Adam W.A. Geraghty

Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial

Summary Background High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems. Methods After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214. Results The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42–0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54–0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36–0·74, p<0·0001; enhanced communication 0·68, 0·50–0·89, p=0·003; combined 0·38, 0·25–0·55, p<0·0001). Interpretation Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. Funding European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.

Attrition from self-directed interventions: investigating the relationship between psychological predictors, intervention content and dropout from a body dissatisfaction intervention

The aims of this study were to (a) identify the predictors of attrition from a fully self-directed intervention, and (b) to test whether an intervention to increase gratitude is an effective way to reduce body dissatisfaction. Participants (N=479, from the United Kingdom) aged 18-76 years took part in a self-help study via the Internet and were randomized to receive one of two interventions, gratitude diaries (n=130), or thought monitoring and restructuring (n=118) or a waitlist control (n=231) for a two week body dissatisfaction intervention. The gratitude intervention (n=40) was as effective as monitoring and restructuring (n=22) in reducing body dissatisfaction, and both interventions were significantly more effective than the control condition (n=120). Participants in the gratitude group were more than twice as likely to complete the intervention compared to those in the monitoring and restructuring group. Intervention content, baseline expectancy and internal locus of control significantly predicted attrition. This study shows that a gratitude intervention can be as effective as a technique commonly used in cognitive therapy and is superior in retaining participants. Prediction of attrition is possible from both intervention content and psychological variables.

Treatment non-adherence in pediatric long-term medical conditions: systematic review and synthesis of qualitative studies of caregivers’ views

BackgroundNon-adherence to prescribed treatments is the primary cause of treatment failure in pediatric long-term conditions. Greater understanding of parents and caregivers’ reasons for non-adherence can help to address this problem and improve outcomes for children with long-term conditions.MethodsWe carried out a systematic review and thematic synthesis of qualitative studies. Medline, Embase, Cinahl and PsycInfo were searched for relevant studies published in English and German between 1996 and 2011. Papers were included if they contained qualitative data, for example from interviews or focus groups, reporting the views of parents and caregivers of children with a range of long-term conditions on their treatment adherence. Papers were quality assessed and analysed using thematic synthesis.ResultsNineteen papers were included reporting 17 studies with caregivers from 423 households in five countries. Long-term conditions included; asthma, cystic fibrosis, HIV, diabetes and juvenile arthritis. Across all conditions caregivers were making on-going attempts to balance competing concerns about the treatment (such as perceived effectiveness or fear of side effects) with the condition itself (for instance perceived long-term threat to child). Although the barriers to implementing treatment regimens varied across the different conditions (including complexity and time-consuming nature of treatments, un-palatability and side-effects of medications), it was clear that caregivers worked hard to overcome these day-to-day challenges and to deal with child resistance to treatments. Yet, carers reported that strict treatment adherence, which is expected by health professionals, could threaten their priorities around preserving family relationships and providing a ‘normal life’ for their child and any siblings.ConclusionsTreatment adherence in long-term pediatric conditions is a complex issue which needs to be seen in the context of caregivers balancing the everyday needs of the child within everyday family life. Health professionals may be able to help caregivers respond positively to the challenge of treatment adherence for long-term conditions by simplifying treatment regimens to minimise impact on family life and being aware of difficulties around child resistance and supportive of strategies to attempt to overcome this. Caregivers would also welcome help with communicating with children about treatment goals.

Internet-based intervention for smoking cessation (StopAdvisor) in people with low and high socioeconomic status: a randomised controlled trial

BACKGROUND Internet-based interventions for smoking cessation could help millions of people stop smoking at very low unit costs; however, long-term biochemically verified evidence is scarce and such interventions might be less effective for smokers with low socioeconomic status than for those with high status because of lower online literacy to engage with websites. We aimed to assess a new interactive internet-based intervention (StopAdvisor) for smoking cessation that was designed with particular attention directed to people with low socioeconomic status. METHODS We did this online randomised controlled trial between Dec 6, 2011, and Oct 11, 2013, in the UK. Participants aged 18 years and older who smoked every day were randomly assigned (1:1) to receive treatment with StopAdvisor or an information-only website. Randomisation was automated with an unseen random number function embedded in the website to establish which treatment was revealed after the online baseline assessment. Recruitment continued until the required sample size had been achieved from both high and low socioeconomic status subpopulations. Participants, and researchers who obtained data and did laboratory analyses, were masked to treatment allocation. The primary outcome was 6 month sustained, biochemically verified abstinence. The main secondary outcome was 6 month, 7 day biochemically verified point prevalence. Analysis was by intention to treat. Homogeneity of intervention effect across the socioeconomic subsamples was first assessed to establish whether overall or separate subsample analyses were appropriate. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN99820519. FINDINGS We randomly assigned 4613 participants to the StopAdvisor group (n=2321) or the control group (n=2292); 2142 participants were of low socioeconomic status and 2471 participants were of high status. The overall rate of smoking cessation was similar between participants in the StopAdvisor and control groups for the primary (237 [10%] vs 220 [10%] participants; relative risk [RR] 1·06, 95% CI 0·89-1·27; p=0·49) and the secondary (358 [15%] vs 332 [15%] participants; 1·06, 0·93-1·22; p=0·37) outcomes; however, the intervention effect differed across socioeconomic status subsamples (1·44, 0·99-2·09; p=0·0562 and 1·37, 1·02-1·84; p=0·0360, respectively). StopAdvisor helped participants with low socioeconomic status stop smoking compared with the information-only website (primary outcome: 90 [8%] of 1088 vs 64 [6%] of 1054 participants; RR 1·36, 95% CI 1·00-1·86; p=0·0499; secondary outcome: 136 [13%] vs 100 [10%] participants; 1·32, 1·03-1·68, p=0·0267), but did not improve cessation rates in those with high socioeconomic status (147 [12%] of 1233 vs 156 [13%] of 1238 participants; 0·95, 0·77-1·17; p=0·61 and 222 [18%] vs 232 [19%] participants; 0·96, 0·81-1·13, p=0·64, respectively). INTERPRETATION StopAdvisor was more effective than an information-only website in smokers of low, but not high, socioeconomic status. StopAdvisor could be implemented easily and made freely available, which would probably improve the success rates of smokers with low socioeconomic status who are seeking online support. FUNDING National Prevention Research Initiative.

Context Effects and Behaviour Change Techniques in Randomised Trials: a Systematic Review Using the Example of Trials to Increase Adherence to Physical Activity in Musculoskeletal Pain

Objective: To describe and explore the effects of contextual and behaviour change technique (BCT) content of control and target interventions in clinical trials. Design: Review and meta-analysis of 42 trials from a Cochrane review of physical activity in chronic musculoskeletal pain. Main Outcome Measures: Two researchers coded descriptions of target and control interventions for (a) 93 BCTs and (b) whether target and control interventions shared each of five contextual features (practitioners’ characteristics, patient-practitioner relationship, intervention credibility, superficial treatment characteristics e.g. delivery modality, and environment). Quality of study reporting was assessed. Effect sizes for adherence to physical activity and class attendance were computed (Cohen’s d) and analysed separately. Results: For physical activity outcomes, after controlling for reporting quality, larger effect sizes were associated with target and control interventions using different modalities (β = −.34, p = .030), target and control interventions involving equivalent patient-practitioner relationship (β = .40, p = .002), and target interventions having more unique BCTs (i.e. more BCTs not also in the control) (β = .008, p = .030). There were no significant effect moderators for class attendance outcomes. Conclusion: Contents of control conditions can influence effect sizes and should be considered carefully in trial design and systematic reviews.

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.

Development of StopAdvisor: A theory-based interactive internet-based smoking cessation intervention

ABSTRACTReviews of internet-based behaviour-change interventions have shown that they can be effective but there is considerable heterogeneity and effect sizes are generally small. In order to advance science and technology in this area, it is essential to be able to build on principles and evidence of behaviour change in an incremental manner. We report the development of an interactive smoking cessation website, StopAdvisor, designed to be attractive and effective across the social spectrum. It was informed by a broad motivational theory (PRIME), empirical evidence, web-design expertise, and user-testing. The intervention was developed using an open-source web-development platform, ‘LifeGuide’, designed to facilitate optimisation and collaboration. We identified 19 theoretical propositions, 33 evidence- or theory-based behaviour change techniques, 26 web-design principles and nine principles from user-testing. These were synthesised to create the website, ‘StopAdvisor’ (see http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The systematic and transparent application of theory, evidence, web-design expertise and user-testing within an open-source development platform can provide a basis for multi-phase optimisation contributing to an ‘incremental technology’ of behaviour change.

Predictors of adherence to home-based physical therapies: a systematic review

Abstract Purpose: Self-managed, home-based physical therapy (HBPT) is an increasingly common element of physical therapy rehabilitation programmes but non-adherence can reach 70%. Understanding factors that influence patients’ adherence to HBPTs could help practitioners support better adherence. Research to date has focussed largely on clinic-based physiotherapy. The objective of this review, therefore, was to identify specific factors, which influence adherence to home-based, self-managed physical therapies. Method: A systematic review was conducted, in which eight online databases were searched using combinations of key terms relating to physical therapies, adherence and predictors. Matching records were screened against eligibility criteria and 30 quantitative articles were quality assessed and included in the final review. Relevant data were extracted and a narrative synthesis approach was taken to aggregating findings across studies. Results: There was relatively strong evidence that the following factors predicted adherence to HBPTs: intention to engage in the HBPT, self-motivation, self-efficacy, previous adherence to exercise-related behaviours and social support. Conclusions: This review has identified a range of factors that appear to be related to patients’ adherence to their self-managed physical rehabilitation therapies. Awareness of these factors may inform design of interventions to improve adherence. Implications for Rehabilitation Non-adherence to physical rehabilitation therapies is often high – particularly in self-managed, home-based programmes, despite good adherence being important in achieving positive outcomes. The findings of this systematic review indicate that greater self-efficacy, self-motivation, social support, intentions and previous adherence to physical therapies predict higher adherence to HBPTs. Assessment of these domains before providing individuals with their HBPT regimes may allow identification of ‘risk factors’ for poor adherence. These can then potentially be addressed or managed prior to, or alongside, the therapy. Interventions to support patients’ self-managed physical rehabilitation should include elements designed to enhance patients’ self-efficacy, self-motivation and social support given the evidence that these factors are good predictors of adherence.

Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003–2013

BACKGROUND Both the 2004 NICE depression guidelines and 2006 general practice Quality Outcomes Framework (QOF) encouraged improved targeting of antidepressant treatment for depression. METHODS Possible effects of the NICE guideline from January 2005, and QOF from April 2006, on rates of GP antidepressant prescribing were examined using time trend analyses of anonymised data from 142 English practices contributing to the Clinical Practice Research Datalink (CPRD), 2003-2013. RESULTS Sustained reductions were found in the proportion of first-ever depression episodes treated within 12 months, of 4.2% (95% C.I. 1.0-7.3%) following introduction of the NICE guideline, and 4.4% (2.3-6.5%) following introduction of the QOF. Treatment rates for first-ever episodes fell from 72.5% (70.8-74.1%) in Quarter 2 (Q2) 2003 to 61.0% (59.3-62.7%) in Q1 2012, but treatment rates for recurrent episodes increased from 74.3% (72.8-75.8%) to 77.8% (76.5-79.1%), so overall rates remained around 70%. Mean prescriptions per patient per year doubled from 2.06 (2.05-2.07) to 3.98 (3.97-3.99). LIMITATIONS Participating practices were larger than average and not representative across regions. Inferences of cause and effect from time trend analyses are subject to the possibility of unidentified confounders. No data were available on depression severity or appropriateness of prescribing. CONCLUSIONS Rates of GP antidepressant treatment for patients with incident depression fell following introduction of NICE depression guidelines and the QOF, but treatment rates for recurrent depression increased. Prescription numbers increased due to longer treatment courses. To impact on antidepressant prescribing rates, guidelines and performance indicators must address recurrent and long-term prescribing, rather than initial treatment decisions.

Changes in rates of recorded depression in English primary care 2003–2013: Time trend analyses of effects of the economic recession, and the GP contract quality outcomes framework (QOF)

BACKGROUND Depression may be increasing, particularly since the economic recession. Introduction of quality outcomes framework (QOF) performance indicators may have altered GP recording of depression. METHODS Time trend analyses of GP recording of depression before and after the recession (from April 2008), and the QOF (from April 2006) were conducted on anonymised consultation data from 142 English practices contributing to the Clinical Practice Research Datalink, April 2003-March 2013. RESULTS 293,596 patients had computer codes for depressive diagnoses or symptoms in the 10 years. Prevalence of depression codes fell from 44.6 (95% CI 44.2, 45.0) per 1000 person years at risk (PYAR) in 2003/2004 to 38.0 (37.7, 38.3) in 2008/2009, rising to 39.5 (39.2, 39.9) in 2012/2013. Incidence of first-ever depression codes fell from 11.9 (95% CI 11.7, 12.1) per 1000 PYAR in 2003/2004 to 9.5 (9.3, 9.7) in 2008/2009, rising to 10.0 (9.8, 10.2) in 2012/1203. Prevalence increased in men but not women following the recession, associated with increased unemployment. Following introduction of the QOF, GPs used more non-QOF-qualifying symptom or other codes than QOF-qualifying diagnostic codes for new episodes. LIMITATIONS Clinical data recording is probably incomplete. Participating practices were relatively large and not representative across English regions. CONCLUSIONS Rates of recorded depression in English general practices were falling prior to the economic recession but increased again subsequently, among men, associated with increased unemployment. GPs responded to the QOF by switching from diagnostic to symptom codes, removing most depressed patients from the denominator for measuring GP performance in assessing depression.