Understanding the delayed prescribing of antibiotics for respiratory tract infection in primary care: a qualitative analysis

OBJECTIVE: To identify general practitioner (GP) views and understanding on the use of delayed prescribing in primary care.DESIGN: Qualitative semistructured telephone interview study.SETTING: Primary care general practices in England.PARTICIPANTS: 32 GPs from identified high-prescribing and low-prescribing general practices in England.METHOD: Semistructured telephone interviews were conducted with GPs identified from practices within clinical commissioning groups with the highest and lowest prescribing rates in England. A thematic analysis of the data was conducted to generate themes.RESULTS: All GPs had a good understanding of respiratory tract infection (RTI) management and how the delayed prescribing approach could be used in primary care. However, GPs highlighted factors that were influential as to whether delayed prescribing was successfully carried out during the consultation. These included the increase in evidence of antimicrobial resistance, and GPs' prior experiences of using delayed prescribing during the consultation. The patient-practitioner relationship could also influence treatment outcomes for RTI, and a lack of an agreed prescribing strategy within and between practices was considered to be of significance to GPs. Participants expressed that a lack of feedback on prescribing data at an individual and practice level made it difficult to know if delayed prescribing strategies were successful in reducing unnecessary consumption. GPs agreed that coherent and uniform training and guidelines would be of some benefit to ensure consistent prescribing throughout the UK.CONCLUSIONS: Delayed prescribing is encouraged in primary care, but is not always implemented successfully. Greater uniformity within and between practices in the UK is needed to operationalise delayed prescribing, as well as providing feedback on the uptake of antibiotics. Finally, GPs may need further guidance on how to answer the concerns of patients without interpreting these questions as a demand for antibiotics, as well as educating the patient about antimicrobial resistance and supporting a good patient-practitioner relationship

Depression management in primary care: an observational study of management changes related to PHQ-9 score for depression monitoring

Background:Since 2009 UK GPs have been incentivised to use depression severity scores to monitor patients' response to treatment after 5-12 weeks of treatment.Aim:To examine the association between the severity scores obtained and follow-up questionnaires to monitor depression and subsequent changes made to the treatment of it.Design and setting:A retrospective cohort study utilising routine primary care records was conducted between April 2009 and March 2011 in 13 general practices recruited from within Hampshire, Wiltshire, and Southampton City primary care trusts.Method:Records were examined of 604 patients who had received a new diagnosis of depression since 1 April 2009, and who had completed the nine-item depression scale of the Patient Health Questionnaire (PHQ-9) at initial diagnosis and a subsequent PHQ-9 within 6 months. The main outcome measure was the odds ratio (OR) for a change in depression management. Change in management was defined as change in antidepressant drug prescription, dose, or referral.Results:Controlling for the effects of potentially confounding factors, patients who showed an inadequate response in score change at the time of second assessment were nearly five times as likely to experience a subsequent change to treatment in comparison with those who showed an adequate response (OR 4.72, 95% confidence interval = 2.83 to 7.86).Conclusion:GPs' decisions to change treatment or to make referrals following a second PHQ-9 appear to be in line with guidance from the National Institute for Health and Clinical Excellence for the monitoring of depression in primary care. Although the present study demonstrates an association between a lack of change in questionnaire scores and treatment changes, the extent to which scores influence choice and whether they are associated with improvements in depression outcomes is an important area for further research

A descriptive survey of cancer helplines in the UK: who they are, the services offered and accessibility of those services

BACKGROUND: There are over 1500 UK health helplines in operation, yet we have scant knowledge about the resources in place to support the seeking and delivering of cancer-related telephone help and support. This research aimed to identify and describe cancer and cancer-related helpline service provision: the number of helplines available, the variety of services provided and accessibility of those services.METHOD: Online national questionnaire survey sent to 95 cancer and cancer-related helplines in the UK RESULTS: 69 (73%) of 95 surveyed cancer and cancer-related helplines completed the survey. Most helplines/organisations were registered charities, supported by donations. 73.5% of helplines had national coverage. Most helplines served all age groups, ethnic groups, and men and women. Only 13.4% had a number that was free from landlines and most mobile networks and 56.6% could only be contacted during working hours. Over 50% of helplines reported no provisions for callers with additional needs. 55% had no clinical staff available to callers. Ongoing support and training for helpline staff was available but variable.CONCLUSION: While cancer helplines in the UK offer reasonably broad coverage across the country, there are still potential barriers to accessibility. There are also opportunities to optimise the training of staff/volunteers across the sector. There are further prospects for helplines to enhance services and sustain appropriate and realistic quality standards

Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial

Background: Systematic reviews support saline nasal irrigation for chronic/recurrent sinus symptoms but the trials are small, and few in typical primary care settings. Steam inhalation is poorly evidence-based. Our aim was to estimate the impact of brief pragmatic interventions to use steam and nasal irrigation.Methods: Adults with a history of recurrent/chronic sinusitis and reporting significant impact on quality-of-life from 72 UK general practices, were randomised to four advice strategies by a practice nurse, using numbered opaque sealed envelopes: 1) usual care 2) steam inhalation daily 3) saline nasal irrigation daily supported by a demonstration video 4) Irrigation and steam inhalation. Results: 961 individuals consented. 871 returned baseline questionnaires (respectively n=210,n=219,n=232,n=210) and 671/871 (77%) participants self-reported Rhinosinusitis Disability Index (RSDI) scores at 3 months (the primary outcome). Multiple imputation avoided assuming data was missing completely at random. RSDI scores improved with both nasal irrigation and no irrigation (-7.4 and -5.2 respectively; adjusted estimate of the difference -2.51, 95% confidence intervals -4.65 to -0.37, p=0.021). By 6 months, significantly more patients maintained a 10 point clinically important improvement in the RSDI (44.1%, 36.6% respectively); fewer used over-the-counter (OTC) medications (59.4%, 68%) or intended to consult the doctor. Steam inhalation reduced headache but no other outcomes. There was no evidence of harms with either intervention. Interpretation: Steam inhalation for chronic sinus symptoms in primary care is not effective. A brief pragmatic intervention to encourage nasal irrigation is less effective than prior evidence suggests, but provides some symptomatic benefit, and empowers self- management. ISRCTN88204146<br/

A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: "swamped with sore throats?"

Objective: To explore patient and healthcare professionals’ (HCP) views of clinical scores and rapid streptococcal antigen detection tests (RADTs) for acute sore throat. Design: Qualitative semistructured interview study. Setting: UK primary care. Participants: General practitioners (GPs), nurse practitioners (NPs) and patients from general practices across Hampshire, Oxfordshire and the West Midlands who were participating in the Primary Care Streptococcal Management (PRISM) study. Method: Semistructured, face-to-face and phone interviews were conducted with GPs, NPs and patients from general practices across Hampshire, Oxfordshire and the West Midlands. Results: 51 participants took part in the study. Of these, 42 were HCPs (29 GPs and 13 NPs) and 9 were patients. HCPs could see a positive role for RADTs in terms of reassurance, as an educational tool for patients, and for aiding inexperienced practitioners, but also had major concerns about RADT use in clinical practice. Particular concerns included the validity of the tests (the role of other bacteria, and carrier states), the tension and possible disconnect with clinical assessment and intuition, the issues of time and resource use and the potential for medicalisation of self-limiting illness. In contrast, however, experience of using RADTs over time seemed to make some participants more positive about using the tests. Moreover, patients were much more positive about the place of RADTs in providing reassurance and in limiting their antibiotic use. Conclusions: It is unlikely that RADTs will have a (comfortable) place in clinical practice in the near future until health professionals’ concerns are met, and they have direct experience of using them. The routine use of clinical scoring systems for acute upper respiratory illness also face important barriers related to clinicians’ perceptions of their utility in the face of clinician experience and intuition.</p