Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care

Background: Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. Objectives: To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. Search methods: We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. Selection criteria: Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. Data collection and analysis: Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. Main results: We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients. The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this. We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively. There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. Authors' conclusions: Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death

Curriculum renewal for interprofessional education in health

In this preface we comment on four matters that we think bode well for the future of interprofessional education in Australia. First, there is a growing articulation, nationally and globally, as to the importance of interprofessional education and its contribution to the development of interprofessional and collaborative health practices. These practices are increasingly recognised as central to delivering effective, efficient, safe and sustainable health services. Second, there is a rapidly growing interest and institutional engagement with interprofessional education as part of pre-registration health professional education. This has changed substantially in recent years. Whilst beyond the scope of our current studies, the need for similar developments in continuing professional development (CPD) for health professionals was a consistent topic in our stakeholder consultations. Third, we observe what might be termed a threshold effect occurring in the area of interprofessional education. Projects that address matters relating to IPE are now far more numerous, visible and discussed in terms of their aggregate outcomes. The impact of this momentum is visible across the higher education sector. Finally, we believe that effective collaboration is a critical mediating process through which the rich resources of disciplinary knowledge and capability are joined to add value to existing health service provision. We trust the conceptual and practical contributions and resources presented and discussed in this report contribute to these developments.Office of Learning and Teaching Australi

New Zealand spinal cord impairment action plan 2014–2019

Outlines a vision, purpose, priorities and eight overarching objectives to help ensure the best possible health and wellbeing outcomes for people with spinal cord impairment, enhancing their quality of life and ability to participate in society. Introduction Spinal cord impairment (SCI) is rare but complex. Every year in New Zealand approximately 80 to 130 people are diagnosed with SCI through injury or medical/congenital causes. This affects their lives and those of many others, especially their families and whānau. SCI can occur at any age from birth, during childhood or as an adult. Due to medical advancements most people living with SCI now have a near normal life expectancy, but this brings with it progressive complexity for people and their lifelong self-management

Treat him as a normal baby: paediatrician's framing of parental responsibility as advice in the management of a genetic condition

Oral Presentation - Parallel Session 2: 2E Risk and Uncertainty/Ethics: no. 2E.4Parental responsibility in the management of genetic conditions has been the focus of both family-oriented interview-based research (e.g. Arribas-Ayllon et al. 2008; 2011) as well as real-life face-to-face genetic counselling research (Sarangi fc; Thomassen and Sarangi 2012). The current paper is an attempt to contribute to the latter tradition involving paediatricians and parents where parental responsibility is constitutive of professional advice. The genetic condition in question is G6PD deficiency (commonly known as favism), a mild hereditary disorder prevalent in Asia (Zayts and Sarangi 2013). We draw on 18 consultations in a maternal unit in Hong Kong (recruitment ongoing) where paediatricians communicate with mothers of newborns diagnosed with G6PD. We employ theme-oriented discourse analysis – comprising activity analysis and accounts analysis (Sarangi 2010) – to examine how the paediatricians frame their advice-giving trajectories – on to which elements of parental responsibility (in terms of future actions and moral selves) can be mapped. We show how 'causal responsibility' (Sarangi, fc) that concerns potential consequences of the mothers' actions in managing the condition emerges as a dominant thread in our data corpus. 'Causal [parental] responsibility' is embedded in the paediatrician's advice-giving trajectories which include, among other things, how to 'treat' these children, ranging from safeguards against certain medications and food to prevention of negative physiological scenarios (such as an acute hemolytic reaction). We examine closely the attendant discourse devices through which parental responsibility is framed, e.g., modalisation, contrast, character/event work. We conclude that, in terms of temporality, 'causal [parental] responsibility' is 'forward-looking' as the mothers' responsible actions can normalise the child’s immediate and future wellbeing.postprin