Rationale, design and organization of the delayed antibiotic prescription (DAP) trial: a randomized controlled trial of the eficacy and safety of delayed antibiotic prescribing strategies in the non-complicated acute respiratory tract infections in general practice

Background: Respiratory tract infections are an important burden in primary care and it's known that they are usually self-limited and that antibiotics only alter its course slightly. This together with the alarming increase of bacterial resistance due to increased use of antimicrobials calls for a need to consider strategies to reduce their use. One of these strategies is the delayed prescription of antibiotics. Methods: Multicentric, parallel, randomised controlled trial comparing four antibiotic prescribing strategies in acute non-complicated respiratory tract infections. We will include acute pharyngitis, rhinosinusitis, acute bronchitis and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (mild to moderate). The therapeutic strategies compared are: immediate antibiotic treatment, no antibiotic treatment, and two delayed antibiotic prescribing (DAP) strategies with structured advice to use a course of antibiotics in case of worsening of symptoms or not improving (prescription given to patient or prescription left at the reception of the primary care centre 3 days after the first medical visit). Discussion: Delayed antibiotic prescription has been widely used in Anglo-Saxon countries, however, in Southern Europe there has been little research about this topic. The DAP trial wil evaluate two different delayed strategies in Spain for the main respiratory infections in primary care

Impact of the implementation of best practice guidelines on nurse's evidence-based practice and on nurses' work environment: research protocol

Abstract Aim: To determine the impact of the Best Practice Spotlight Organization® initia- tive on nurses' perception of their work environment and their attitudes to evidence- based practice. Design: Quasi-experimental, multicentre study. The intervention is the participation in Best Prectice Spotilight Organizations to implement Best Practice Guidelines. Methods: The study will include seven centres in the interventional group and 10 in the non-equivalent control group, all of them belonging to the Spanish national health system. The Practice Environment Scale of the Nursing Work Index, and the Health Sciences Evidence-Based Practice Questionnaire will be administered to a sample of 1,572 nurses at the beginning of the programme and at 1 year. This 3-year study started in April 2018 and will continue until December 2021. Statistical analy- ses will be carried out using the SPSS 25.0. This project was approved by the Drug Research Ethics Committee of the Parc de Salut Mar and registered in Clinical Trials. Discussion: The study findings will show the current state of nurses' perception of their work environment and attitudes to evidence-based practice, and possible changes in these parameters due to the programme. Impact: The findings could provide a strong argument for health policymakers to scale up the Best Practice Spotlight Organization® initiative in the Spanish national health system

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

La prescripció antibiòtica diferida en infeccions respiratòries a l'atenció primària : assaig clínic, anàlisi cost-efectivitat i estudi qualitatiu

Antecedents Els antibiòtics es prescriuen en excés en les infeccions respiratòries agudes (IRA) en l'àmbit de l'atenció primària (AP). La prescripció diferida d'antibiòtics (PDA) és una estratègia dissenyada per promoure un ús més racional dels antibiòtics. L'evidència sobre l'eficàcia de la PDA en nens amb IRAs atesos a l'AP és escassa i encara més, en estudis que hagin avaluat el seu cost-efectivitat. La PDA encara no és àmpliament implementada pels professionals i hi ha una manca d'estudis qualitatius d'aquesta estratègia en el nostre entorn. Objectius Els objectius d'aquesta tesi van ser els següents: (1) determinar l'eficàcia i seguretat de la PDA comparada amb la prescripció antibiòtica immediata (PIA) i la no prescripció antibiòtica (NPA) en nens amb IRAs tractats a l'AP; (2) comparar el cost-efectivitat de les tres estratègies de prescripció i; (3) explorar les percepcions i actituds dels professionals en relació a l'ús dels antibiòtics i de les estratègies de PDA en el tractament de les IRAs en adults atesos a l'AP. Mètodes La tesi es presenta com a compendi de 3 articles corresponents a estudis publicats en revistes biomèdiques revisades per parells, que són els següents: (1) un assaig clínic aleatoritzat que va avaluar l'eficàcia de la PDA en comparació amb la PIA i la NPA en nens amb IRAs, atesos en 39 centres d'AP pertanyents a 9 comunitats autònomes d'Espanya; (2) una anàlisi cost-efectivitat, des d'una perspectiva social, de tres estratègies de prescripció en el context de l' assaig clínic previ; i (3) un estudi qualitatiu en el qual es van incloure professionals de 6 centres d'AP de l'àrea metropolitana de Barcelona, basat en 4 grups de discussió i posteriorment, 3 entrevistes individuals semiestructurades. Resultats L'assaig clínic va incloure 436 nens. La durada mitjana dels símptomes severs va ser lleugerament major en la PDA en comparació amb la PIA i la NPA. El valor mitjà per la major severitat de qualsevol símptoma va ser similar per a les 3 estratègies. L'ús d'antibiòtics i els efectes adversos gastrointestinals van ser significativament més freqüents per a la PIA. Les complicacions, les visites addicionals a l'AP i la satisfacció van ser similars per a les 3 estratègies. En termes de cost-efectivitat, inclús quan es va incloure el cost de les resistències antimicrobianes (RAM), la PDA va ser la més cost-efectiva de les 3 estratègies. Els valors de dies de vida ajustats per la qualitat (QALD) per a les tres estratègies van ser molt similars. L'anàlisi de sensibilitat determinista va indicar que els costos indirectes no sanitaris van tenir el major impacte en la relació incremental cost-efectivitat (ICER). L'estudi qualitatiu, el qual va incloure 25 metges de família i 1 infermera, va destacar que la consulta per IRAs en adults estava associada amb una pobre educació en salut, i que l'ús inadequat d'antibiòtics estava relacionat principalment amb una estratègia de medicina defensiva. La PDA s'utilitzava quan hi havia dubtes sobre l'etiologia i tenint en compte el context de la visita i el perfil del pacient. Conclusions En nens amb IRAs no complicades atesos a l'AP, per a la PDA en comparació amb la PIA i la NPA, els resultats d'eficàcia i seguretat van ser similars i els resultats cost-efectivitat van ser lleugerament millors. Les pressions de temps sobre els professionals, la pobre educació en salut dels pacients i la falta de relació metge-pacient en alguns escenaris van ser debilitats que afectaven tant l'ús adequat d'antibiòtics com de la PDA en població adulta.Antecedentes Los antibióticos se prescriben en exceso en las infecciones respiratorias agudas (IRA) en el ámbito de la atención primaria (AP). La prescripción diferida de antibióticos (PDA) es una estrategia diseñada para promover un uso más racional de los antibióticos. La evidencia sobre la eficacia de la PDA en niños con IRAs atendidos en la AP es escasa y aún más, en estudios que hayan evaluado su coste-efectividad. La PDA todavía no es ampliamente implementada por los profesionales y hay una falta de estudios cualitativos de esta estrategia en nuestro entorno. Objetivos Los objetivos de esta tesis fueron los siguientes: (1) determinar la eficacia y seguridad de la PDA comparada con la prescripción antibiótica inmediata (PIA) y la no prescripción antibiótica (NPA) en niños con IRAs tratados en AP; (2) comparar el coste-efectividad de las tres estrategias de prescripción y; (3) explorar las percepciones y actitudes de los profesionales en relación al uso de los antibióticos y de las estrategias de PDA en el tratamiento de las IRAs en adultos atendidos en AP. Métodos La tesis se presenta como compendio de 3 artículos correspondientes a estudios publicados en revistas biomédicas revisadas por pares, que son los siguientes: (1) un ensayo clínico aleatorizado que evaluó la eficacia de la PDA en comparación con la PIA y la NPA en niños con IRAs, atendidos en 39 centros de AP pertenecientes a 9 comunidades autónomas de España; (2) un análisis coste-efectividad, desde una perspectiva social, de tres estrategias de prescripción en el contexto del ensayo clínico previo; y (3) estudio cualitativo en el que se incluyeron profesionales de 6 centros de AP del área metropolitana de Barcelona, basado en 4 grupos de discusión y posteriormente, 3 entrevistas individuales semiestructuradas. Resultados El ensayo clínico incluyó a 436 niños. La duración media de los síntomas severos fue ligeramente mayor en la PDA en comparación con la PIA y la NPA. El valor medio por la mayor severidad de cualquier síntoma fue similar para las 3 estrategias. El uso de antibióticos y los efectos adversos gastrointestinales fueron significativamente más frecuentes para la PIA. Las complicaciones, las visitas adicionales en AP y la satisfacción fueron similares para las 3 estrategias. En términos de coste-efectividad, incluso cuando se incluyó el costo de las resistencias antimicrobianas (RAM), la PDA fue la más coste-efectiva de las 3 estrategias. Los valores de días de vida ajustados por la calidad (QALD) para las 3 estrategias fueron muy similares. El análisis de sensibilidad determinista indicó que los costes indirectos no sanitarios tuvieron el mayor impacto en la relación incremental coste-efectividad (ICER). El estudio cualitativo, el cual incluyó a 25 médicos de familia y 1 enfermera, destacó que la consulta por IRAs en adultos estaba asociada con una pobre educación en salud, y que el uso inadecuado de antibióticos estaba relacionado principalmente con una estrategia de medicina defensiva. La PDA se utilizaba cuando había dudas sobre la etiología y teniendo en cuenta el contexto de la visita y el perfil del paciente. Conclusiones En niños con IRAs no complicadas atendidos en AP, para la PDA en comparación con la PIA y la NPA, los resultados de eficacia y seguridad fueron similares y los resultados coste-efectividad fueron ligeramente mejores. Las presiones de tiempo sobre los profesionales, la pobre educación en salud de los pacientes y la falta de relación médico-paciente en algunos escenarios fueron debilidades que afectaban tanto al uso adecuado de antibióticos como de la PDA en población adulta.Background Antibiotics are overprescribed in acute respiratory tract infections (RTIs) in the primary care (PC) setting. Delayed antibiotic prescription (DAP) is a strategy designed to promote more rational use of antibiotics. Evidence on the efficacy of DAP in children with RTIs attended to in PC is scarce, and especially so in studies that have evaluated its cost-effectiveness. DAP is not yet widely implemented by professionals and there is a lack of qualitative studies of this strategy in our setting. Objectives The objectives of this thesis were as follows: (1) to determine the efficacy and safety of DAP compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with RTIs treated in PC; (2) to compare the cost-effectiveness of the 3 prescribing strategies; and (3) to explore professional's perceptions and attitudes regarding antibiotic use and DAP strategies in the treatment of RTIs in adults attended to in PC. Methods The thesis is presented as a compendium of 3 articles corresponding to studies published in peer-reviewed biomedical journals, as follows: (1) a randomized clinical trial that evaluated DAP efficacy compared to IAP and NAP in children with RTIs attended in 39 PC centres located in 9 Spanish autonomous communities.; (2) a cost-effectiveness analysis, from a social perspective, of the 3 prescribing strategies in the context of the previous clinical trial; and (3) a qualitative study involving professionals from 6 centres in the metropolitan area of Barcelona, based on 4 focus group were carried out and subsequently, 3 individual semi-structured interviews. Results The clinical trial included 436 children. Mean duration of severe symptoms was slightly greater in DAP compared to IAP and NAP. The median value for the greatest severity of any symptom was similar for the 3 strategies. Antibiotic use and gastrointestinal adverse effects were significantly more frequent for IAP. Complications, additional PC visits, and satisfaction were similar for the 3 strategies. In cost-effectiveness terms, and even when the cost of antimicrobial resistance (AMR) was considered, DAP was the most cost-effective of the 3 strategies. The quality-adjusted life-days (QALD) values for the 3 strategies were very similar. Deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the incremental cost-effectiveness ratio (ICER). Finally, the qualitative study, which included 25 family physicians and 1 nurse from 6 PC centres, highlighted that adult consultation for RTIs were associated with poor health education, and that inappropriate antibiotic use was mainly related to a defensive medicine strategy. DAP was deployed when there were doubts about the aetiology and taking into account the visit context and the patient's profile. Conclusions In children with uncomplicated RTIs attended to in PC, for DAP compared to IAP and NAP, efficacy and safety results were similar and cost-effectiveness results were slightly better. Time pressures on professionals, poor health education of patients, and an absent doctor-patient relationship in some scenarios were weaknesses that affected both the appropriate use of antibiotics and of DAP in adult population

La prescripció antibiòtica diferida en infeccions respiratòries a l'atenció primària: assaig clínic, anàlisi cost-efectivitat i estudi qualitatiu

Antecedents Els antibiòtics es prescriuen en excés en les infeccions respiratòries agudes (IRA) en l'àmbit de l'atenció primària (AP). La prescripció diferida d'antibiòtics (PDA) és una estratègia dissenyada per promoure un ús més racional dels antibiòtics. L'evidència sobre l'eficàcia de la PDA en nens amb IRAs atesos a l'AP és escassa i encara més, en estudis que hagin avaluat el seu cost-efectivitat. La PDA encara no és àmpliament implementada pels professionals i hi ha una manca d'estudis qualitatius d'aquesta estratègia en el nostre entorn. Objectius Els objectius d'aquesta tesi van ser els següents: (1) determinar l'eficàcia i seguretat de la PDA comparada amb la prescripció antibiòtica immediata (PIA) i la no prescripció antibiòtica (NPA) en nens amb IRAs tractats a l'AP; (2) comparar el cost-efectivitat de les tres estratègies de prescripció i; (3) explorar les percepcions i actituds dels professionals en relació a l'ús dels antibiòtics i de les estratègies de PDA en el tractament de les IRAs en adults atesos a l'AP. Mètodes La tesi es presenta com a compendi de 3 articles corresponents a estudis publicats en revistes biomèdiques revisades per parells, que són els següents: (1) un assaig clínic aleatoritzat que va avaluar l'eficàcia de la PDA en comparació amb la PIA i la NPA en nens amb IRAs, atesos en 39 centres d'AP pertanyents a 9 comunitats autònomes d'Espanya; (2) una anàlisi cost-efectivitat, des d'una perspectiva social, de tres estratègies de prescripció en el context de l' assaig clínic previ; i (3) un estudi qualitatiu en el qual es van incloure professionals de 6 centres d'AP de l'àrea metropolitana de Barcelona, basat en 4 grups de discussió i posteriorment, 3 entrevistes individuals semiestructurades. Resultats L'assaig clínic va incloure 436 nens. La durada mitjana dels símptomes severs va ser lleugerament major en la PDA en comparació amb la PIA i la NPA. El valor mitjà per la major severitat de qualsevol símptoma va ser similar per a les 3 estratègies. L'ús d'antibiòtics i els efectes adversos gastrointestinals van ser significativament més freqüents per a la PIA. Les complicacions, les visites addicionals a l'AP i la satisfacció van ser similars per a les 3 estratègies. En termes de cost-efectivitat, inclús quan es va incloure el cost de les resistències antimicrobianes (RAM), la PDA va ser la més cost-efectiva de les 3 estratègies. Els valors de dies de vida ajustats per la qualitat (QALD) per a les tres estratègies van ser molt similars. L'anàlisi de sensibilitat determinista va indicar que els costos indirectes no sanitaris van tenir el major impacte en la relació incremental cost-efectivitat (ICER). L'estudi qualitatiu, el qual va incloure 25 metges de família i 1 infermera, va destacar que la consulta per IRAs en adults estava associada amb una pobre educació en salut, i que l'ús inadequat d'antibiòtics estava relacionat principalment amb una estratègia de medicina defensiva. La PDA s'utilitzava quan hi havia dubtes sobre l'etiologia i tenint en compte el context de la visita i el perfil del pacient. Conclusions En nens amb IRAs no complicades atesos a l'AP, per a la PDA en comparació amb la PIA i la NPA, els resultats d'eficàcia i seguretat van ser similars i els resultats cost-efectivitat van ser lleugerament millors. Les pressions de temps sobre els professionals, la pobre educació en salut dels pacients i la falta de relació metge-pacient en alguns escenaris van ser debilitats que afectaven tant l'ús adequat d'antibiòtics com de la PDA en població adulta.Antecedentes Los antibióticos se prescriben en exceso en las infecciones respiratorias agudas (IRA) en el ámbito de la atención primaria (AP). La prescripción diferida de antibióticos (PDA) es una estrategia diseñada para promover un uso más racional de los antibióticos. La evidencia sobre la eficacia de la PDA en niños con IRAs atendidos en la AP es escasa y aún más, en estudios que hayan evaluado su coste-efectividad. La PDA todavía no es ampliamente implementada por los profesionales y hay una falta de estudios cualitativos de esta estrategia en nuestro entorno. Objetivos Los objetivos de esta tesis fueron los siguientes: (1) determinar la eficacia y seguridad de la PDA comparada con la prescripción antibiótica inmediata (PIA) y la no prescripción antibiótica (NPA) en niños con IRAs tratados en AP; (2) comparar el coste-efectividad de las tres estrategias de prescripción y; (3) explorar las percepciones y actitudes de los profesionales en relación al uso de los antibióticos y de las estrategias de PDA en el tratamiento de las IRAs en adultos atendidos en AP. Métodos La tesis se presenta como compendio de 3 artículos correspondientes a estudios publicados en revistas biomédicas revisadas por pares, que son los siguientes: (1) un ensayo clínico aleatorizado que evaluó la eficacia de la PDA en comparación con la PIA y la NPA en niños con IRAs, atendidos en 39 centros de AP pertenecientes a 9 comunidades autónomas de España; (2) un análisis coste-efectividad, desde una perspectiva social, de tres estrategias de prescripción en el contexto del ensayo clínico previo; y (3) estudio cualitativo en el que se incluyeron profesionales de 6 centros de AP del área metropolitana de Barcelona, basado en 4 grupos de discusión y posteriormente, 3 entrevistas individuales semiestructuradas. Resultados El ensayo clínico incluyó a 436 niños. La duración media de los síntomas severos fue ligeramente mayor en la PDA en comparación con la PIA y la NPA. El valor medio por la mayor severidad de cualquier síntoma fue similar para las 3 estrategias. El uso de antibióticos y los efectos adversos gastrointestinales fueron significativamente más frecuentes para la PIA. Las complicaciones, las visitas adicionales en AP y la satisfacción fueron similares para las 3 estrategias. En términos de coste-efectividad, incluso cuando se incluyó el costo de las resistencias antimicrobianas (RAM), la PDA fue la más coste-efectiva de las 3 estrategias. Los valores de días de vida ajustados por la calidad (QALD) para las 3 estrategias fueron muy similares. El análisis de sensibilidad determinista indicó que los costes indirectos no sanitarios tuvieron el mayor impacto en la relación incremental coste-efectividad (ICER). El estudio cualitativo, el cual incluyó a 25 médicos de familia y 1 enfermera, destacó que la consulta por IRAs en adultos estaba asociada con una pobre educación en salud, y que el uso inadecuado de antibióticos estaba relacionado principalmente con una estrategia de medicina defensiva. La PDA se utilizaba cuando había dudas sobre la etiología y teniendo en cuenta el contexto de la visita y el perfil del paciente. Conclusiones En niños con IRAs no complicadas atendidos en AP, para la PDA en comparación con la PIA y la NPA, los resultados de eficacia y seguridad fueron similares y los resultados coste-efectividad fueron ligeramente mejores. Las presiones de tiempo sobre los profesionales, la pobre educación en salud de los pacientes y la falta de relación médico-paciente en algunos escenarios fueron debilidades que afectaban tanto al uso adecuado de antibióticos como de la PDA en población adulta.Background Antibiotics are overprescribed in acute respiratory tract infections (RTIs) in the primary care (PC) setting. Delayed antibiotic prescription (DAP) is a strategy designed to promote more rational use of antibiotics. Evidence on the efficacy of DAP in children with RTIs attended to in PC is scarce, and especially so in studies that have evaluated its cost-effectiveness. DAP is not yet widely implemented by professionals and there is a lack of qualitative studies of this strategy in our setting. Objectives The objectives of this thesis were as follows: (1) to determine the efficacy and safety of DAP compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with RTIs treated in PC; (2) to compare the cost-effectiveness of the 3 prescribing strategies; and (3) to explore professional's perceptions and attitudes regarding antibiotic use and DAP strategies in the treatment of RTIs in adults attended to in PC. Methods The thesis is presented as a compendium of 3 articles corresponding to studies published in peer-reviewed biomedical journals, as follows: (1) a randomized clinical trial that evaluated DAP efficacy compared to IAP and NAP in children with RTIs attended in 39 PC centres located in 9 Spanish autonomous communities.; (2) a cost-effectiveness analysis, from a social perspective, of the 3 prescribing strategies in the context of the previous clinical trial; and (3) a qualitative study involving professionals from 6 centres in the metropolitan area of Barcelona, based on 4 focus group were carried out and subsequently, 3 individual semi-structured interviews. Results The clinical trial included 436 children. Mean duration of severe symptoms was slightly greater in DAP compared to IAP and NAP. The median value for the greatest severity of any symptom was similar for the 3 strategies. Antibiotic use and gastrointestinal adverse effects were significantly more frequent for IAP. Complications, additional PC visits, and satisfaction were similar for the 3 strategies. In cost-effectiveness terms, and even when the cost of antimicrobial resistance (AMR) was considered, DAP was the most cost-effective of the 3 strategies. The quality-adjusted life-days (QALD) values for the 3 strategies were very similar. Deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the incremental cost-effectiveness ratio (ICER). Finally, the qualitative study, which included 25 family physicians and 1 nurse from 6 PC centres, highlighted that adult consultation for RTIs were associated with poor health education, and that inappropriate antibiotic use was mainly related to a defensive medicine strategy. DAP was deployed when there were doubts about the aetiology and taking into account the visit context and the patient's profile. Conclusions In children with uncomplicated RTIs attended to in PC, for DAP compared to IAP and NAP, efficacy and safety results were similar and cost-effectiveness results were slightly better. Time pressures on professionals, poor health education of patients, and an absent doctor-patient relationship in some scenarios were weaknesses that affected both the appropriate use of antibiotics and of DAP in adult population.Universitat Autònoma de Barcelona. Programa de Doctorat en Metodologia de la Recerca Biomèdica i Salut Públic

Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation : a qualitative systematic review

Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients' and physicians' perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients' and physicians' perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. We included studies that used qualitative or mixed methods and focused on patients' and/or physicians' perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. Physicians' and patients' perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation

La formación on-line : una mirada integral sobre el e-learning, b-learning...

Se ofrecen el instrumento para los profesionales y las organizaciones que quieran analizar y profundizar en la formación on-line. Este tipo de formación supone la toma de decisiones sobre multitud de aspectos vinculados a la impartición, implica la creación y la coordinación de equipos multiprofesionales, y la generación de procesos y circuitos internos. Se basa en la experiencia docente de sus autores.CataluñaBiblioteca de Educación del Ministerio de Educación, Cultura y Deporte; Calle San Agustín 5 -3 Planta; 28014 Madrid; Tel. +34917748000; [email protected]

Use of delayed antibiotic prescription in primary care: a cross-sectional study

Abstract Background One of several strategies developed to reduce inappropriate antibiotic use in situations where the indication is not clear is delayed antibiotic prescription (DAP), defined as an antibiotic prescription issued for the patient to take only in case of feeling worse or not feeling better several days after the visit. We conducted a survey to identify DAP use in Spanish primary care settings. Methods We surveyed 23 healthcare centers located in 4 autonomous regions where a randomized controlled trial (RCT) on DAP was underway. The primary variable was use of DAP. Categorical and quantitative variables were analyzed by means of the chi-squared test and non-parametric tests, respectively. Results The survey was sent to 375 healthcare professionals, 215 of whom responded (57.3% response rate), with 46% of these respondents declaring that they had used DAP in routine practice before the RCT started (66.6% afterwards), mostly (91.5%) for respiratory tract infections (RTIs), followed by urinary infections (45.1%). Regarding DAP use for RTIs, the most frequent conditions were pharyngotonsillitis (88.7%), acute bronchitis (62.7%), mild chronic obstructive pulmonary disease exacerbations (59.9%), sinusitis (51.4%), and acute otitis media (45.1%). Most respondents considered that DAP reduced emergency visits (85.4%), scheduled visits (79%) and inappropriate antibiotic use (73.7%) and most also perceived patients to be generally satisfied with the DAP approach (75.6%). Having participated or not in the DAP RCT (74.1% versus 46.2%; p < 0.001), having previously used or not used DAP (86.8% versus 44.2%; p < 0.001), and being a physician versus being a nurse (81.8% versus 18.2%; p < 0.001) were factors that reflected significantly higher rates of DAP use. Conclusions The majority of primary healthcare professionals in Spain do not use DAP. Those who use DAP believe that it reduces primary care visits and inappropriate antibiotic use, while maintaining patient satisfaction. Given the limited use of DAP in our setting, and given that its use is mainly limited to RTIs, DAP has considerable potential in terms of its implementation in routine practice

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

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. 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. 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

Do clinicians understand the size of treatment effects? A randomized survey across 8 countries.

BACKGROUND Meta-analyses of continuous outcomes typically provide enough information for decision-makers to evaluate the extent to which chance can explain apparent differences between interventions. The interpretation of the magnitude of these differences - from trivial to large - can, however, be challenging. We investigated clinicians' understanding and perceptions of usefulness of 6 statistical formats for presenting continuous outcomes from meta-analyses (standardized mean difference, minimal important difference units, mean difference in natural units, ratio of means, relative risk and risk difference). METHODS We invited 610 staff and trainees in internal medicine and family medicine programs in 8 countries to participate. Paper-based, self-administered questionnaires presented summary estimates of hypothetical interventions versus placebo for chronic pain. The estimates showed either a small or a large effect for each of the 6 statistical formats for presenting continuous outcomes. Questions addressed participants' understanding of the magnitude of treatment effects and their perception of the usefulness of the presentation format. We randomly assigned participants 1 of 4 versions of the questionnaire, each with a different effect size (large or small) and presentation order for the 6 formats (1 to 6, or 6 to 1). RESULTS Overall, 531 (87.0%) of the clinicians responded. Respondents best understood risk difference, followed by relative risk and ratio of means. Similarly, they perceived the dichotomous presentation of continuous outcomes (relative risk and risk difference) to be most useful. Presenting results as a standardized mean difference, the longest standing and most widely used approach, was poorly understood and perceived as least useful. INTERPRETATION None of the presentation formats were well understood or perceived as extremely useful. Clinicians best understood the dichotomous presentations of continuous outcomes and perceived them to be the most useful. Further initiatives to help clinicians better grasp the magnitude of the treatment effect are needed