Assessment of the comparability of CLSI, EUCAST and Stokes antimicrobial susceptibility profiles for Escherichia coli uropathogenic isolates.

BACKGROUND: As many clinical laboratories convert between Stokes, Clinical and Laboratory Standards Institute (CLSI) and European Committee for Antimicrobial Susceptibility Testing (EUCAST) methods, the problem of comparing differently derived sets of antimicrobial susceptibility testing (AST) data with each other arises, owing to a scarcity of knowledge of inter-method comparability. The purpose of the current study was to determine the comparability of CLSI, EUCAST and Stokes AST methods for determining susceptibility of uropathogenic Escherichia coli to ampicillin, amoxicillin-clavulanate, trimethoprim, cephradine/cephalexin, ciprofloxacin and nitrofurantoin. METHODS: A total of 100 E. coli isolates were obtained from boric acid urine samples from patients attending GP surgeries. For EUCAST and CLSI, the Kirby-Bauer disc diffusion method was used and results interpreted using the respective breakpoint guidelines. For the Stokes method, direct susceptibility testing was performed on the urine samples. RESULTS: The lowest levels of agreement were for amoxicillin-clavulanate (60%) and ciprofloxacin (89%) between the three AST methods, when using 2017 interpretive guidelines for CLSI and EUCAST. A comparison of EUCAST and CLSI without Stokes showed 82% agreement for amoxicillin-clavulanate and 94% agreement for ciprofloxacin. Discrepancies were compounded by varying breakpoint susceptibility guidelines issued during the period 2011-2017, and through the inclusion of a definition of intermediate susceptibility in some cases. CONCLUSIONS: Our data indicate that the discrepancies generated through using different AST methods and different interpretive guidelines may result in confusion and inaccuracy when prescribing treatment for urinary tract infection.

Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: a pragmatic, cluster randomized, controlled trial.

OBJECTIVE: Chronic joint pain is a major cause of pain and disability. Exercise and self-management have short-term benefits, but few studies follow participants for more than 6 months. We investigated the long-term (up to 30 months) clinical and cost effectiveness of a rehabilitation program combining self-management and exercise: Enabling Self-Management and Coping of Arthritic Knee Pain Through Exercise (ESCAPE-knee pain). METHODS: In this pragmatic, cluster randomized, controlled trial, 418 people with chronic knee pain (recruited from 54 primary care surgeries) were randomized to usual care (pragmatic control) or the ESCAPE-knee pain program. The primary outcome was physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function), with a clinically meaningful improvement in physical function defined as a ≥15% change from baseline. Secondary outcomes included pain, psychosocial and physiologic variables, costs, and cost effectiveness. RESULTS: Compared to usual care, ESCAPE-knee pain participants had large initial improvements in function (mean difference in WOMAC function -5.5; 95% confidence interval [95% CI] -7.8, -3.2). These improvements declined over time, but 30 months after completing the program, ESCAPE-knee pain participants still had better physical function (difference in WOMAC function -2.8; 95% CI -5.3, -0.2); lower community-based health care costs (£-47; 95% CI £-94, £-7), medication costs (£-16; 95% CI £-29, £-3), and total health and social care costs (£-1,118; 95% CI £-2,566, £-221); and a high probability (80-100%) of being cost effective. CONCLUSION: Clinical and cost benefits of ESCAPE-knee pain were still evident 30 months after completing the program. ESCAPE-knee pain is a more effective and efficient model of care that could substantially improve the health, well-being, and independence of many people, while reducing health care costs.

Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain.

OBJECTIVE: To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program. METHODS: Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness. RESULTS: Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost 224 pounds (95% confidence interval [95% CI] 184 pounds, 262 pounds) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Indiv-rehab cost 314 pounds/person and Grp-rehab 125 pounds/person. Indiv-rehab cost 189 pounds (95% CI 168 pounds, 208 pounds) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP 5,500 pounds. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome. CONCLUSION: Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.

From parallel policies to integrated practice: PMS and PCG/Ts.

This paper describes findings from an exploratory study of attempts by primary care clinicians and managers to utilize two distinct Government policy initiatives (the establishment of Primary Care Groups [PCGs] and Trusts [PCTs] and the establishment of Primary Medical Services [PMS] pilots) to promote innovation in primary care. The study purposively selected three whole PCG-PMS sites and one PCT-PMS site. A range of different qualitative methods were used to collect data. Although the data suggest that attempts to integrate the two policies produced impressive corporate innovation by practices working together to benefit patients in whole localities, the four sites shared features that would not necessarily be present in all PCG/Ts. These include a strong history of inter-practice working, mutually supportive relationships between clinicians and managers, and a carefully designed, managed and inclusive change process led by credible clinicians. The study has implications for the continuing implementation of both policies, especially in view of the increasing size of PCTs.

Physical, functional and other non-pharmacological interventions for osteoarthritis.

Non-pharmacological interventions are frequently and widely used in the management of patients with osteoarthritis (OA). However, there is little evidence that most of these interventions are efficacious (i.e. that they work under ideal circumstances) owing to the paucity of research studies on these interventions and the fundamental methodological flaws in published studies. Moreover, the clinical effectiveness of non-pharmacological interventions (i.e. their efficacy under the conditions prevailing in clinical practice) is unknown, and cost-analysis of these interventions has not been carried out. If evidence-based management guidelines were to be constructed solely from firm research studies few could be recommended. Established and developing research methodologies and techniques should be employed to construct and conduct research programmes that appropriately evaluate the clinical and cost effectiveness of these complex non-pharmacological healthcare interventions. Establishing clinical effectiveness will ensure that we have practice-based evidence and are administering relevant, effective and optimal healthcare for patients with OA, maximizing the efficient use of healthcare resources.

Primary care. This is your pilot speaking.

An evaluation of 14 personal medical services pilot schemes has found the GPs involved welcome the reduction in paperwork. The flexibility in funding of the schemes has allowed GPs greater leeway in managing their workload. Some of the financial risks of running a practice have been removed. It is questionable whether the schemes are fully using the freedoms envisaged. Some schemes reported a lack of support from their health authority.

Personal medical services. Friends and relations.

Personal medical services pilot schemes remain internally focused. In many areas hospital doctors' willingness to work with general practice has been hampered by chief executives' fear of loss of income. Health authorities have generally failed to take responsibility for the pilot schemes. There are some fears of the schemes creating inequity at local level.

Total purchasing in primary care: three case studies.

Total purchasing in primary care (TPPC) was piloted in the mid-1990's, first by four "pioneer sites", and later by over 80 first and second waves of "pilot sites". Separate evaluations of three of the pioneers show that they faced challenges similar to those experienced by the pilot sites, namely: the need to develop organisations which were effective both internally and, in their relationships with other health-care agencies, externally; and the difficulties encountered when attempting to change the behaviour of local acute care providers. Although GP fund holding and/or TPPC have had some successes in influencing the pattern of delivery for some elective and community services, the challenge of reducing hospital admissions and lengths of stay remains formidable.

Primary care groups. Going through the change.

The successful establishment of primary care groups will demand sensitivity from managers. It is important to acknowledge, and mourn, what is being lost by ending the old arrangements. People do not resist change itself, but the losses and endings it involves. Despite the tight timetable, management should be participative rather than directive.

What cost chronic pain?

Chronic non-malignant pain costs the American economy $40 billion a year. An attempt to quantify the total cost to the Irish economy of 95 patients attending a Multi-Disciplinary Pain Clinic was made. The cost to the Health Services was estimated and added to the amount of Social Welfare payments received and the lost earnings of each patient. The results indicated that the 95 patients cost 1.9 million pounds at the time of referral. A subgroup of 22 patients who were younger and unemployed, accounted for 1.5 million pounds. Allocation of resources to treat these patients is necessary.

Physical medicine and rehabilitation workforce study: the supply of and demand for physiatrists.

OBJECTIVE: Analysis, results, and implications of a supply and demand workforce model for physical medicine and rehabilitation. Explicit issues addressed include: (1) the supply implications of maintaining current (1994-1995) output of physiatrists from residency programs; (2) the implications of continued growth in managed care on the demand for the services of physiatrists; (3) likely future supply and demand conditions; and (4) strategies to adapt to future conditions. DESIGN: A workforce model of the supply and demand for physiatrists was developed. Parameters of the model are estimated using econometric models and by applying the judgments of a consensus panel. The model evaluated several different scenarios regarding managed care growth, competition from other providers and other factors. RESULTS: Based on the analysis, physiatrists will continue to be in excess demand through the year 2000. More aggressive growth in managed care can affect this result. CONCLUSIONS: Based on an overall assessment of supply and demand conditions, and under the assumption that the supply of new entrants each year remains in the range of 1994-1995 levels, demand for physiatrists will continue to exceed supply, on average, through the year 2000. Excess supply has, and will, emerge in selected geographic areas. If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.

The influence of compensation on recovery from low back pain.

The influence of financial compensation on recovery is one of the most controversial issues in the treatment of low back pain. In this review the authors include psychological aspects of compensation and the effects of compensation on injury rate, injury duration, and rehabilitation outcomes.