A.W. van der Velden

Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial

BackgroundTo reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners’ (GPs’) and patients’ attitudes.MethodsGPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics.ResultsGPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful.ConclusionsOur findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.

Maintenance treatment for GERD: residual symptoms are associated with psychological distress.

Aim: The aim of this study was to explore determinants of residual reflux symptoms among patients with gastroesophageal reflux disease (GERD) despite maintenance treatment with acid suppressive medication (ASM). Methods: Primary care GERD patients on chronic ASM were classified as symptom-free (55%) or symptomatic (45%) according to the impact of their residual reflux symptoms (QolRad). They were compared with respect to lifestyle (BMI, alcohol, smoking, physical exercise), compliance (daily ASM dosage), disease history, psychological factors (SCL-90) and quality of life (SF-36). Results: None of the investigated lifestyle factors, nor dosage and disease history were related to residual symptoms. However, symptomatic patients differed from patients with relief on all psychological and quality of life dimensions. In a multiple logistic regression model somatization, hostility, mental health, body pain, as well as gender were independently associated with residual symptoms; the derived ROC curve had an AUC of 0.78. Conclusions: The majority of GERD patients is symptom-free on chronic ASM; they display a healthy psychological state and high quality of life. Residual symptoms however, are associated with psychological distress and lower quality of life. Recognition of this subgroup might hold the key to improving long-term management of gastroesophageal reflux.

Pharmacological dependency in chronic treatment of gastroesophageal reflux disease: a randomized controlled clinical trial.

Background: Despite evidence of the overuse of acid suppressive medication for gastroesophageal reflux disease (GERD), a transfer to noncontinuous therapy after long-term treatment proves difficult. Aim: To quantify the effect of blinded dosage reduction after long-term therapy on symptom control and quality of life while assessing pharmacological and placebo needs. Methods: Primary care patients with a history of GERD and long-term treatment were randomized to daily placebo with pantoprazole rescue (n = 141) or daily pantoprazole with placebo rescue (n = 62) upon relief after 4 weeks pantoprazole 20 mg. The number of rescue tablets, symptom control and generic quality of life were analyzed. Results: Measured from the daily placebo arm, 19% of the patients terminated treatment, 33% managed with 2–6 tablets/week, 38% needed a daily dosage and 10% needed more than a daily dosage in the long run. At these final dosages, symptom control and quality of life were dosage-independent and, furthermore, equal to values of patients on fixed daily pantoprazole. A temporal decrease in well-being was seen in 24% of the patients. Conclusion: A significant placebo response is apparent in long-term users of acid suppressive medication and pharmacological dependency is overestimated. Despite their history of long-term treatment, the majority of GERD patients can be switched from daily to on-demand treatment without impairing symptom control and quality of life.

Sore throat: effective communication delivers improved diagnosis, enhanced self-care and more rational use of antibiotics

The majority of throat infections are of viral origin and resolve without antibiotic treatment. Despite this, antibiotic use for sore throat infections remains high, partly because it is difficult to determine when antibiotics may be useful, on the basis of physical findings alone. Antibiotics may be beneficial in bacterial throat infections under certain clinical and epidemiological circumstances; however, even many of those infections in which bacteria play a role do resolve just as quickly without antibiotics. Furthermore, non‐medical factors such as patient expectations and patient pressure are also important drivers of antibiotic use. To address these issues, a behavioural change is required that can be facilitated by improved communication between primary healthcare providers and patients. In this article, we provide doctors, nurses and pharmacy staff, working in primary care or in the community, with a structured approach to sore throat management, with the aim of educating and empowering patients to self‐manage their condition. The first component of this approach involves identifying and addressing patients’ expectations and concerns with regard to their sore throat and eliciting their opinion on antibiotics. The second part is dedicated to a pragmatic assessment of the severity of the condition, with attention to red‐flag symptoms and risk factors for serious complications. Rather than just focusing on the cause (bacterial or viral) of the upper respiratory tract infections as a rationale for antibiotic use, healthcare providers should instead consider the severity of the patients condition and whether they are at high risk of complications. The third part involves counselling patients on effective self‐management options and providing information on the expected clinical course. Such a structured approach to sore throat management, using empathetic, non‐paternalistic language, combined with written patient information, will help to drive patient confidence in self‐care and encourage them to accept the self‐limiting character of the illness – important steps towards improving antibiotic stewardship in acute throat infections.

Patient Selection for Therapy Reduction after Long-Term Daily Proton Pump Inhibitor Treatment for Gastro-Oesophageal Reflux Disease: Trial and Error

Background: Proton pump inhibitor (PPI) therapy reduction after long-term daily treatment for gastro-oesophageal reflux disease (GORD) symptomatology proves difficult in primary care practice. We aimed to identify patient and/or disease characteristics in long-term daily PPI users predicting a successful switch to less than daily therapy. Methods: GORD patients who after long-term continuous treatment were able to use less than a daily PPI dose in a placebo-controlled trial were compared to patients who persisted in a daily dosage with respect to general, lifestyle and quality of life characteristics (SF-36 Health Survey) as well as psychological factors (Symptom Check List 90), symptom control on daily PPI (Quality of Life in Reflux and Dyspepsia questionnaire), disease and medication history. Results: Adequate symptom control on daily PPI use and female gender were determinants of successful therapy reduction. A prediction rule including the Quality of Life in Reflux and Dyspepsia vitality dimension and gender correctly predicted 64% of patients to both less than daily and sustained daily treatment (area under the receiver operating characteristic curve = 0.69). Conclusion: In the heterogeneous population of PPI users for GORD in primary care, no clinically useful, easily obtainable combination of patient characteristics was able to adequately predict eligibility for therapy reduction. Switching to less than daily therapy remains a process of trial and error in which motivation of the patient and support by the physician will be important factors for success.

Huisartsen volgen de herziene NHG-Standaard OMA

BackgroundDutch primary care has over 100 practical evidence-based treatment guidelines. The second revised guideline for Acute Otitis Media (AOM) was published in 2006.4 Antibiotics are indicated for children with AOM younger than 6 months, with severe or exacerbating illness, or with increased risk of complications. New in this guideline are groups of children for whom antibiotics can be considered: children younger than 2 years with bilateral otitis media, children with a discharging ear at first presentation (meta-analysis showed that these subgroups benefit more than others from antibiotics)9, and children with symptoms lasting longer than 3 days.10AimTo investigate whether general practitioners (GPs) comply with the revised guideline AOM.MethodsInsight in GPs’ prescribing behaviour was obtained by mirroring 198 detailed described consultations involving children with AOM to the revised guideline.ResultsAntibiotics were prescribed to 55% of patients with AOM, amoxicillin in 83.5% of prescriptions. Over-prescription (prescribed when not indicated) and underprescription (not prescribed when indicated) were very rare; the guideline was followed in 96% of the consultations. However, most of the children (60%) fell in the category ‘antibiotics can be considered’, which gives GPs the choice of whether to prescribe or not. There was consensus regarding the GPs’ treatment decisions in this category: fever and bilateral otitis (irrespective of age) in particular led to the prescription of antibiotics.ConclusionThe second revised guideline AOM is adhered to in Dutch primary care. However, due to inclusion of the category ‘consider antibiotics’ the guideline does not provide a clear treatment advice for the majority of patients presenting with AOM in Dutch primary care. As resistance problems are globally increasing, prudent use of antibiotics lists high on the international agenda. To decrease prescription of antibiotics for children, defining a more specific evidence-based prescribing advice for AOM remains necessary, and will provide more clarity for physicians and parents.SamenvattingAchtergrondIn 2006 verscheen de tweede herziene standaard Otitis Media Acuta (OMA), met onder meer richtlijnen voor behandeling van OMA met antibiotica. Naast de kinderen voor wie antibiotica zijn geïndiceerd, kan de huisarts nu bij 3 groepen een antibioticum overwegen: kinderen jonger dan 2 jaar met dubbelzijdige otitis, kinderen die bij eerste presentatie een loopoor hebben, en kinderen bij wie de klachten langer dan 3 dagen duren.VraagstellingIn welke mate handelen huisartsen naar deze OMA-richtlijn?MethodeWe spiegelden 198 gedetailleerd beschreven OMA-consulten aan de richtlijn om inzicht te krijgen in het voorschrijfgedrag van de huisarts.ResultatenOver- en onderprescriptie kwamen zelden voor. In 96% van de consulten handelde de huisarts in overeenstemming met de richtlijn. Van de kinderen viel 60% in de categorie ‘overwegen’; voor hen definieert de richtlijn geen duidelijk beleid. Binnen deze categorie blijken huisartsen wel eenduidig te handelen: vooral koorts en (leeftijdsonafhankelijke) bilaterale otitis leiden tot prescriptie.ConclusieDe tweede herziene standaard OMA wordt goed nageleefd. Wel rijst de vraag of huisartsen werkelijk anders zijn gaan voorschrijven door de herziene richtlijn, of dat prescriptie alleen gerichter lijkt door de categorie ‘antibiotica overwegen’.