Predictors of patient-initiated reconsultation for lower respiratory tract infections in general practice

Cals, Jochen; Hood, Kerenza; Aaftink, Nienke; Hopstaken, Rogier; Francis, Nick; Dinant, Geert-Jan; Butler, Christopher Collett

doi:10.3399/bjgp09x472656

Cited by 16 publications

(12 citation statements)

References 12 publications

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“…Concerns have been expressed about the potential medicalization of point-of-care testing in family practice. 17,18 We found, however, no evidence to suggest that the disease-focused intervention effect of a point-of-care test to rule out serious infection resulted in a subsequent increase in offi ce visit rates. Additionally, giving patients evidence-based information by physicians trained in illness-focused communication skills could theoretically lead to fewer visits through increased patient self-management of future respiratory tract infections.…”

Section: Discussion Summary and Main Findingsmentioning

confidence: 66%

Enhanced Communication Skills and C-reactive Protein Point-of-Care Testing for Respiratory Tract Infection: 3.5-year Follow-up of a Cluster Randomized Trial

Cals

Bock

Beckers

et al. 2013

The Annals of Family Medicine

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PURPOSEThe purpose of the study was to assess the long-term effect of family physicians' use of C-reactive protein (CRP) point-of-care testing and/or physician training in enhanced communication skills on offi ce visit rates and antibiotic prescriptions for patients with respiratory tract infections. METHODSWe conducted a 3.5-year follow-up of a pragmatic, factorial, clusterrandomized controlled trial; 379 patients (20 family practices in the Netherlands) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available (88% of original trial cohort). Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year (PPPY), and the percentage of the episodes for which patients were treated with antibiotics during follow-up. RESULTSThe mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group (P = .12). In the communication skills training group, there was a mean of 0.36 PPPY episodes of respiratory tract infections, and in the no training group the mean was 0.57 PPPY (P = .09). During follow-up 30.7% of all episodes of respiratory tract infection were treated with antibiotics in the CRP test group compared with 35.7% in the no test group (P = .36). Family physicians trained in communication skills treated 26.3% of all episodes of respiratory tract infection with antibiotics compared with 39.1% treated by family physicians without training in communication skills (P = .02) CONCLUSIONS Family physicians' use of CRP point-of-care testing and/or training in enhanced communication skills did not signifi cantly affect offi ce visit rates related to respiratory tract infections. Patients who saw a family physician trained in enhanced communication skills were prescribed signifi cantly fewer antibiotics during episodes of respiratory tract infection in the subsequent 3.5 years. 2013;11:157-164. doi:10.1370/afm.1477. Ann Fam Med INTRODUCTIONR espiratory tract infections are the most common reasons for acute care offi ce visits and antibiotic prescribing in primary care.1,2 Reducing overprescribing of antibiotics for respiratory tract infections is essential in an era of increasing antimicrobial resistance.3 Important determinants infl uencing overprescription of antibiotics are patients' expectations of antibiotics, physicians' assumptions regarding these expectations, and physicians' diagnostic uncertainty in differentiating serious from selflimiting disease. 4,5 Differentiating those patients who are more likely to benefi t from antibiotics from those who are unlikely to benefi t is consid- 9,10 A systematic review of the diagnostic role of CRP testing in lower respiratory tract infections in primary care showed that CRP levels were a strong predictor in differentiating pneumonia from acute bronchitis. 11In 2 randomized trials including 688 primary care patients with respiratory tr...

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Section: Discussion Summary and Main Findingsmentioning

confidence: 66%

Enhanced Communication Skills and C-reactive Protein Point-of-Care Testing for Respiratory Tract Infection: 3.5-year Follow-up of a Cluster Randomized Trial

Cals

Bock

Beckers

et al. 2013

The Annals of Family Medicine

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“…Nonetheless, interpreting and communicating intermediately elevated test results to patients is challenging, and patients with these values commonly return for further consultation. 23,24 A delayed prescribing may provide an appropriate safety net for both patients and family physicians for patients with intermediately elevated CRP results.…”

Section: T Es T Ing Cr P F or A N T Ibiot Ic Pr Es Cr Ibingmentioning

confidence: 99%

Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial

Cals¹,

Schot²,

Jong³

et al. 2010

The Annals of Family Medicine

159

188

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PURPOSE Antibiotics are only benefi cial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) pointof-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis. METHODSWe conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery. RESULTSPatients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confi dence interval [CI], 0.56-0.98). This difference remained signifi cant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were fi lled only in a minority of cases (23% vs 72% in control group, P <.001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03).CONCLUSIONS CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery. Ann Fam Med 2010;8:124-133. doi:10.1370/afm.1090. INTRODUCTIONR espiratory tract infections are among the most common reasons to consult in family practice. Although antibiotic treatment is considered necessary only for community-acquired pneumonia and for small subgroups of the other lower and upper respiratory tract infections, [1][2][3][4][5] antibiotics are prescribed to roughly 80% of patients consulting for lower respiratory tract infection (LRTI) or acute rhinosinusitis. 6,7 Signs and symptoms are of limited value in identifying those patients in need of antibiotic treatment for these conditions. 2,[8][9][10] Diagnostic uncertainty and patient-related factors, such as patient expectations and pressure, often lead to unjustifi ed antibiotic prescribing by family physicians. 11,12 C-reactive protein (CRP) is an acute-phase protein with levels quickly rising during infl ammatory processes. Currently, CRP can be measured by using a point-of-care test, which has been proved both accurate and robust in a family practice setting. 13 T ES T ING CR P F OR A N T IBIOT IC PR ES CR IBINGparameters, increases diagnostic certainty [14][15][16] and may thereby help identify those patients who will benefi t from antibiotic treatment. Latest randomized evidence has shown that antibiotic prescribing rates ...

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“…[15][16][17] Reconsultations provide an opportunity for patients (and parents) with new concerns to have these addressed. However, they can be a marker that patient (parent) concerns were not adequately addressed during the first consultation.…”

Section: Re-consultations For the Same Illness Episodementioning

confidence: 99%

Reducing uncertainty in managing respiratory tract infections in primary care

2010

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Respiratory tract infections (RTIs) remain the commonest reason for acute consultations in primary care in resource-rich countries. Their spectrum and severity has changed from the time that antibiotics were discovered, largely from improvements in the socioeconomic determinants of health as well as vaccination. The benefits from antibiotic treatment for common RTIs have been shown to be largely overstated. Nevertheless, serious infections do occur. Currently, no clinical features or diagnostic test, alone or in combination, adequately determine diagnosis, aetiology, prognosis, or response to treatment. This narrative review focuses on emerging evidence aimed at helping clinicians reduce and manage uncertainty in treating RTIs. Consultation rate and prescribing rate trends are described, evidence of increasing rates of complications are discussed, and studies and the association with antibiotic prescribing are examined. Methods of improving diagnosis and identifying those patients who are at increased risk of complications from RTIs, using clinical scoring systems, biomarkers, and point of care tests are also discussed. The evidence for alternative management options for RTIs are summarised and the methods for changing public and clinicians' beliefs about antibiotics, including ways in which we can improve clinician-patient communication skills for management of RTIs, are described.

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Predictors of patient-initiated reconsultation for lower respiratory tract infections in general practice

Cited by 16 publications

References 12 publications

Enhanced Communication Skills and C-reactive Protein Point-of-Care Testing for Respiratory Tract Infection: 3.5-year Follow-up of a Cluster Randomized Trial

Enhanced Communication Skills and C-reactive Protein Point-of-Care Testing for Respiratory Tract Infection: 3.5-year Follow-up of a Cluster Randomized Trial

Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial

Reducing uncertainty in managing respiratory tract infections in primary care

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