Cost-effectiveness and return-on-investment of C-reactive protein point-of-care testing in comparison with usual care to reduce antibiotic prescribing for lower respiratory tract infections in nursing homes: a cluster randomised trial.

OBJECTIVES: C-reactive protein point-of-care testing (CRP POCT) is a promising diagnostic tool to guide antibiotic prescribing for lower respiratory tract infections (LRTI) in nursing home residents. This study aimed to evaluate cost-effectiveness and return-on-investment (ROI) of CRP POCT compared with usual care for nursing home residents with suspected LRTI from a healthcare perspective. DESIGN: Economic evaluation alongside a cluster randomised, controlled trial. SETTING: 11 Dutch nursing homes. PARTICIPANTS: 241 nursing home residents with a newly suspected LRTI. INTERVENTION: Nursing home access to CRP POCT (POCT-guided care) was compared with usual care without CRP POCT (usual care). MAIN OUTCOME MEASURES: The primary outcome measure for the cost-effectiveness analysis was antibiotic prescribing at initial consultation, and the secondary outcome was full recovery at 3 weeks. ROI analyses included intervention costs, and benefits related to antibiotic prescribing. Three ROI metrics were calculated: Net Benefits, Benefit-Cost-Ratio and Return-On-Investment. RESULTS: In POCT-guided care, total costs were on average €32 higher per patient, the proportion of avoided antibiotic prescribing was higher (0.47 vs 0.18; 0.30, 95% CI 0.17 to 0.42) and the proportion of fully recovered patients statistically non-significantly lower (0.86 vs 0.91; -0.05, 95% CI -0.14 to 0.05) compared with usual care. On average, an avoided antibiotic prescription was associated with an investment of €137 in POCT-guided care compared with usual care. Sensitivity analyses showed that results were relatively robust. Taking the ROI metrics together, the probability of financial return was 0.65. CONCLUSION: POCT-guided care effectively reduces antibiotic prescribing compared with usual care without significant effects on recovery rates, but requires an investment. Future studies should take into account potential beneficial effects of POCT-guided care on costs and health outcomes related to antibiotic resistance. TRIAL REGISTRATION NUMBER: NL5054.

Performance Assessment of a Rapid Molecular Respiratory Syncytial Virus Point-of-Care Test: A Prospective Community Study in Older Adults.

BACKGROUND: Respiratory syncytial virus (RSV) causes a substantial burden in older adults. Viral load in RSV-infected adults is generally lower compared to young children, which could result in suboptimal sensitivity of RSV diagnostics. Although the Xpert® Xpress Flu/RSV assay has been used in routine clinical care, its sensitivity to diagnose RSV infection in older adults is largely unknown. We aimed to compare the performance of the Xpert® Xpress Flu/RSV assay with real-time reverse-transcription polymerase chain reaction (RT-PCR) in home-dwelling older adults (≥60 years of age). METHODS: Nasopharyngeal swabs were tested with Xpert® Xpress Flu/RSV and compared to RSV RT-PCR in older adults with acute respiratory tract infections with different levels of disease severity. RESULTS: We studied 758 respiratory samples from 561 older adults from 2 consecutive RSV seasons. Thirty-five (4.6%) samples tested positive for RSV by at least 1 of the assays, of which 2 samples were negative by Xpert® Xpress Flu/RSV and 3 samples by real-time RT-PCR. The positive percentage agreement (PPA) was 90.9% (95% confidence interval [CI], 76.4%-96.8%) and negative percentage agreement was 99.7% (95% CI, 99.0%-99.9%). Viral loads were low (≤103 copies/mL or cycle threshold value ≥34) in all cases with discordant results for the 2 assays. CONCLUSIONS: The PPA of Xpert® Xpress Flu/RSV compared to routine RT-PCR is high for RSV detection in home-dwelling older adults. The assay is fast and easy to use at the point of care. CLINICAL TRIALS REGISTRATION: NCT03621930.

Incidence and management of acute otitis media in adults: a primary care-based cohort study.

BACKGROUND: Although primarily considered a childhood disease, acute otitis media (AOM) also occurs in adults. Data on the burden of this condition in adults are, however, scarce. OBJECTIVE: To explore the primary care incidence and current management of AOM in adults. METHODS: All patients aged 15 and older included in the routine health care database of the Julius General Practitioners' Network were followed from 2015 to 2018 (contributing to a total of 1 261 575 person-years). We extracted data on AOM episodes, AOM-related consultations, comorbidities, and antibiotic and analgesic prescriptions. RESULTS: Five thousand three hundred and fifty-eight patients experienced one or more AOM episodes (total number of AOM episodes: 6667; mean 1.2 per patient). The overall AOM incidence was 5.3/1000 person-years and was fairly stable over the study period. Incidence was particularly high in atopic patients (7.3/1000 person-years) and declined with age (from 7.1 in patients 15-39 years of age to 2.7/1000 person-years in those aged 64 years and older). Oral antibiotics, predominantly amoxicillin, were prescribed in 46%, and topical antibiotics in 21% of all episodes. CONCLUSION: Over the past years, the incidence of AOM in adults in primary care has been stable. Oral antibiotic prescription rates resemble those in children with AOM, whereas a remarkably high topical antibiotic prescription rate was observed. Future prognostic research should inform on the need and feasibility of prospective studies into the best management strategy in this condition.

[Effectiveness of vaccination against influenza in children: is it time for another policy?] / Effectiviteit van influenzavaccinatie bij kinderen.

A recent study found no protective effect of influenza vaccination on the frequency of respiratory tract infections in children with pre-existing medical conditions in the Netherlands, based on a retrospective primary care database review. Rightfully, the investigators did not conclude that influenza vaccination for children with pre-existing medical conditions is not effective, but that more information is needed about the effects of influenza vaccination on severe influenza and hospitalisations. Another strategy could be to vaccinate all children against influenza. A recent meta-analysis showed that vaccinating all children against influenza reduced influenza related hospitalizations. The Dutch Health Council is currently re-evaluating influenza vaccination in children. Herd immunity and therefore indirect protection of high risk groups should be taken into consideration when evaluating cost-effectiveness of this strategy.

Cost-effectiveness analysis of a GP- and parent-directed intervention to reduce antibiotic prescribing for children with respiratory tract infections in primary care.

OBJECTIVES: We evaluated costs and effects of the RAAK (RAtional Antibiotic use Kids) intervention (GP online training and information booklets for parents), aiming to reduce antibiotic prescribing for children with respiratory tract infection (RTI). METHODS: We conducted a trial-based cost-effectiveness analysis from a societal perspective. We included children consulting the GP with RTI for whom parents kept a 2 week (cost) diary. The antibiotic prescribing rate was the percentage of children receiving an antibiotic prescription at the index consultation and during the 2 weeks of follow-up. The cost difference between the intervention and usual care groups per percentage decrease in antibiotic prescribing was calculated. Bootstrapping was used to assess uncertainty surrounding the outcomes. RESULTS: Costs and effects of 153 children in the intervention group and 107 children in the usual care group were available for analysis. Antibiotic prescribing was 12% lower in the intervention group and costs were €10.27 higher in the intervention group compared with the usual care group. This resulted in an incremental cost-effectiveness ratio of €0.85 per percentage decrease in antibiotic prescribing. The probability that the intervention was more effective, but more expensive, was 53%, whereas the probability that the intervention was more effective and less expensive compared with usual care was 41%. CONCLUSIONS: The online training for GPs and the information booklet for parents resulted in a decrease in antibiotic prescribing in children with RTI, at very low cost, and should therefore be considered for implementation in primary care.

Improving patient safety culture in general practice: an interview study.

BACKGROUND: When improving patient safety a positive safety culture is key. As little is known about improving patient safety culture in primary care, this study examined whether administering a culture questionnaire with or without a complementary workshop could be used as an intervention for improving safety culture. AIM: To gain insight into how two interventions affected patient safety culture in everyday practice. DESIGN AND SETTING: After conducting a randomised control trial of two interventions, this was a qualitative study conducted in 30 general practices to aid interpretation of the previous quantitative findings. METHOD: Interviews were conducted at practice locations (n = 27) with 24 GPs and 24 practice nurses. The theory of communities of practice--in particular, its concepts of a domain, a community, and a practice--was used to interpret the findings by examining which elements were or were not present in the participating practices. RESULTS: Communal awareness of the problem was only raised after getting together and discussing patient safety. The combination of a questionnaire and workshop enhanced the interaction of team members and nourished team feelings. This shared experience also helped them to understand and develop tools and language for daily practice. CONCLUSION: In order for patient safety culture to improve, the safety culture questionnaire was more successful when accompanied by a practice workshop. Initial discussion and negotiation of shared goals during the workshop fuelled feelings of coherence and belonging to a community wishing to learn about enhancing patient safety. Team meetings and day-to-day interactions enhanced further liaison and sharing, making patient safety a common and conscious goal.

Cost-effectiveness of adult pneumococcal conjugate vaccination in the Netherlands.

The Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA) demonstrated the efficacy of 13-valent pneumococcal conjugate vaccine (PCV13) in preventing vaccine-type community-acquired pneumonia and vaccine-type invasive pneumococcal disease in elderly subjects. We examined the cost-effectiveness of PCV13 vaccination in the Netherlands. Using a Markov-type model, incremental cost-effectiveness ratios (ICER) of PCV13 vaccination in different age- and risk-groups for pneumococcal disease were evaluated using a societal perspective. Estimates of quality-adjusted life-years (QALYs), costs, vaccine efficacy and epidemiological data were based on the CAPiTA study and other prospective studies. The base-case was PCV13 vaccination of adults aged 65-74 years compared to no vaccination, assuming no net indirect effects in base-case due to paediatric 10-valent pneumococcal conjugate vaccine use. Analyses for age- and risk-group specific vaccination strategies and for different levels of hypothetical herd effects from a paediatric PCV programme were also conducted. The ICER for base-case was €8650 per QALY (95% CI 5750-17,100). Vaccination of high-risk individuals aged 65-74 years was cost-saving and extension to medium-risk individuals aged 65-74 years yielded an ICER of €2900. Further extension to include medium- and high-risk individuals aged ≥18 years yielded an ICER of €3100.PCV13 vaccination is highly cost-effective in the Netherlands. The transferability of our results to other countries depends upon vaccination strategies already implemented in those countries.

Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients.

BACKGROUND: Numerous studies suggest overprescribing of antibiotics for respiratory tract indications (RTIs), without really authenticating inappropriate prescription; the strict criteria of guideline recommendations were not taken into account as information on specific diagnoses, patient characteristics and disease severity was not available. OBJECTIVE: The aim of this study is to quantify and qualify inappropriate antibiotic prescribing for RTIs. METHODS: This is an observational study of the (antibiotic) management of patients with RTIs, using a detailed registration of RTI consultations by general practitioners (GPs). Consultations of which all necessary information was available were benchmarked to the prescribing guidelines for acute otitis media (AOM), acute sore throat, rhinosinusitis or acute cough. Levels of overprescribing for these indications and factors associated with overprescribing were determined. RESULTS: The overall antibiotic prescribing rate was 38%. Of these prescriptions, 46% were not indicated by the guidelines. Relative overprescribing was highest for throat (including tonsillitis) and lowest for ear consultations (including AOM). Absolute overprescribing was highest for lower RTIs (including bronchitis). Overprescribing was highest for patients between 18 and 65 years of age, when GPs felt patients' pressure for an antibiotic treatment, for patients presenting with fever and with complaints longer than 1 week. Underprescribing was observed in <4% of the consultations without a prescription. CONCLUSION: Awareness of indications and patient groups provoking antibiotic overprescribing can help in the development of targeted strategies to improve GPs' prescribing routines for RTIs.

Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial.

BACKGROUND: A constructive safety culture is essential for the successful implementation of patient safety improvements. AIM: To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture. DESIGN AND SETTING: A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands. METHOD: The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires. RESULTS: The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups. CONCLUSION: Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety.

Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups.

BACKGROUND: Antibiotics are of limited overall clinical benefit for uncomplicated lower respiratory tract infection (LRTI) but there is uncertainty about their effectiveness for patients with features associated with higher levels of antibiotic prescribing. AIM: To estimate the benefits and harms of antibiotics for acute LRTI among those producing coloured sputum, smokers, those with fever or prior comorbidities, and longer duration of prior illness. DESIGN AND SETTING: Secondary analysis of a randomised controlled trial of antibiotic placebo for acute LRTI in primary care. METHOD: Two thousand and sixty-one adults with acute LRTI, where pneumonia was not suspected clinically, were given amoxicillin or matching placebo. The duration of symptoms, rated moderately bad or worse (primary outcome), symptom severity on days 2-4 (0-6 scale), and the development of new or worsening symptoms were analysed in pre-specified subgroups of interest. Evidence of differential treatment effectiveness was assessed in prespecified subgroups by interaction terms. RESULTS: No subgroups were identified that were significantly more likely to benefit from antibiotics in terms of symptom duration or the development of new or worsening symptoms. Those with a history of significant comorbidities experienced a significantly greater reduction in symptom severity between days 2 and 4 (interaction term -0.28, P = 0.003; estimated effect of antibiotics among those with a past history -0.28 [95% confidence interval = -0.44 to -0.11], P = 0.001), equivalent to three people in 10 rating symptoms as a slight rather than a moderately bad problem. For subgroups not specified in advance antibiotics provided a modest reduction in symptom severity for non-smokers and for those with short prior illness duration (<7 days), and a modest reduction in symptom duration for those with short prior illness duration. CONCLUSION: There is no clear evidence of clinically meaningful benefit from antibiotics in the studied high-risk groups of patients presenting in general practice with uncomplicated LRTIs where prescribing is highest. Any possible benefit must be balanced against the side-effects and longer-term effects on antibiotic resistance.

Central or local incident reporting? A comparative study in Dutch GP out-of-hours services.

BACKGROUND: Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented. AIM: To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure. DESIGN OF STUDY: Quasi experiment. SETTING: Three GPs' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention. METHOD: A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported. RESULTS: At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems. CONCLUSION: It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues. The advantages of both approaches should be combined.

Asthma medication use in infancy: determinants related to prescription of drug therapy.

BACKGROUND: Little is known about factors that determine prescribing of asthma therapy in infancy. OBJECTIVE: To describe factors related to the initiation and refill of asthma therapy in infancy. METHODS: This study included 1202 infants who participated in a prospective birth cohort study: the 'Wheezing Illnesses Study Leidsche Rijn (WHISTLER)'. Outcomes, asthma therapy initiation and refill, were assessed using prescription data. Logistic regression analysis was used to study determinants of therapy initiation in two groups: total population and infants with a respiratory system symptom diagnosis. In addition, determinants of refilling prescriptions were studied in infants who started therapy in their first year of life. RESULTS: Fifteen per cent of all infants started asthma therapy in their first year of life. Respiratory symptoms were an important driver of both initiation and refill of prescriptions. In the total population, therapy initiation was associated with male gender [odds ratio (OR): 1.6, 95% confidence interval (CI): 1.1-2.6], day-care attendance (OR: 1.6, 95% CI: 1.0-2.5) and breastfeeding (OR: 0.6, 95% CI: 0.3-1.0). For infants with a respiratory system symptom diagnosis, day-care attendance was associated with an increased chance of therapy initiation (OR: 5.3, 95% CI: 1.8-16.2) and breastfeeding was associated with a lower chance of starting therapy (OR: 0.4, 95% CI: 0.1-1.1). Dutch children had a higher chance of refilling prescriptions in infancy (OR: 5.3, 95% CI: 1.1-26.8). CONCLUSIONS: Apart from other factors involved, the principal reason for initiation and refill of asthma therapy in infancy was the presence of respiratory symptoms. This appeared the only reason to prescribe medication and physicians are not distracted by other factors.

Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study.

OBJECTIVE: To evaluate the feasibility of a locally implemented incident-reporting procedure (IRP) in primary healthcare centres after 1 year. SETTING AND PARTICIPANTS: Five primary healthcare centres caring for more than 43000 patients in The Netherlands. GPs, medical nurses, physiotherapists, pharmacists, pharmacist assistants and trainees reported incidents (a total of 117 employees). METHODS: An IRP was implemented in which participants were encouraged to report all incidents. In addition, dedicated 'reporting weeks' were introduced that emphasised reporting of minor incidents and near misses. In every centre, an IRP committee analysed the reported incidents in order to initiate improvements when necessary. OUTCOME MEASURES: Frequency and nature of reported incidents, number of incidents analysed by the IRP committees and number of improvements implemented. In addition, the authors studied the actual implementation of the IRP and the acceptability as experienced by participants. RESULTS: A total of 476 incidents were reported during a 9-month reporting period. Of all incidents, 62% were reported in a reporting week, and most were process-related. Possible harm for patients was none or small in 87% of the reported incidents. IRP committees analysed 84 incidents and found 230 root causes. All participating centres had initiated improvement projects as a result of reported incidents. Most interviewees considered the IRP feasible, but several practical, professional and personal barriers to implementation of the IRP were identified. CONCLUSION: The implementation of a centre-based IRP in primary care is feasible. Reporting weeks enhance the willingness to report.

Antibiotics in Dutch general practice: nationwide electronic GP database and national reimbursement rates.

PURPOSE: In order to assess whether different databases generate information which can be reliable compared with each other, this study aimed to assess to which degree prescribing rates for systemic antibiotics from a nationwide electronic general practitioner (GP) database correspond with national reimbursement rates, and to investigate for which indications antibiotics are prescribed. METHODS: Nationwide GP prescribing data were collected from the Second Dutch National Survey of General Practice (DNSGP-2) based on 90 general practices serving 358 008 patients in 2001. Dutch national reimbursement rates for GPs were derived from claims data of the Dutch Drug Information System/Health Care Insurance Board (GIP/CVZ) from 2001. We calculated antibiotic prescribing rates per 1000 patients/inhabitants for each database, and these rates were compared for the total rates and according to antibiotic subgroups. Indications for which GPs prescribed antibiotics were described. RESULTS: In national reimbursement data, 339 antibiotic prescriptions per 1000 inhabitants were prescribed by GPs, while the nationwide GP database showed 255 prescriptions per 1000 patients (75% coverage with reimbursement rates). The nationwide GP database showed high volumes of sulphonamides & trimethoprim, and small volumes of macrolides and quinolones. Half of the prescriptions (48%) were prescribed for respiratory diseases, a quarter (26%) for urinary diseases and 7% for ear diseases. CONCLUSIONS: GPs voluntarily participating in a research network prescribe less antibiotics than Dutch GPs in general, and are cautious in prescribing newer and more broad-spectrum antibiotics. This point has to be taken into account when databases will be compared with each other.

European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe.

BACKGROUND AND OBJECTIVE: Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug-specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data. METHODS: 27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997-2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA-RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1-6 interval and if there was consensus (number of scores within the 1-3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators-values were updated with 2004 ESAC data. RESULTS: 22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected. CONCLUSION: 12 of the proposed ESAC-based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.

Diagnostic labelling as determinant of antibiotic prescribing for acute respiratory tract episodes in general practice.

BACKGROUND: Next to other GP characteristics, diagnostic labelling (the proportion of acute respiratory tract (RT) episodes to be labelled as infections) probably contributes to a higher volume of antibiotic prescriptions for acute RT episodes. However, it is unknown whether there is an independent association between diagnostic labelling and the volume of prescribed antibiotics, or whether diagnostic labelling is associated with the number of presented acute RT episodes and consequently with the number of antibiotics prescribed per patient per year. METHODS: Data were used from the Second Dutch National Survey of General Practice (DNSGP-2) with 163 GPs from 85 Dutch practices, serving a population of 359,625 patients. Data over a 12 month period were analysed by means of multiple linear regression analysis. Main outcome measure was the volume of antibiotic prescriptions for acute RT episodes per 1,000 patients. RESULTS: The incidence was 236.9 acute RT episodes/1,000 patients. GPs labelled about 70% of acute RT episodes as infections, and antibiotics were prescribed in 41% of all acute RT episodes. A higher incidence of acute RT episodes (beta 0.67), a stronger inclination to label episodes as infections (beta 0.24), a stronger endorsement of the need of antibiotics in case of white spots in the throat (beta 0.11) and being male (beta 0.11) were independent determinants of the prescribed volume of antibiotics for acute RT episodes, whereas diagnostic labelling was not correlated with the incidence of acute RT episodes. CONCLUSION: Diagnostic labelling is a relevant factor in GPs' antibiotic prescribing independent from the incidence of acute RT episodes. Therefore, quality assurance programs and postgraduate courses should emphasise to use evidence based prognostic criteria (e.g. chronic respiratory co-morbidity and old age) as an indication to prescribe antibiotics in stead of single inflammation signs or diagnostic labels.

Is co-morbidity taken into account in the antibiotic management of elderly patients with acute bronchitis and COPD exacerbations?

BACKGROUND: Guidelines on acute lower respiratory tract infections recommend restrictive use of antibiotics, however, in patients with relevant co-morbid conditions treatment with antibiotics should be considered. Presently, it is unknown whether GPs adhere to these guidelines and target antibiotic treatment more often at patients with risk-elevating conditions. OBJECTIVES: We assessed whether in elderly primary care patients with acute bronchitis or exacerbations of chronic pulmonary disease (COPD), antibiotics are more often prescribed to patients with risk-elevating co-morbid conditions. METHODS: Using the Utrecht GP research database, we analysed 2643 episodes in patients of 65 years of age or older with a GP-diagnosed acute bronchitis or exacerbation of COPD. Multivariable logistic regression analysis was applied to determine independent determinants of antibiotic use. RESULTS: Antibiotic prescribing rates were high in both acute bronchitis (84%) and in exacerbations of COPD (53%). In acute bronchitis, only age was an independent determinant of antibiotic use [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.003-1.048], whereas in exacerbations of COPD antibiotics were more often prescribed to male patients (OR 1.3, 95% CI 1.0-1.5), patients with diabetes (OR 1.7, 95% CI 1.1-2.4) and heart failure (OR 1.3, 95% CI 1.0-1.7). CONCLUSION: Dutch GPs prescribe antibiotics in the majority of elderly patients with acute bronchitis and in half of the episodes of exacerbations of COPD. Tailoring their antibiotic treatment according to the presence or absence of high-risk co-morbid conditions could help GPs in improving antibiotic use in patients with respiratory tract infections in primary care.

Views on respiratory tract symptoms and antibiotics of Dutch general practitioners, practice staff and patients.

OBJECTIVES: To explore views on respiratory tract symptoms (cough, sore throat and earache) and antibiotics of GPs, practice staff, and patients. METHODS: In a nationwide study, 181 GPs, 204 practice staff members and 1250 patients from 90 practices participated by answering 14 items relating to views on respiratory tract symptoms and antibiotics in a written questionnaire. Differences in means were compared. RESULTS: Patients more than GPs endorsed the seriousness of respiratory tract symptoms, the need to consult a GP, the need to prescribe antibiotics, and the ability of antibiotics to speed up recovery. GPs were more than patients convinced of the self-limiting character of respiratory tract symptoms and of the fact that antibiotics have side effects. Practice staff took a middle ground in most of these views. CONCLUSIONS: Differences between GPs, practice staff and patients must be taken into account when exploring patients' complaints and advising on treatment. Education and knowledge programmes for practice staff might be advocated.

Determinants of prescribing of second-choice antibiotics for upper and lower respiratory tract episodes in Dutch general practice.

OBJECTIVES: The aim of this study was to assess the association between general practitioners' (GPs') characteristics and the volume of second-choice antibiotics for acute respiratory tract (RT) episodes by GPs. METHODS: Morbidity and antibiotic prescription data originated from the Second Dutch National Survey of General Practice (DNSGP-2). GPs' characteristics, including professional activities and views on RT symptoms and antibiotics, were measured by a written questionnaire. Multiple regression was carried out to assess associations between possible determinants and volume of second-choice antibiotic prescriptions. RESULTS: In approximately 39% of acute RT episodes antibiotics were prescribed, with one-quarter being second-choice antibiotics, relatively more frequently in lower than in upper RT episodes: 30 versus 19%. GPs who were more frequently consulted by patients with RT episodes (beta = 0.29; 95% CI 0.13-0.41), who labelled RT episodes more as diagnoses than as symptoms (beta = 0.27; 95% CI 0.15-0.42), who less frequently used national GP guidelines (beta = -0.17; 95% CI -0.31 to -0.03) and who were more inclined to prescribe new drugs (beta = 0.26; 95% CI 0.13-0.40), prescribed more second-choice antibiotics. CONCLUSIONS: Given the growing number of prescriptions of second-choice antibiotics, it is important to implement professional guidelines in daily practice, while training in being reluctant to prescribe new drugs and being alert to the marketing activities of pharmaceutical companies should be started in the medical curriculum.