Understanding Antibiotic Use in Companion Animals: A Literature Review Identifying Avenues for Future Efforts.

Addressing antibiotic use is essential to tackle antimicrobial resistance, a major human and animal health challenge. This review seeks to inform stewardship efforts in companion animals by collating research insights regarding antibiotic use in this group and identifying overlooked avenues for future research and stewardship efforts. The development of population-based methods has established that antibiotics are frequently used in companion animal care. Research insights are also contributing toward an in-depth comprehension of the contexts to antibiotic use. Qualitative approaches, for example, have enabled a nuanced understanding in four key areas: interactions with owners, clinical and financial risk management, time pressures, and clinic dynamics. This review identifies that much of the existing research frames antibiotic use as the result of choices made by the individuals at the interface of their use. Future research and policy endeavours could look beyond the moment of prescribing to consider the societal structures and networks in which companion animal antibiotic use is entangled. A diversification in research approaches and frameworks through which antibiotic use is understood will facilitate the identification of additional targets for stewardship initiatives beyond providing information and awareness campaigns.

What drives antimicrobial prescribing for companion animals? A mixed-methods study of UK veterinary clinics.

Antimicrobial use in companion animals is a largely overlooked contributor to the complex problem of antimicrobial resistance. Humans and companion animals share living spaces and some classes of antimicrobials, including those categorised as Highest Priority Critically Important Antimicrobials (HPCIAs). Veterinary guidelines recommend that these agents are not used as routine first line treatment and their frequent deployment could offer a surrogate measure of 'inappropriate' antimicrobial use. Anthropological methods provide a complementary means to understand how medicines use makes sense 'on-the-ground' and situated in the broader social context. This mixed-methods study sought to investigate antimicrobial use in companion animals whilst considering the organisational context in which increasing numbers of veterinarians work. Its aims were to i) to epidemiologically analyse the variation in the percentage of antimicrobial events comprising of HPCIAs in companion animal dogs attending UK clinics belonging to large veterinary groups and, ii) to analyse how the organisational structure of companion animal practice influences antimicrobial use, based on insight gained from anthropological fieldwork. A VetCompassTM dataset composed of 468,665 antimicrobial dispensing events in 240,998 dogs from June 2012 to June 2014 was analysed. A hierarchical model for HPCIA usage was built using a backwards elimination approach with clinic and dog identity numbers included as random effects, whilst veterinary group, age quartile, breed and clinic region were included as fixed effects. The largest odds ratio of an antimicrobial event comprising of a HPCIA by veterinary group was 7.34 (95% confidence interval 5.14 - 10.49), compared to the lowest group (p < 0.001). Intraclass correlation was more strongly clustered at dog (0.710, 95% confidence interval 0.701 - 0.719) than clinic level (0.089, 95% confidence interval 0.076 -0.104). This suggests that veterinarians working in the same clinic do not automatically share ways of working with antimicrobials. Fieldwork revealed how the structure of the companion animal veterinary sector was more fluid than that depicted in the statistical model, and identified opportunities and challenges regarding altering antimicrobial use. These findings were organised into the following themes: "Highest priority what?"; "He's just not himself"; "Oh no - here comes the antibiotics police"; "We're like ships that pass in the night"; and "There's not enough hours in the day". This rigorous mixed-methods study demonstrates the importance of working across disciplinary silos when tackling the complex problem of antimicrobial resistance. The findings can help inform the design of sustainable stewardship schemes for the companion animal veterinary sector.

Acceptability and psychological impact of out-of-office monitoring to diagnose hypertension: an evaluation of survey data from primary care patients.

BACKGROUND: Out-of-office blood pressure (BP) is recommended for diagnosing hypertension in primary care due to its increased accuracy compared to office BP. Moreover, being diagnosed as hypertensive has previously been linked to lower wellbeing. There is limited evidence regarding the acceptability of out-of-office BP and its impact on wellbeing. AIM: To assess the acceptability and psychological impact of out-of-office monitoring in people with suspected hypertension. DESIGN AND SETTING: A pre- and post-evaluation of participants with elevated (≥130 mmHg) systolic BP, assessing the psychological impact of 28 days of self-monitoring followed by ambulatory BP monitoring for 24 hours. METHOD: Participants completed standardised psychological measures pre- and post-monitoring, and a validated acceptability scale post-monitoring. Descriptive data were compared using χ2 tests and binary logistic regression. Pre- and post-monitoring comparisons were made using the paired t-test and Wilcoxon signed rank test. RESULTS: Out-of-office BP monitoring had no impact on depression and anxiety status in 93% and 85% of participants, respectively. Self-monitoring was more acceptable than ambulatory monitoring (n = 183, median 2.4, interquartile range [IQR] 1.9-3.1 versus median 3.2, IQR 2.7-3.7, P<0.01). When asked directly, 48/183 participants (26%, 95% confidence interval [CI] = 20 to 33%) reported that self-monitoring made them anxious, and 55/183 (30%, 95% CI = 24 to 37%) reported that ambulatory monitoring made them anxious. CONCLUSION: Out-of-office monitoring for hypertension diagnosis does not appear to be harmful. However, health professionals should be aware that in some patients it induces feelings of anxiety, and self-monitoring may be preferable to ambulatory monitoring.

Patient experience of home and waiting room blood pressure measurement: a qualitative study of patients with recently diagnosed hypertension.

BACKGROUND: Out-of-office blood pressure (BP) measurement is advocated to confirm hypertension diagnosis. However, little is known about how primary care patients view and use such measurement. AIM: To investigate patient experience of out-of-office BP monitoring, particularly home and practice waiting room BP measurement, before, during, and after diagnosis. DESIGN AND SETTING: A cross-sectional, qualitative study with patients from two UK GP surgeries participating in a feasibility study of waiting room BP measurement. METHOD: Interviewees were identified from recent additions to the practice hypertension register. Interviews were recorded, transcribed, and coded thematically. RESULTS: Of 29 interviewees, 9 (31%) and 22 (76%) had used the waiting room monitor and/or monitored at home respectively. Out-of-office monitoring was used by patients as evidence of control or the lack of need for medication, with the printed results slips from the waiting room monitor perceived to improve 'trustworthiness'. The waiting room monitor enabled those experiencing uncertainty about their equipment or technique to double-check readings. Monitoring at home allowed a more intensive and/or flexible schedule to investigate BP fluctuations and the impact of medication and lifestyle changes. A minority used self-monitoring to inform drug holidays. Reduced intensity of monitoring was reported with both modalities following diagnosis as initial anxiety or patient and GP interest decreased. CONCLUSION: Home and practice waiting room measurements have overlapping but differing roles for patients. Waiting room BP monitors may be a useful out-of-office measurement modality for patients unwilling and/or unable to measure and record their BP at home.

Direct access cancer testing in primary care: a systematic review of use and clinical outcomes.

BACKGROUND: Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay. AIM: To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations. DESIGN AND SETTING: Systematic review assessing the effectiveness of GP DA testing in adults. METHOD: MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively. RESULTS: The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high. CONCLUSION: GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction.

Global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews.

OBJECTIVE: To identify, critically appraise and summarise existing systematic reviews on the impact of global cardiovascular risk assessment in the primary prevention of cardiovascular disease (CVD) in adults. DESIGN: Systematic review of systematic reviews published between January 2005 and October 2016 in The Cochrane Library, EMBASE, MEDLINE or CINAHL databases, and post hoc analysis of primary trials. PARTICIPANTS, INTERVENTIONS, OUTCOMES: Systematic reviews of interventions involving global cardiovascular risk assessment relative to no formal risk assessment in adults with no history of CVD. The primary outcomes of interest were CVD-related morbidity and mortality and all-cause mortality; secondary outcomes were systolic blood pressure (SBP), cholesterol and smoking. RESULTS: We identified six systematic reviews of variable but generally of low quality (mean Assessing the Methodological Quality of Systematic Reviews 4.2/11, range 0/11 to 7/11). No studies identified by the systematic reviews reported CVD-related morbidity or mortality or all-cause mortality. Meta-analysis of reported randomised controlled trials (RCTs) showed small reductions in SBP (mean difference (MD) -2.22 mm Hg (95% CI -3.49 to -0.95); I2=66%; n=9; GRADE: very low), total cholesterol (MD -0.11 mmol/L (95% CI -0.20 to -0.02); I2=72%; n=5; GRADE: very low), low-density lipoprotein cholesterol (MD -0.15 mmol/L (95% CI -0.26 to -0.05), I2=47%; n=4; GRADE: very low) and smoking cessation (RR 1.62 (95% CI 1.08 to 2.43); I2=17%; n=7; GRADE: low). The median follow-up time of reported RCTs was 12 months (range 2-36 months). CONCLUSIONS: The quality of existing systematic reviews was generally poor and there is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality. There are reductions in SBP, cholesterol and smoking but they may not be clinically significant given their small effect size and short duration. Resources need to be directed to conduct high-quality systematic reviews focusing on hard patient outcomes, and likely further primary RCTs. TRIAL REGISTRATION NUMBER: CRD42015019821.

Patient use of blood pressure self-screening facilities in general practice waiting rooms: a qualitative study in the UK.

BACKGROUND: Blood pressure (BP) self-screening, whereby members of the public have access to BP monitoring equipment outside of healthcare consultations, may increase the detection and treatment of hypertension. Currently in the UK such opportunities are largely confined to GP waiting rooms. AIM: To investigate the reasons why people do or do not use BP self-screening facilities. DESIGN AND SETTING: A cross-sectional, qualitative study in Oxfordshire, UK. METHOD: Semi-structured interviews with members of the general public recruited using posters in GP surgeries and community locations were recorded, transcribed, and coded thematically. RESULTS: Of the 30 interviewees, 20% were hypertensive and almost half had self-screened. Those with no history of elevated readings had limited concern over their BP: self-screening filled the time waiting for their appointment or was done to help their doctor. Patients with hypertension self-screened to avoid the feelings they associated with 'white coat syndrome' and to introduce more control into the measurement process. Barriers to self-screening included a lack of awareness, uncertainty about technique, and worries over measuring BP in a public place. An unanticipated finding was that several interviewees preferred monitoring their BP in the waiting room than at home. CONCLUSION: BP self-screening appeared acceptable to service users. Further promotion and education could increase awareness among non-users of the need for BP screening, the existence of self-screening facilities, and its ease of use. Waiting room monitors could provide an alternative for patients with hypertension who are unwilling or unable to monitor at home.