Defining timeliness in care for patients with lung cancer : a scoping review

Objectives Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer. Methods This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles. Results A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure. Conclusion This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Measuring the potential unintended consequences of national policy aimed at reducing antibiotic prescribing in primary care in England

Background Inappropriate antibiotic use is a known driver of antimicrobial resistance. Primary care antibiotic prescribing accounts for approximately 80% of antibiotic consumption in England, with respiratory tract infections (RTIs) being the most common indication. RTIs are largely viral and self-limiting, and antibiotics are often inappropriate. The 2015/16 NHS England Quality Premium (QP) financially incentivised reductions in primary care antibiotic prescribing. This may have led to unintended consequences such as a reduction in appropriate antibiotic treatment with some patients developing more severe infections. Aim To assess the reduction in antibiotic prescribing following introduction of the 2015/16 QP, and the occurrence of unintended consequences in patients presenting to English general practices with RTIs, as measured by re-consultations, severe infections (in primary and secondary care) and death. Methods A systematic literature review and meta-analysis were undertaken pooling evidence on the risk of RTI complications where there was lack of exposure to timely antibiotic treatment. This contributed to a modified Delphi method, defining RTI infection pathways. Subsequent investigations of the potential impact of the QP used linkage of routinely collected national healthcare datasets. Interrupted time series analysis (ITSA) and hierarchical multivariable analysis were the statistical methods utilised, comparing antibiotic prescribing for RTIs in general practices across England, and unintended consequence (measured by re-consultations, severe infections and death, within 30-days of an initial RTI) pre- and post-QP. Results The systematic review found that RTI complications were rare. The pooled odds ratio favoured the use of antibiotics in preventing RTI complications. There was a high-level of heterogeneity between studies, high risk of bias (particularly indication bias) and studies were often not powered or designed to assess complications. ITSA demonstrated that antibiotic prescribing for RTIs decreased over the six-year study period, with a significantly decrease coinciding with the introduction of the QP (decline was particularly evident in children, 0.05]) were reported, particularly for elderly patients (≥65 years) and patients who had been prescribed antibiotics; increased mortality was also noted, although this was not sustained. Complications were shown to have been on a gradual rise prior to the QP, hence findings from the multivariable analysis may reflect this increase. Findings from this analysis also showed a significant reduction in antibiotic prescribing post-QP, and greater odds of complications in patients who had been prescribed antibiotics compared to those who had not. Conclusions The 2015/16 QP has been safely implemented with no significant unintended consequences. Future reductions in antibiotic prescribing should be tailored based on infection indication and patient risk factors (e.g. by age/elderly). Future surveillance would benefit from improvements in national primary care data acquisition, linkage and surveillance of unintended consequences.Open Acces

Medicines and choices. Health policy and individual decision-making

Background and aims: Decisions about choices of medicines are made concerning a population or an individual health care user. Key aims of the thesis were first, to investigate authoritative decision-making in the British National Health Service (NHS) about the access to medicines; second, to investigate the views of health care professionals (HCPs) and patients on making choices about medicine treatment within the medical consultation, including the use of informed consent for medicines; and finally, to seek similarities and differences between the factors found to contribute to each type of decision-making about choices investigated before. Methods: Health policy decision-making was investigated by using a document analysis and in-depth interviews with a range of policy-makers and stakeholders. Individual decision-making was explored by conducting in-depth interviews with doctors, nurses and hospital in- and outpatients from various medical specialities. Informed consent was chosen as an applied model of decision-making where the patient makes a choice. Results: Cost containment and generating politically and legally defensible decisions were strong influences on the process and the outcomes of health policy decisionmaking. Although data about benefit, safety and cost considerations were used as the main legitimisation for the definition of access criteria, several informal and organisational factors were found to have significant influence on decision-making. The lack of information provision about side effects and treatment alternatives made it impossible for patients to make an informed decision about their medication. Informed consent was not regarded as a model to support patients in making informed decisions. Although doctors described patients as a 'partner' in the decisions, an eliciting and implementation of the patients' preferences and values was largely absent. Conclusions: A more consistent application of a minimum moral standard of patient involvement in prescribing decisions could improve individual decision-making. Health policy decisions could benefit from an awareness of the influence of informal factors on health policy decisions

Uncomplicated urinary tract infection in primary care; evaluation of point of care tests and patient management

Antibiotic resistance is an increasing global public health problem. Resistance is increasing sharply in gram-negative organisms, including Escherichia coli (E. coli), the main causative organism for community-acquired urinary tract infection (UTI). Antimicrobial stewardship strategies in primary care to help contain antibiotic resistance include supporting general practitioners (GPs) in deciding whether to prescribe an antibiotic for UTI and selecting the most appropriate antibiotic. In this thesis, I aim to describe the management of uncomplicated UTI in primary care and evaluate potential point of care tests (POCT) to assist the diagnosis and/or appropriate prescribing of antibiotics for uncomplicated UTI. The program of work includes: 1. Laboratory evaluation of a culture-based test that allows the quantification, identification and susceptibility profile of infecting bacteria from urine (FlexicultTM). 2. Evaluation of a novel chromatic sensing technique to identify bacterially infected urine compared to visual assessment of urine turbidity and urinalysis dipsticks. 3. Systematic review and analysis of data (descriptive and multi-level modelling) from an international primary care based observational study to describe UTI management. I identified unwarranted variation in clinical management of UTI between countries and between general practices within countries. Empirical antibiotic prescribing for UTI in Europe is high and treatment is generally prescribed for longer than guidelines recommend. FlexicultTM identifying bacterial UTI. The use of FlexicultTM in practice may support GPs in screening out negative samples reducing the proportion of patients that are prescribed antibiotics empirically. Chromatic sensing and visually assessing turbidity were equally useful at identifying negative urine samples and both improved the analytic performance of urinalysis dipsticks. The chromatic sensing system requires development prior to further evaluation

Examining the inter-relationships between antibiotic prescribing, complications and resistance in acute respiratory tract infections

The threat to public health from antibiotic resistance has increased, with growing evidence that antibiotic use is a major driver of resistance. This has led to campaigns to reduce prescribing of antibiotics by GPs, particular for respiratory tract infections (RTIs). These are among the most common reasons for prescribing antibiotics in primary care, in spite of the fact that there is evidence that most RTIs recover at a similar rate without antibiotic treatment, rarely resulting in complications if untreated. There are concerns, that a ‘blanket’ reduction in prescribing may occur, with reductions in prescribing that may benefit patients, leading to an increase in complications that can arise from untreated RTIs. The aim of this thesis was to explore the relationships between community antibiotic dispensing, complications from RTIs and resistance. We showed that decreasing rates of antibiotic dispensing in Wales coincided with increases in hospital diagnosed complications such as pneumonia and septicaemia from 1996-2006. At a practice level, there was evidence of a negative association between dispensing and complications. While a positive association was found between lagged dispensing and resistance, no clear pattern was found between change in dispensing and resistance for any of the organism/ antibiotic combinations examined possibly due to a lack of power. At an individual patient level, antibiotics are not justified to reduce the risk of a complication in those diagnosed with an acute RTI or sore throat. However, for patients presenting with a chest infection, the risk of developing a complication is higher and antibiotics appear to reduce the risk of complications; GPs should therefore consider prescribing for these patients. Further research is required to examine different lag periods of dispensing and their association with resistance and also to identify subgroups of patients at high risk of complications to help GPs target their prescribing of antibiotics