Point-of-care testing with CRP in primary care: a registry-based observational study from Norway

Rebnord, Ingrid Keilegavlen; Hunskaar, Steinar; Gjesdal, Sturla; Hetlevik, Øystein

doi:10.1186/s12875-015-0385-8

Cited by 12 publications

(17 citation statements)

References 27 publications

(25 reference statements)

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“…At the OOH services, the doctor is a GP, a GP in training or other specialists or locums. We have no detailed information about the experience of these OOH doctors, but know that younger doctors are working more often at OOH-services and make more use of CRP 9. How the experience affects prescription is not known, but in our study we did not find a significant association between being a paediatrician and prescription.…”

Section: Discussioncontrasting

confidence: 62%

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Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

et al. 2017

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ObjectivesAcute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children.DesignSecondary analysis of a randomised controlled study.Setting4 out-of-hours services and 1 paediatric emergency clinic in Norwegian primary care.Participants401 children aged 0–6 years with respiratory symptoms and/or fever visiting the out-of-hours services.Outcomes2 main outcome variables were registered: antibiotic prescription and referral to hospital.ResultsThe total prescription rate of antibiotics was 23%, phenoxymethylpenicillin was used in 67% of the cases. Findings on ear examination (OR 4.62; 95% CI 2.35 to 9.10), parents' assessment that the child has a bacterial infection (OR 2.45; 95% CI 1.17 to 5.13) and a C reactive protein (CRP) value >20 mg/L (OR 3.57; 95% CI 1.43 to 8.83) were significantly associated with prescription of antibiotics. Vomiting in the past 24 hours was negatively associated with prescription (OR 0.26; 95% CI 0.13 to 0.53). The main predictors significantly associated with referral to hospital were respiratory rate (OR 1.07; 95% CI 1.03 to 1.12), oxygen saturation <95% (OR 3.39; 95% CI 1.02 to 11.23), signs on auscultation (OR 5.57; 95% CI 1.96 to 15.84) and the parents' assessment before the consultation that the child needs hospitalisation (OR 414; 95% CI 26 to 6624).ConclusionsCRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents' assessment was also significantly associated with the outcomes.Trial registration numberNCT02496559; Results.

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Section: Discussioncontrasting

confidence: 62%

“…It is possible that the test is used to assure parents that there is no serious bacterial infection. It is also possible that the widespread use may have economic reasons 9. The test result is difficult to interpret, especially for low values between 20 and 50 mg/L 10…”

Section: Introductionmentioning

confidence: 99%

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

et al. 2017

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“…We have no detailed information about the experience of these OOH doctors but know that younger doctors are working more often OOH and use more CRP. 9 19 How the experience affects the prescription is not known. The paediatric emergency clinic had the function as an OOH service for children in Bergen city, but the children at the clinic seemed to be slightly healthier, maybe due to the walk-in, open access facility.…”

Section: Discussionmentioning

confidence: 99%

“… 8 It has high popularity in Norwegian primary care as a point-of-care test, and in OOH services it is used in more than half of all children with respiratory symptoms. 1 9 It thus seems that CRP testing is more like a routine, rather than a supplement to history taking and clinical examination.…”

Section: Introductionmentioning

confidence: 99%

Out-of-hours antibiotic prescription after screening with C reactive protein: a randomised controlled study

et al. 2016

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ObjectiveTo evaluate the effect of preconsultation C reactive protein (CRP) screening on antibiotic prescribing and referral to hospital in Norwegian primary care settings with low prevalence of serious infections.DesignRandomised controlled observational study at out-of-hours services in Norway.SettingPrimary care.Participants401 children (0–6 years) with fever and/or respiratory symptoms were recruited from 5 different out-of-hours services (including 1 paediatric emergency clinic) in 2013–2015.InterventionData were collected from questionnaires and clinical examination results. Every third child was randomised to a CRP test before the consultation; for the rest, the doctor ordered a CRP test if considered necessary.Outcome measuresMain outcome variables were prescription of antibiotics and referral to hospital.ResultsIn the group pretested with CRP, the antibiotic prescription rate was 26%, compared with 22% in the control group. In the group pretested with CRP, 5% were admitted to hospital, compared with 9% in the control group. These differences were not statistically significant. The main predictors for ordering a CRP test were parents' assessment of seriousness of the illness and the child's temperature. Paediatricians ordered CRP tests less frequently than did other doctors (9% vs 56%, p<0.001).ConclusionsPreconsultation screening with CRP of children presenting to out-of-hours services with fever and/or respiratory symptoms does not significantly affect the prescription of antibiotics or referral to hospital.Trial registration numberNCT02496559; Results.

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“…We could not find population based studies on uptake of the other three interventions in clinical populations similar to those in trials. One nationwide cross-sectional study found that 70% of Norwegian GPs used CRP for children aged 5 years or under who presented with a respiratory infection [ 24 ], but use of CRP for adult patients is not known. We estimated that CRP had an uptake rate of 28% (95% CI 20–36%) for use in adults, and although this was the highest uptake out of the 4 interventions we studied, it may still be an underestimate.…”

Section: Challenges To This Methodsmentioning

confidence: 99%

What’s the uptake? Pragmatic RCTs may be used to estimate uptake, and thereby population impact of interventions, but better reporting of trial recruitment processes is needed

Bell

McCullough

Mar

et al. 2017

BMC Med Res Methodol

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BackgroundEffectiveness of interventions in pragmatic trials may not translate directly into population impact, because of limited uptake by clinicians and/or the public. Uptake of an intervention is influenced by a number of factors.MethodsWe propose a method for calculating population impact of clinical interventions that accounts for the intervention uptake. We suggest that population impact may be estimated by multiplying the two key components: (1) the effectiveness of the intervention in pragmatic trials (trial effect); and, (2) its uptake in clinical practice. We argue that participation rates in trials may be a valid proxy for uptake in clinical practice and, in combination with trial effectiveness estimates, be used to rank interventions by their likely population impact. We illustrate the method using the example of four interventions to decrease antibiotic prescription for acute respiratory infections in primary care: delayed prescribing, procalcitonin test, C-Reactive Protein, shared decision making.ResultsIn order to estimate uptake of interventions from trial data we need detailed reporting on the recruitment processes used for clinician participation in the trials. In the antibiotic prescribing example, between 75 and 91% of the population would still be prescribed or consume antibiotics because effective interventions were not taken up. Of the four interventions considered, we found that delayed prescribing would have the highest population impact and shared decision making the lowest.ConclusionEstimates of uptake and population impact of an intervention may be possible from pragmatic RCTs, provided the recruitment processes for these trials are adequately reported (which currently few of them are). Further validation of this method using empirical data on intervention uptake in the real world would support use of this method to decide on public funding of interventions.

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Point-of-care testing with CRP in primary care: a registry-based observational study from Norway

Cited by 12 publications

References 27 publications

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

Out-of-hours antibiotic prescription after screening with C reactive protein: a randomised controlled study

What’s the uptake? Pragmatic RCTs may be used to estimate uptake, and thereby population impact of interventions, but better reporting of trial recruitment processes is needed

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