Geraldine Leydon

Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study

Objective To gain understanding of general practitioners’ and patients’ opinions of the routine introduction of standardised measures of severity of depression through the UK general practice quality and outcomes framework. Design Semistructured qualitative interview study, with purposive sampling and constant comparative analysis. Participants 34 general practitioners and 24 patients. Setting 38 general practices in three sites in England: Southampton, Liverpool, and Norfolk. Results Patients generally favoured the measures of severity for depression, whereas general practitioners were generally cautious about the validity and utility of such measures and sceptical about the motives behind their introduction. Both general practitioners and patients considered that assessments of severity should be seen as one aspect of holistic care. General practitioners considered their practical wisdom and clinical judgment (“phronesis”) to be more important than objective assessments and were concerned that the assessments reduced the human element of the consultation. Patients were more positive about the questionnaires, seeing them as an efficient and structured supplement to medical judgment and as evidence that general practitioners were taking their problems seriously through a full assessment. General practitioners and patients were aware of the potential for manipulation of indicators: for economic reasons for doctors and for patients to avoid stigma or achieve desired outcomes. Conclusions Despite general practitioners’ caution about measures of severity for depression, these may benefit primary care consultations by increasing patients’ confidence that general practitioners are correct in their diagnosis and are making systematic efforts to assess and manage their mental health problems. Further education of primary care staff may optimise the use and interpretation of depression questionnaires.

Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial

Objective To assess the impact of different management strategies in urinary tract infections. Design Randomised controlled trial. Setting Primary care. Participants 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection. Intervention Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group. Main outcome measures Symptom severity (days 2 to 4) and duration, and use of antibiotics. Results Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration). Conclusion All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use. Study registration National Research Register N0484094184 ISRCTN: 03525333.

Depression and anxiety in prostate cancer: a systematic review and meta-analysis of prevalence rates

Objectives To systematically review the literature pertaining to the prevalence of depression and anxiety in patients with prostate cancer as a function of treatment stage. Design Systematic review and meta-analysis. Participants 4494 patients with prostate cancer from primary research investigations. Primary outcome measure The prevalence of clinical depression and anxiety in patients with prostate cancer as a function of treatment stage. Results We identified 27 full journal articles that met the inclusion criteria for entry into the meta-analysis resulting in a pooled sample size of 4494 patients. The meta-analysis of prevalence rates identified pretreatment, on-treatment and post-treatment depression prevalences of 17.27% (95% CI 15.06% to 19.72%), 14.70% (95% CI 11.92% to 17.99%) and 18.44% (95% CI 15.18% to 22.22%), respectively. Pretreatment, on-treatment and post-treatment anxiety prevalences were 27.04% (95% CI 24.26% to 30.01%), 15.09% (95% CI 12.15% to 18.60%) and 18.49% (95% CI 13.81% to 24.31%), respectively. Conclusions Our findings suggest that the prevalence of depression and anxiety in men with prostate cancer, across the treatment spectrum, is relatively high. In light of the growing emphasis placed on cancer survivorship, we consider that further research within this area is warranted to ensure that psychological distress in patients with prostate cancer is not underdiagnosed and undertreated.

Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study

Objective To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance. Design Observational study. Setting Primary care. Participants 839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection. Main outcome measure Duration and severity of symptoms. Results 684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline. Conclusion Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.

Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)

Objective To determine the effect of clinical scores that predict streptococcal infection or rapid streptococcal antigen detection tests compared with delayed antibiotic prescribing. Design Open adaptive pragmatic parallel group randomised controlled trial. Setting Primary care in United Kingdom. Patients Patients aged ≥3 with acute sore throat. Intervention An internet programme randomised patients to targeted antibiotic use according to: delayed antibiotics (the comparator group for analyses), clinical score, or antigen test used according to clinical score. During the trial a preliminary streptococcal score (score 1, n=1129) was replaced by a more consistent score (score 2, n=631; features: fever during previous 24 hours; purulence; attends rapidly (within three days after onset of symptoms); inflamed tonsils; no cough/coryza (acronym FeverPAIN). Outcomes Symptom severity reported by patients on a 7 point Likert scale (mean severity of sore throat/difficulty swallowing for days two to four after the consultation (primary outcome)), duration of symptoms, use of antibiotics. Results For score 1 there were no significant differences between groups. For score 2, symptom severity was documented in 80% (168/207 (81%) in delayed antibiotics group; 168/211 (80%) in clinical score group; 166/213 (78%) in antigen test group). Reported severity of symptoms was lower in the clinical score group (−0.33, 95% confidence interval −0.64 to −0.02; P=0.04), equivalent to one in three rating sore throat a slight versus moderate problem, with a similar reduction for the antigen test group (−0.30, −0.61 to −0.00; P=0.05). Symptoms rated moderately bad or worse resolved significantly faster in the clinical score group (hazard ratio 1.30, 95% confidence interval 1.03 to 1.63) but not the antigen test group (1.11, 0.88 to 1.40). In the delayed antibiotics group, 75/164 (46%) used antibiotics. Use of antibiotics in the clinical score group (60/161) was 29% lower (adjusted risk ratio 0.71, 95% confidence interval 0.50 to 0.95; P=0.02) and in the antigen test group (58/164) was 27% lower (0.73, 0.52 to 0.98; P=0.03). There were no significant differences in complications or reconsultations. Conclusion Targeted use of antibiotics for acute sore throat with a clinical score improves reported symptoms and reduces antibiotic use. Antigen tests used according to a clinical score provide similar benefits but with no clear advantages over a clinical score alone. Trial registration ISRCTN32027234

Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial

Objective To estimate the effectiveness of different strategies involving delayed antibiotic prescription for acute respiratory tract infections. Design Open, pragmatic, parallel group, factorial, randomised controlled trial. Setting Primary care in the United Kingdom. Patients 889 patients aged 3 years and over with acute respiratory tract infection, recruited between 3 March 2010 and 28 March 2012 by 53 health professionals in 25 practices. Interventions Patients judged not to need immediate antibiotics were randomised to undergo four strategies of delayed prescription: recontact for a prescription, post-dated prescription, collection of the prescription, and be given the prescription (patient led). During the trial, a strategy of no antibiotic prescription was added as another randomised comparison. Analysis was intention to treat. Main outcome measures Mean symptom severity (0-6 scale) at days 2-4 (primary outcome), antibiotic use, and patients’ beliefs in the effectiveness of antibiotic use. Secondary analysis included comparison with immediate use of antibiotics. Results Mean symptom severity had minimal differences between the strategies involving no prescription and delayed prescription (recontact, post-date, collection, patient led; 1.62, 1.60, 1.82, 1.68, 1.75, respectively; likelihood ratio test χ2 2.61, P=0.625). Duration of symptoms rated moderately bad or worse also did not differ between no prescription and delayed prescription strategies combined (median 3 days v 4 days; 4.29, P=0.368). There were modest and non-significant differences in patients very satisfied with the consultation between the randomised groups (79%, 74%, 80%, 88%, 89%, respectively; likelihood ratio test χ2 2.38, P=0.667), belief in antibiotics (71%, 74%, 73%, 72%, 66%; 1.62, P=0.805), or antibiotic use (26%, 37%, 37%, 33%, 39%; 4.96, P=0.292). By contrast, most patients given immediate antibiotics used antibiotics (97%) and strongly believed in them (93%), but with no benefit for symptom severity (score 1.76) or duration (median 4 days). Conclusion Strategies of no prescription or delayed antibiotic prescription result in fewer than 40% of patients using antibiotics, and are associated with less strong beliefs in antibiotics, and similar symptomatic outcomes to immediate prescription. If clear advice is given to patients, there is probably little to choose between the different strategies of delayed prescription. Trial registration ISRCTN38551726.

Women’s views about management and cause of urinary tract infection: qualitative interview study

Objectives To explore the views of women with urinary tract infection on the acceptability of different strategies for managing the infection, including delayed use of antibiotics, and the cause of infection. Design Qualitative interview study with semistructured one to one interviews within a randomised controlled trial of different management strategies. Analysis drew on some of the principles of constant comparison to generate key themes grounded in reported experiences and understandings. Setting Seven general practices across four counties in southern England. Participants 21 women presenting to general practices who were taking part in the larger trial. Results Women preferred not to take antibiotics and were open to alternative management approaches. With a strategy of “antibiotic delay” some women felt a lack of validation or that they were not listened to by their general practitioner. Women attributed urinary tract infection to lifestyle habits and behaviours, such as poor hygiene, general “negligence,” and even a “penalty of growing old.” Conclusion A clear acknowledgment of women’s triggers to consult is needed. If women are asked to delay taking antibiotics, the clinician must address the particular worries that women might have and explain the rationale for not using antibiotics immediately.

Do men with prostate or colorectal cancer seek different information and support from women with cancer

Male cancer patients’ use of a national cancer information service, their requests and key predictors of these over the period April 1996 to March 1998 are presented, in comparison with women. The most frequent requests of 411 prostate, 162 male and 217 female colorectal cancer patients were similar: site-specific information, emotional support, publications, specific therapies. Research or clinical trials (P< 0.05), diet and nutrition (P< 0.001) requests differed between men with prostate and colorectal cancers; complementary therapies (P< 0.05), prognosis (P< 0.05) requests differed between male and female colorectal cancer patients. Among prostate cancer patients, employed men aged 60+ were more likely to need emotional support than retired men aged 70 +; men < 59 years old were more likely to request publications, but less likely to enquire about specific therapies than others. Among male colorectal cancer patients, employed men were less likely to request site-specific information, but more likely to need emotional support than retired men; patients from geographical areas other than Thames were more likely to request publications; patients from manual classes were less likely to enquire about specific therapies than those from non-manual classes. The complexity of information and support seeking behaviour is demonstrated; no pattern was found among men or in comparison with women. Further research is needed to enable development of services that are appropriate to individual needs and concerns.

Understanding by older patients of dialysis and conservative management for chronic kidney failure

Background Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients’ reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design Qualitative study with semistructured interviews. Settings & Participants Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology Semistructured interviews audiorecorded and transcribed verbatim. Analytical Approach Data were analyzed using thematic analysis. Results 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.

Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women

BACKGROUND Dipsticks are one of the most commonly used near-patient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed. AIM To confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI). DESIGN OF STUDY Validation study. SETTING Primary care. METHOD A total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines. RESULTS Sixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule--based on presence of nitrite, or both leucocytes and blood-- was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features. CONCLUSION A clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.