Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial.

BACKGROUND: When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI. METHODS: This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062. FINDINGS: Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33). INTERPRETATION: The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality. FUNDING: Danish Ministry of Health and the Velux Foundation.

"We have two different agendas": the views of general practitioners, social workers and hospital staff on interprofessional coordination for patients with chronic widespread pain.

Patients with chronic widespread pain (CWP) are often unfit for work and go through lengthy treatment. In Denmark, this includes contacts with the job center in their municipality, their general practitioner (GP) and one or more hospital units. Little is known about how coordination around patients with CWP functions and is perceived by professionals. Therefore, our aim is to explore how GPs, social workers from municipality job centers and hospital staff experience interprofessional coordination for patients with CWP. Interviews with 7 GPs, 12 social workers, and 10 hospital staff were analyzed using interpretative phenomenological analysis. The participants experienced challenges with coordination, primarily in the relations between social workers and GPs. There was an over-reliance on written communication in situations where the actors had divergent agendas, opposing professional roles and conflicting approaches to time. GPs tended to lengthen the time spans for treating patients, while social workers tried to shorten them so that patients could get back to work. Applying the theory of relational coordination (RC), the findings correspond to a low level of RC, indicating a need for shared accountability, and strengthened interpersonal communication between professionals.Abbreviations: CWP: Chronic widespread pain; GPs: General practitioners; RC: Relational coordination; IPA: Interpretative phenomenological analysis.

Sustaining an intervention for physical health promotion in community mental health services: A multisite case study.

There is a growing body of literature on sustainability, but its definition and the factors that affect it are not well understood. This paper focuses on the sustainment of health promotion interventions in community mental health organisations, where the institutional context has been found to play an important role. Normalisation Process Theory (NPT) was used to characterise the extent of sustainment of health promotion interventions and to identify important factors that influence it. The study builds on a previously reported qualitative multiple case design focusing on four Danish community mental health organisations. We aimed to include cases (provider organisations) with varied political-administrative contexts that were expected to impact sustainment. Data included 27 semistructured interviews with managers and frontline staff. The analysis adopted a thematic approach combining within-case and cross-case analysis. One important factor contributing to sustainment was the high degree of coherence generated during and after implementation. Perceptions of meaningfulness and formal tools for external accountability such as municipal activity plans also stimulated the cognitive participation of management and staff in sustaining the intervention. On the practical level of collective action, working with health promotion in a continuous way was particularly supported by two formal tools: internal health policies and municipal activity plans. Sustainment was further aided by reflexive monitoring based on ongoing informal assessments, supplemented by information required for status reports to the municipality on individual users and information from the annual individual user health checks. Future studies should adapt NPT to a broader range of cases to assess more thoroughly its contribution to the literature on sustainment. Future interventions need to pay closer attention to securing continuous and active local management support as well as to political-administrative contexts as potential external drivers of sustainment.

Enactments and experiences of 'enhanced interprofessional communication' in collaborative care - a qualitative study.

One of the key components in collaborative care (CC) for anxiety and depression between general practitioners (GPs) and psychiatry is 'enhanced interprofessional communication'. However, the literature contains few detailed descriptions of the interprofessional roles and specific collaborative behaviours that are required to enhance communication. Using semi-structured interviews and observations, this study explores how interprofessional communication was enacted in a CC intervention in Denmark. Analysis was by Interpretative Phenomenological Analysis and interaction analysis. In the intervention the components of the enhanced communication were a) weekly meetings between care managers (CMs) and GPs and b) group supervision of GPs by a psychiatrist. This study showed that the meetings between CMs and GPs were enacted very differently across clinics, with communication ranging from monological 'giving report'-style to more dialogical 'peer-discussion'-style with development of new shared knowledge. The type of communication depended on the GP's professional style. The supervision element was not perceived as being meaningful and GPs reacted by non-attendance and non-response. Engagement of the GPs in a shared process requires a more dialogical model. However, the choice depends on whether a referral or a collaborative model is aimed at. A dialogical model would demand the teaching and guidance of the professionals.

Group supervision for general practitioners: a case study.

AIM: Group supervision is a sparsely researched method for professional development in general practice. The aim of this study was to explore general practitioners' (GPs') experiences of the benefits of group supervision for improving the treatment of mental disorders. METHODS: One long-established supervision group was studied closely for six months by observing the group sessions, and by interviewing GPs and their supervisors, individually and collectively. The interviews were recorded digitally and transcribed verbatim. The data were analysed using systematic text condensation. RESULTS: The GPs found participation in a supervision group to be a meaningful and professionally valuable activity. They experienced that supervision had improved their psychiatric skills, and that they had become more confident in carrying out talking therapies. Improvements in referral letters were also reported in relation to the communication with local community psychiatry centres. Furthermore, the GPs experienced that supervision had a positive 'spill-over effect' on everyday consultations, and that the supervision group became a forum for coping with other difficulties in their professional life as well. Trust and continuity were considered important prerequisites for disclosing and discussing professional problems. CONCLUSION: The results of this study indicate that participation in a supervision group can be beneficial for maintaining and developing GPs' skills in dealing with patients with mental health problems. Group supervision influenced other areas of GPs' professional lives as well. However, more studies are needed to assess the impact of supervision groups.