical advice often falls to single figures. Review articles on compliance have traditionally concentrated on factors that make it easier for patients to adhere to medical advice. However, recent articles urge clinicians to be more understanding of the wider implications of compliance in their patients' lives. This article focuses on how clinicians' consulting methods can affect patients' behaviour. Specifically, the authors consider the patient-centred clinical method as well as insights from and consulting techniques pioneered in the addictions field that can help to bring ambivalent patients closer to decisions about change. Instead of seeing resistance to change as rooted entirely in the patient, the authors view it as stemming partly from the way clinicians talk to patients. An advice-giving approach is usually inadequate to motivate people to embark on major lifestyle changes. Instead, the authors propose a negotiation-based framework that harnesses patients' intrinsic motivation to make their own decisions. This approach also promotes clinicians' acceptance of patients' decisions, even if these decisions run counter to current medical wisdom.
Canadian Medical Association Journal 06/1996; 154(9):1357-62. · 8.22 Impact Factor
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ABSTRACT: The interaction between a clinician and a patient who put his problems down to myalgic encephalomyelitis is described. Despite attempting a patient-centred approach, the doctor acted on his own understanding of the meaning of this diagnosis without gaining proper insight into what it meant for the patient. This failure not only led to damaged rapport, it may have contributed to delayed recovery.
The unsatisfactory nature of this encounter led the clinician to consider more effective consulting techniques.
A hypothetical interaction is constructed in which the clinician uses reflective listening statements to understand the patient's true meaning of this self-diagnosis.
Despite well intentioned attempts to be patient-centered through widening the consultation beyond the biomedical to include personal and contextual factors, clinicians may still end up imposing their own medical meaning on patient's words. Damaged rapport is a signal that another track could be more fruitful and reflective listening is one strategy which enables clinicians to check that they fully understand the patient's meaning. Provoking resistance by following strategies which are not appropriate for the patient might then be avoided.
Family Practice 03/1996; 13(1):106-9. · 1.50 Impact Factor
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ABSTRACT: To examine current targets for glycated haemoglobin as a marker for metabolic control in diabetes mellitus in relation to datasets from several areas, and to consider whether target setting could be improved.
Data collected from enhanced care records of general practices for a representative community based sample of people with diabetes.
3022 people with diabetes on the lists of 37 general practices (total list size 222,550) in South Glamorgan in 1992; samples of glycated haemoglobin had been processed at two laboratories with different methodologies and reference ranges.
Last glycated haemoglobin level measured in subjects for 1992 and published data from other studies considered in relation to existing goals and standards for the metabolic control of diabetes.
An ascertainment rate for people with diabetes of 1.36% was obtained. The rate of data capture for haemoglobin A1 was 75.7%, and the mean level for study samples was 10.5% at one laboratory and 10.0% at the other (similar values to those of comparable studies). These mean levels of haemoglobin A1 in representative populations of people with diabetes are poor or very poor according to published standards, including those of the British Diabetic Association. These findings are set in the context of the psychology of goal setting and performance in complex clinical situations.
Targets for clinical care that are set in the absence of normative data and local feasibility assessments should be treated with caution. Targets are more likely to enhance health care if target setters recognise the importance of psychological aspects of goal setting and motivation.
BMJ 04/1995; 310(6982):784-8. · 14.09 Impact Factor
