M De Meyere

What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care

Objective: To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis. Design: A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles. Setting: General practice in Flanders, Belgium. Participants: General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team. Main outcome measures: Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study. Results: A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37). Conclusion: A single intervention in quality circles of GPs integrated in the group’s normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.

Influence of the presence of doctors-in-training on the blood pressure of patients: a randomised controlled trial in 22 teaching practices

Until now, no information is available about the effect of the presence of a doctor-in-training on a patients blood pressure. We tested the hypothesis that the presence of a last year medical student might increase the blood pressure of the patient, in addition to the possible pressor response to the doctor-trainer. Normotensive and hypertensive patients with a minimum age of 25 years, visiting for any reason, were recruited at 22 teaching general practices. Patients were randomised into a ‘trainee’ group (n=133) and a ‘no trainee’ (n=129) group. The blood pressure was measured at two subsequent contacts. In the ‘trainee’ group, a student was present at the first visit only. In the ‘no trainee’ group, both visits were without student. Both groups had similar anthropometric characteristics at entry. At the first visit, systolic pressure was higher in the ‘trainee’ group than in the control group (139.5 vs 133.1 mmHg, P=0.004), with a similar trend for diastolic pressure (80.2 vs 77.8 mmHg, P=0.07). From the first contact to the follow-up visit, blood pressure decreased in the trainee group by 4.8 mmHg systolic (P<0.001) and 1.7 mmHg diastolic (P=0.03), whereas the corresponding changes in the control group were −0.1 mmHg (P=0.90) and +1.5 mmHg (P=0.03). Thus, the between group differences in these trends averaging 4.7 mmHg (CI 1.5–7.9, P=0.005) systolic and 3.2 mmHg (CI 1.1–5.3, P=0.003) diastolic were statistically significant. We conclude that in teaching-practices, the presence of a doctor-in-training has a significant pressor effect when an experienced general practitioner measures a patients blood pressure. If confirmed, our findings imply that doctors should be cautious to initiate or adjust antihypertensive treatment when blood pressure readings are obtained in the presence of a student.

Which bacteria are found in Belgian women with uncomplicated urinary tract infections in primary health care, and what is their susceptibility pattern anno 95-96?

Dysuria is a frequent reason for encounter in general practice and also gynaecologists and urologists will be frequently confronted with it. In female patients 1/2 to 2/3 of dysuric episodes are due to urinary tract infections. In nearly all cases therapy is started before the results of a culture is available. Therefore it is very important to know which bacteria are most prevalent in the treated population, and what their susceptibility pattern is . Because most available information is based on retrospective data issued from very mixed populations, we performed a prospective study including the most frequently involved population: symptomatic adult women without any symptom of complicated UTI. Among 279 urine specimens collected in general practices, 164 were positive (59%). The most frequent micro-organism found was E. coli (78%), followed by S. saprophyticus (9%) and Proteus spp. (4%). In the 15 remaining specimens, 8 different bacterial species were found. Overall resistance to ampicillin was 30%, to cotrimoxazole 14%, to nitrofurantoin 7%, to fluoroquinolones 1%. The E.coli resistance to ampicillin was 27%, to co-trimoxazole 17%, to nitrofurantoin 1% and to fluoroquinolones 1%. In this population the same bacteria, in the same proportion, are found as in earlier studies in other countries. The susceptibility pattern confirms a substantial resistance level to ampicillin and co-trimoxazole. On the contrary, resistance to nitrofurantoin and fluoroquinolones is negligible. Resistance data from Belgian regional laboratories in their outpatient population were significantly different from ours.

Disappointing specificity of the leucocyte-esterase test for the diagnosis of urinary tract infection in general practice

Objectives: To determine the sensitivity and specificity of the leucocyte-esterase test (LE test) as a diagnostic tool in general practice.Methods: In 249 women consulting their general practitioners for dysuria, both the LE test (Nephur testR + leuco/Boehringer Mannheim) and a culture (UricultRdipslide) were performed on freshly voided urine. The sensitivity and specificity of the LE test were determined with urine culture as standard.Results: Sensitivity was 96%, specificity only 15.5% (criterion for positivity of the stick: each colour change; positivity for culture:

Interobserver variation in the interpretation of the leucocyte-esterase test by general practitioners

100,000 colony-forming units (cfu)/ml or every pure culture of Staphylococcus saprophyticus. By lowering the criterion for culture from

Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women.

100,000 cfu/ml to

Does amoxicillin improve outcomes in patients with purulent rhinorrhea? A pragmatic randomized double-blind controlled trial in family practice.

10,000 cfu/ml, the specificity increased by only 0.3%. An increase in the specificity to 36% was possible by classifying ‘lightly positive’ dipsticks (10-20 white blood cells/Ml) as negative; the sensitivity then dropped to 87%. Interpretation after one minute also gave a slightly high...

Op wetenschappelijke evidentie gebaseerde zorg: van theorie naar praktijk: een tweevoudige strategie

Background: Urinary tract infections are frequent in general practice and the search for a rapid and reliable diagnostic aid continues. Test strips are attractive but need more evaluation in the general practice context. Objective: To determine the interobserver variation between general practitioners in the interpretation of the leucocyte-esterase test (LE test) to detect leucocytes in urine. Methods: 37 General practitioners (of whom 85% use these sticks more than once a week) were asked to interpret the LE test (Nephur-test® + leuco Boehringer Mannheim) in 11 urine samples. There were four types of samples: four plainly positive (>500 wbc/ul), one containing 75 wbc/ul, three between 10 and 20 wbc/ul and three negative samples. Evaluation with a spectrophotometric analyser was done twice (MEDITRON® Boehringer): before and after the visual interpretations. The main outcome measure was K for interobserver agreement. Results: In one of the three negative samples, 26/37 (72%) judged the sample correctly as negative, in the two other negative samples 36/37 (97%) judged them correctly as negative. One in 37 (3%) and 25/37 (68%) of the two slightly positive samples (10-25 wbc) were wrongly interpreted as negative. The k of interobserver agreement in all the observations was 0.68; in the clinically most relevant cut-off point between negative and slightly positive samples (10 wbc/ul), k was 0.54, indicating a modest agreement. In 3 to 68% of the observations, the GP will consider a slightly positive specimen as non-infected. Three to 28% of the negative specimens will be considered as infected. In the four clearly positive specimens the interobserver agreement was between 98 and 100%. In the sample with “nearly 75” leucocytes 24/37 participants (65%) judged that it was “more than 500”. Conclusion: In a general practice setting the reliability of the LE test should be questioned because of an important interobserver variation in some slightly positive and some negative samples, which are frequently encountered in clinical practice.