Effect of an educational intervention for telephone triage nurses on out-of-hours attendance: a pragmatic randomized controlled study

Background: Telephone triage has been established in many countries as a response to the challenge of non-urgent use of out-of-hours primary care services. However, limited evidence is available regarding the effect of training interventions on clinicians’ telephone consultation skills and patient outcomes. Methods: This was a pragmatic randomized controlled educational intervention for telephone triage nurses in 59 Norwegian out-of-hours general practitioners’ (GPs) cooperatives, serving 59% of the Norwegian population. Computer-generated randomization was performed at the level of out-of-hours GP cooperatives, stratified by the population size. Thirty-two out-of-hours GP cooperatives were randomized to intervention. One cooperative did not accept the invitation to participate in the educational programme, leaving 31 cooperatives in the intervention group. The intervention comprised a 90-minute e-learning course and 90-minute group discussion about respiratory tract infections (RTIs), telephone communication skills and local practices. We aimed to assess the effect of the intervention on out-of-hours attendance and describe the distribution of RTIs between out-of-hours GP cooperatives and list-holding GPs. The outcome was the difference in the number of doctor’s consultations per 1000 inhabitants between the intervention and control groups during the winter months before and after the intervention. A negative binomial regression model was used for the statistical analyses. The model was adjusted for the number of nurses who had participated in the e-learning course, the population size and patients’ age groups, with the out-of-hours GP cooperatives defined as clusters. Results: The regression showed that the intervention did not change the number of consultations for RTIs between the two groups of out-of-hours GP cooperatives (incidence rate ratio 0.99, 95% confidence interval 0.91–1.07). The winter season’s out-of-hours patient population was younger and had a higher proportion of RTIs than the patient population in the list-holding GP offices. Laryngitis, sore throat, and pneumonia were the most common diagnoses during the out-of-hours primary care service. Conclusions: The intervention did not influence the out-of-hours attendance. This finding may be due to the intervention’s limited scope and the intention-to-treat design. Changing a population’s out-of-hours attendance is complicated and needs to be targeted at several organizational levels.publishedVersio

Symptoms, symptom severity, and contact with primary health care among nonhospitalized COVID-19 patients: a Norwegian web-based survey

Objective Dependent on clinical setting, geography and timing during the pandemic, variable symptoms of COVID-19 have been reported. Our aim was to describe self-reported symptom intensity and contact with primary health care among nonhospitalized COVID-19 patients. Design Web-based survey. Setting Norway between March 2020 and July 2021. Subjects Adults in home isolation. Main outcome measures Participants reported possible COVID-19 symptoms, duration of symptoms, score of symptom severity (Likert scale 0–3), risk factors, comorbidity, and questions regarding follow-up and information from primary health care. Results Of 477 participants, 379 (79%) had PCR-confirmed COVID-19, 324 (68%) were females, and 90% were younger than 60 years. Most common symptoms were “fatigue and/or muscle ache” (80%), nasal symptoms (79%), and headache (73%). The mean severity of symptoms was generally low. Symptoms with the highest mean scores were “fatigue and/or muscle ache” (1.51, SD 1.02) and headache (1.27 (SD 1.00). Mean scores for severity ranged from 0.28 (nausea) to 1.51 (fatigue and/or muscle ache). Women reported higher symptom scores than men. For “affected sense of smell and/or taste”, patients either reported a high symptom score (24%) or no affliction at all (49%). A third of the participants (32%) were followed-up by primary care health personnel, and almost 40% had sought or received information about COVID-19 from general practitioners. Conclusion The mean severity of symptoms among nonhospitalized adult COVID-19 patients was generally low. We found large variations in the occurrence and severity of symptoms between patients.publishedVersio

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study

Objective: When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change. Design: Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September–December 2020, the second round from January–April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2–4 months apart. To analyze the data, we used thematic analysis. Results: The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal. Conclusions: Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response

Use and feasibility of delayed prescribing for respiratory tract infections: A questionnaire survey

<p>Abstract</p> <p>Background</p> <p>Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives.</p> <p>Methods</p> <p>Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method.</p> <p>Results</p> <p>304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002).</p> <p>Conclusion</p> <p>Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses.</p

General practitioners and tutors' experiences with peer group academic detailing: a qualitative study

<p>Abstract</p> <p>Background</p> <p>The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice.</p> <p>Methods</p> <p>Data was collected through nine focus group interviews with a total of 39 GPs and 20 tutors. Transcripts from the interviews were analyzed by two researchers according to a procedure for thematic content analysis.</p> <p>Results</p> <p>A shared understanding of the complex decision-making involved in prescribing in general practice was reported by both GPs and tutors as essential for an open discussion in the CME groups. Tutors experienced that CME groups differed regarding structure and atmosphere, and in some groups it was a challenge to run the scheme as planned. Individual feedback motivated GPs to reflect on and to improve their prescribing practice, though feedback reports could cause distress if the prescribing practice was unfavourable. Explanations for inappropriate prescriptions were lack of knowledge, factors associated with patients, the GP's background, the practice, and other health professionals or health care facilities.</p> <p>Conclusions</p> <p>GPs and tutors experienced peer group academic detailing as a suitable method to discuss and learn more about pharmacotherapy. An important outcome for GPs was being more reflective about their prescriptions. Disclosure of inappropriate prescribing can cause distress in some doctors, and tutors must be prepared to recognise and manage such reactions.</p

Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries

OBJECTIVE: To evaluate whether antibiotic prescribing for suspected urinary tract infections in frail older adults can be reduced through a multifaceted antibiotic stewardship intervention. DESIGN: Pragmatic, parallel, cluster randomised controlled trial, with a five month baseline period and a seven month follow-up period. SETTING: 38 clusters consisting of one or more general practices (n=43) and older adult care organisations (n=43) in Poland, the Netherlands, Norway, and Sweden, from September 2019 to June 2021. PARTICIPANTS: 1041 frail older adults aged 70 or older (Poland 325, the Netherlands 233, Norway 276, Sweden 207), contributing 411 person years to the follow-up period. INTERVENTION: Healthcare professionals received a multifaceted antibiotic stewardship intervention consisting of a decision tool for appropriate antibiotic use, supported by a toolbox with educational materials. A participatory-action-research approach was used for implementation, with sessions for education, evaluation, and local tailoring of the intervention. The control group provided care as usual. MAIN OUTCOME MEASURES: The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year. Secondary outcomes included the incidence of complications, all cause hospital referrals, all cause hospital admissions, all cause mortality within 21 days after suspected urinary tract infections, and all cause mortality. RESULTS: The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). No differences between intervention and control group were observed in the incidence of complications (<0.01 v 0.05 per person year), hospital referrals (<0.01 v 0.05), admissions to hospital (0.01 v 0.05), and mortality (0 v 0.01) within 21 days after suspected urinary tract infections, nor in all cause mortality (0.26 v 0.26). CONCLUSIONS: Implementation of a multifaceted antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infections in frail older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT03970356

Delayed prescribing – a feasible strategy to lower antibiotic use for respiratory tract infections in primary care

Widespread use of antibiotics leads to development of antimicrobial resistance, an increasing threat to health worldwide. The strategy of delayed antibiotic prescribing reduces antibiotics use for respiratory tract infections (RTIs) in experimental settings. The overall aim of this thesis is to explore delayed antibiotic prescribing and its potential in reducing antibiotic use for RTIs in routine primary care. In a Norwegian primary care setting, we did 1) a controlled trial among GPs on the antibiotics saving effect of recommending delayed prescribing through lectures/group discussion and through a computerised pop-up reminder, 2) a qualitative study among GPs, and 3) a questionnaire study among GPs issuing and patients receiving delayed prescriptions. We found that GPs regard delayed prescribing as an acceptable strategy for reserving antibiotics to the cases where it turns out to be medically indicated, especially acute otitis and acute sinusitis. GPs have strict requirements as to which patients, for which diagnoses and in which situations they will issue delayed prescriptions, resulting in an infrequent use of the strategy. GPs who received the interventions issued 11% of the antibiotic prescriptions as delayed prescriptions, and 59% of these were dispensed from pharmacies. The interventions gave a statistically significant but clinically modest decrease (RR 0.97) in dispensed antibiotics, without any accompanying increase in prescribed antibiotics. The use of delayed prescribing should be encouraged as a tool to adhere to treatment guidelines, especially in cases of acute otitis and acute sinusitis. Interventions to promote its use have little effect, and pop-up reminders are not to recommend as a sole intervention, but should be considered as part of multi-faceted interventions. Delayed prescribing’s potential in reducing antibiotic use seems to be low in our setting, presumably because of relatively low antibiotic prescribing rates and low patient expectation for antibiotics. The strategy’s potential should be assessed in advance of interventions to implement its use. Further research should focus on the clinical outcomes of delayed prescribing for acute sinusitis, and the effect of other intervention elements in the implementation of delayed prescribing