ObjectiveThe aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care.DesignThis was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017.Eligibility criteria for selecting studiesControlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied.Data extractionData were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool.Results11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission.ConclusionsPerforming a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes.PROSPERO registration numberCRD42016035426; Results.
SummaryGuidelines recommend clinicians intervene on obesity but it is unclear how people with overweight react. In this systematic review, we searched 20 online databases for qualitative studies interviewing people with overweight or obesity who had consulted a primary care clinician. Framework synthesis was used to analyse 21 studies to produce a new theoretical understanding. Consultations in which patients discussed their weight were more infrequent than patients would have liked, which some perceived was because they were unworthy of medical time; others that it indicated doctors feel being overweight is not a serious risk. Patients reported that doctors offered banal advice assuming that the patient ate unhealthily or was not trying to address their weight. Patients reported doctors assumed that their symptoms were due to overweight without a proper history or examination, creating concern that serious illness may be missed. Patients responded positively to offers of support for weight loss and active monitoring of weight. Patients with overweight internalize weight stigma sensitizing them to clues that clinicians are judging them negatively, even if weight is not discussed. Patients' negative experiences in consultations relate to perceived snap judgements and flippant advice and negative experiences appear more salient than positive ones.
We reviewed the evidence for the impact of point-of-care diagnostic tests for influenza. Testing reduced further investigation with chest radiography and full blood counts, and increased antiviral prescribing, but had no impact on antibiotic use, returning for care, or admissions.
Strengths and limitations of this study ► This study was conducted robustly, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using a comprehensive search strategy in the major medical databases, and selection and quality assessment performed by two independent reviewers. ► It offers results on the impact of panel point-of-care tests (POCTs), rather than just their accuracy. ► Included studies were relatively small, and most notably for mortality, may be underpowered to detect clinically relevant differences between laboratory and POCTs. ► Statistical and clinical heterogeneity is evident within our meta-analysis, however the meta-analysis was considered carefully and heterogeneity reduced where possible by ensuring that studies of cardiac and general panel tests were not combined; moreover, we did not combine the before-after study (which also had a high risk of bias) with randomisedcontrolled trials. ► Four studies excluded critically ill patients and patients with myocardial infarction, which may have biased mortality data. AbStrACtObjectives This article summarises all the available evidence on the impact of introducing blood-based pointof-care panel testing (POCT) in ambulatory care on patient outcomes and healthcare processes.Design Systematic review and meta-analysis of randomised-controlled trials and before-after studies. Data sources Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, Database of Abstracts of Reviews and Effects, Science Citation Index from inception to 22 October 2019.Eligibility criteria for selecting studies Included studies were based in ambulatory care and compared POCT with laboratory testing. The primary outcome was the time to decision regarding disposition that is, admission/ referral termed disposition decision (DD) time. Secondary outcomes included length of stay (LOS) at the ambulatory care unit/practice and mortality. results 19 562 patients from nine studies were included in the review, eight of these were randomised-controlled trials, and one was a before-after study. All the studies were based in either emergency departments or the ambulance service; no studies were from primary care settings. General panel tests performed at the POCT resulted in DDs being made 40 min faster (95% CI −42.2 to −36.6, I 2 =0%) compared with the group receiving usual care, including central laboratory testing. This in turn resulted in a reduction in LOS for patients who were subsequently discharged by 34 min (95% CI −63.7 to −5.16). No significant difference in mortality was reported.Discussion Although statistical and clinical heterogeneity is evident and only a small number of studies were included in the meta-analysis, our results suggest that POCTs might lead to faster discharge decisions. Future research should be performed in primary care and identify how POCTs can contribute meaningful changes to patient care rather than focusing on healthcare processes. PrOSPErO registration number CRD42016035426.
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