Challenges and opportunities for general practice specific CME in Europe - a narrative review of seven countries

Background: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. Methods: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. Results: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. Conclusions: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation. Keywords: Continuing medical education; Curriculum; General practice; Narrative review; Program evaluation

Converting habits of antibiotic use for respiratory tract infections in German primary care – study protocol of the cluster-randomized controlled CHANGE-3 trial

Background: The overuse of antibiotics is a major cause for the worldwide rise of antibiotic resistance. Although it is well known that acute respiratory tract infections (ARTI) are mainly caused by viruses and are often self limiting, antibiotics are too frequently prescribed in primary care. CHANGE-3 examines whether a complex intervention focusing on improving communication and provision of prescribing feedback reduces antibiotic use in patients suffering from ARTI. Methods/design: The CHANGE-3 trial is a cluster-randomized controlled trial nested within a web-based public campaign conducted in two regions in Germany. A total of 114 medical practices will be included. Practices randomized to the intervention will receive a practice-specific antibiotic-prescription feedback and an educational outreach visit. During the visit the whole practice team will receive an introduction to e-learning modules addressing patient-centered communication on antibiotics. Furthermore, the practices will receive tablet PCs with information on antibiotics and the treatment of ARTI to be presented to patients. Practices randomized to the control will provide care as usual. The primary outcome measure is the antibiotic prescribing rate for patients with a history of ARTI. Data collected before the intervention, during the intervention and after the intervention will be compared. The use of narrow- vs. broad-spectrum antibiotics will be analyzed as a secondary outcome. A process evaluation is also part of the trial. Discussion: This study should contribute to the growing body of research on reducing antibiotic prescription. Trial registration: ISRCTN, ISRCTN15061174. Registered retrospectively on 13 July 2018

Post-consultation acute respiratory tract infection recovery: a latent class informed analysis of individual patient data from randomised controlled trials and observational studies

Background: There is a lack of evidence regarding post-consultation symptom trajectories for patients with respiratory tract infections (RTIs) and whether patient characteristics can be used to predict illness duration. Aim: To describe symptom trajectories in patients with RTIs, assess baseline characteristics and adverse events associated with trajectories. Design and setting: 9103 adults and children from 12 primary care studies. Method: Individual patient data latent class-informed regression analysis of randomised controlled trials and observational cohort studies. Post-consultation symptom trajectory (severity and duration), re-consultation with same or worsening illness and hospitalisation were assessed. Results: 90% of participants recovered from all symptoms by 28 days, regardless of antibiotic strategy. For studies of RTI with cough as a dominant symptom (n=5314), four trajectories were identified: ‘rapid[6]’ (90% of participants recovered within 6 days)’ in 52.0%; ‘intermediate[10]’ (28.9%); ‘slow progressive improvement[27]’ (12.5%); and ‘slow initial high symptom burden[27]’ (6.6%). Older age (OR: (95% CI): 2.57 (1.72-3.85), higher presenting illness baseline severity (OR) (95% CIs): 1.51 (1.12-2.03)); presence of lung disease (OR (95% CI): 1.78 (1.44-2.21)); above median illness duration prior to consultation (OR (95% CI): 1.99 (1.68-2.37)) were associated with slower recovery (>10 days) compared to faster recovery (≤10 days). Re-consultations and hospitalisations were respectively higher in those with slower recovery (ORs: 2.15 (1.78-2.60) and 7.42 (3.49-15.78)). Conclusion: Older patients presenting with more severe, longer pre-consultation symptoms, and chronic lung disease should be advised they are more likely to experience longer post-consultation illness durations, and that recovery rates are similar with and without antibiotics

Challenges and opportunities for general practice specific CME in Europe: a narrative review of seven countries

Background: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. Methods: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. Results: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. Conclusions: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation

Delayed antibiotic prescribing for respiratory tract infections: protocol of an individual patient data meta-analysis

Introduction Delayed prescribing can be a useful strategy to reduce antibiotic prescribing, but it is not clear for whom delayed prescribing might be effective. This protocol outlines an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) and observational cohort studies to explore the overall effect of delayed prescribing and identify key patient characteristics that are associated with efficacy of delayed prescribing. Methods and analysis A systematic search of the databases Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus and Web of Science was conducted to identify relevant studies from inception to October 2017. Outcomes of interest include duration of illness, severity of illness, complication, reconsultation and patient satisfaction. Study authors of eligible papers will be contacted and invited to contribute raw IPD data. IPD data will be checked against published data, harmonised and aggregated to create one large IPD database. Multilevel regression will be performed to explore interaction effects between treatment allocation and patient characteristics. The economic evaluation will be conducted based on IPD from the combined trial and observational studies to estimate the differences in costs and effectiveness for delayed prescribing compared with normal practice. A decision model will be developed to assess potential savings and cost-effectiveness in terms of reduced antibiotic usage of delayed prescribing and quality-adjusted life years. Ethics and dissemination Ethical approval was obtained from the University of Southampton Faculty of Medicine Research Ethics Committee (Reference number: 30068). Findings of this study will be published in peer-reviewed academic journals as well as General Practice trade journals and will be presented at national and international conferences. The results will have important public health implications, shaping the way in which antibiotics are prescribed in the future and to whom delayed prescriptions are issued

The effect of interventions aiming to optimise the prescription of antibiotics in dental care-A systematic review.

Abundant evidence in dentistry suggests that antibiotics are prescribed despite the existence of guidelines aiming to reduce the development of antibiotic resistance. This review investigated (1) which type of interventions aiming to optimise prescription of antibiotics exist in dentistry, (2) the effect of these interventions and (3) the specific strengths and limitations of the studies reporting on these interventions.Literature search was based on Medline, Embase, Global Health, Cochrane CENTRAL, ClinicalTrials.gov and Current Controlled Trials. Studies with one of the two primary outcomes were included: (1) The number of antibiotics prescribed and/or (2) the accuracy of the prescription, commonly measured as a percentage of adherence to local clinical guidelines.Nine studies met these inclusion criteria. Five studies reported on the prescription of antibiotics in primary dental care and four studies focused on outpatient dental care. Interventions used in primary dental care included a combination of audit, feedback, education, local consensus, dissemination of guidelines and/or academic detailing. Trials in the outpatient setting made use of expert panel discussions, educational feedback on previous acts of prescribing, the dissemination of guidelines and the establishment of internal guidelines. All studies successfully reduced the number of antibiotics prescribed and/or increased the accuracy of the prescription. However, most studies were confounded by a high risk of selection bias, selective outcome reporting and high variance across study groups. In particular, information relating to study design and methodology was insufficient. Only three studies related the prescriptions to the number of patients treated with antibiotics.This systematic review was able to offer conclusions which took the limitations of the investigated studies into account. Unfortunately, few studies could be included and many of these studies were confounded by a low quality of scientific reporting and lack of information regarding study methodology. High-quality research with objective and standardised outcome reporting, longer periods of follow-up, rigorous methodology and adequate standard of study reporting is urgently needed

Non-Marital Cohabitation in Italy

The focus of this dissertation is on the - so far hesitant - spread of non-marital cohabitation in Italy. The combination of quantitative and qualitative research methods offers insights into the effects of individual and family characteristics as well as the subjective motivations behind and perceptions on cohabitation.Im Mittelpunkt der Arbeit steht die bisher zögerliche Verbreitung nichtehelicher Lebensgemeinschaften in Italien. Die Kombination quantitativer und qualitativer Forschungsmethoden eröffnet einerseits Einblicke in die Bedeutung individueller und familiärer Merkmale für den Eintritt in eine nichteheliche Partnerschaft. Auf der anderen Seite werden subjektive Beweggründe und Wahrnehmungen erfasst, die den Übergang in diese Partnerschaftsform ebenfalls maßgeblich beeinflußen

Characteristics of the studies and their guidelines.

<p>Characteristics of the studies and their guidelines.</p

Accuracy of the prescription before (pre) and after (post) intervention, by studies assessing this outcome parameter (measured as a percentage of adherence to guidelines).

<p>Note: Palmer et al. (2001), Steed and Gibson (1997), Raunair et al. (2012) and Thomas and Hill (1997) did not report this outcome measure. Seager et al. (2006) provided information as odds ratios. (a) p<0.001. (b) p = 0.01. (c) p-values were not reported within this publication.</p

Decrease in the number of prescriptions for antibiotics in percentage, by studies assessing this outcome parameter.

<p>Note: Chopra et al. (2014) and Zahabiyoun et al. (2015) do not report that outcome measure. Instead of reporting figures, odds ratios are reported in Seager et al. (2006). (a) Reduction of 1.0 antibiotic items per 100 NHS treatment claims in the intervention group compared to 0.4 antibiotic items in the control group. (b) Reduction from 2,951 prescriptions for antibiotics before the audit to 1,665 prescriptions after the audit. (c) Reduction from 2,316 prescriptions for antibiotics before the audit to 1,330 prescriptions after the audit. (d) The number of prescriptions was not stated in the paper, but the authors report an overall reduction of ~50%. (e) Reduction of the total number of prescriptions for antimicrobial agents from 253 prescriptions among 300 patients at baseline to 82 prescriptions among 300 patients at one month after the intervention. Three months after the intervention these prescriptions were at 63 among 300 patients and at 102 prescriptions among 300 patients six months after the intervention. (f) Reduction of preoperative prescriptions for antibiotics from 15 prescriptions among 80 patients before the audit to one prescription among 52 patients after the audit. A postoperative reduction of prescriptions for antibiotics was not intended.</p