Cost-effectiveness of adding oseltamivir to primary care for influenza-like-illness: economic evaluation alongside the randomised controlled ALIC4E trial in 15 European countries.

BACKGROUND: Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries. METHODS: Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped (N = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers' and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed. RESULTS: The healthcare payers' expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1-€35 per patient). CONCLUSION: Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers' perspective (if willingness-to-pay per QALY gained > €22,459) and cost-saving in adults/adolescents from a societal perspective.

Challenges and opportunities for general practice specific CME in Europe - a narrative review of seven countries.

BACKGROUND: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. METHODS: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. RESULTS: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. CONCLUSIONS: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation.

International promotion of e-Bug, an infection prevention and control educational intervention: survey of partners across 14 countries.

BACKGROUND: Antimicrobial resistance (AMR) is a global threat to public health. e-Bug is an educational resource developed and promoted by a network of international partners. e-Bug seeks to reduce the spread of infection and use of antimicrobials in young people and the community, so helping to control AMR. This study aimed to explore how e-Bug is promoted by international partners and observe barriers to promotion, including the extent of education about antibiotics in schools. METHODS: A total of 29 e-Bug partners were invited to complete online questionnaires on (i) methods they use to promote e-Bug; and (ii) antibiotic topics covered in the national curriculum in their countries. RESULTS: Fourteen and 15 of 29 e-Bug partners across Europe and Palestine completed the promotional activities and curriculum questionnaires respectively. The most frequently reported methods of promotion included endorsement and collaboration with government and non-government sectors and involvement in national and global health awareness campaigns. Barriers to promotion included a lack of time and funding. The curriculum survey data showed variation in antibiotic education across Europe and Palestine, lack of antibiotic education for children under 11 years of age and little change in antibiotic topics included in the curriculum since 2006. CONCLUSIONS: Future and existing e-Bug partners should be encouraged to follow promotional activities reported in this paper, including ministry endorsement, educator training, international campaigns and youth programmes. We encourage all countries to increase antibiotic topics in the school curriculum across all ages.

Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial.

BACKGROUND: Antivirals are infrequently prescribed in European primary care for influenza-like illness, mostly because of perceived ineffectiveness in real world primary care and because individuals who will especially benefit have not been identified in independent trials. We aimed to determine whether adding antiviral treatment to usual primary care for patients with influenza-like illness reduces time to recovery overall and in key subgroups. METHODS: We did an open-label, pragmatic, adaptive, randomised controlled trial of adding oseltamivir to usual care in patients aged 1 year and older presenting with influenza-like illness in primary care. The primary endpoint was time to recovery, defined as return to usual activities, with fever, headache, and muscle ache minor or absent. The trial was designed and powered to assess oseltamivir benefit overall and in 36 prespecified subgroups defined by age, comorbidity, previous symptom duration, and symptom severity, using a Bayesian piece-wise exponential primary analysis model. The trial is registered with the ISRCTN Registry, number ISRCTN 27908921. FINDINGS: Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20-1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74-1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30-1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00-5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group. INTERPRETATION: Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2-3 days sooner. FUNDING: European Commission's Seventh Framework Programme.

Health outcomes of the July 14, 2016 Nice terror attack among hospital-based professionals and students: the « ECHOS de Nice ¼ health survey protocol.

BACKGROUND: The terror attack of July 14, 2016, in Nice, France, resulted in 86 deaths, including children, and several hundred wounded, with a major psychological impact on the population. Hospital staff had to cope with exceptional circumstances which made them vulnerable to detrimental effects on their own health. This paper describes the method that was selected for the survey entitled "ECHOS de Nice 14 Juillet" which aimed to assess the impact of the attack on the psychological, psycho-traumatic and somatic health condition of the Nice University and Lenval hospital staff who were directly or indirectly exposed to the attack, and also to describe the support and care facilities they were offered. METHOD: ECHOS de Nice 14 juillet is an observational, cross-sectional, multicentre study focusing on all the hospital staff and students of both institutions, i.e. 10,100 persons in June 2017. A web-based questionnaire based on the model developed by Santé Publique France (IMPACTS and ESPA 13 novembre 2015) was adapted to the contexts of the healthcare professionals and students employed in these healthcare institutions in Nice and published on line from June 21 to October 30, 2017. The paper describes the tools that were used to meet the aims of the study, i.e. identification of exposure categories ('civilian' exposure for those present during the attack and/or 'professional' exposure); indicators of psychological impact (anxiety, depression, burnout, compassion fatigue, suicidal states, tobacco and alcohol use, self-medications), psycho-traumatic and somatic impact; professional and social impact. Lastly, awareness of availability and use of psychological support and care-follow-up facilities by professionals were investigated. Respondents could include extensive qualitative comments on the various themes explored in the questionnaire, with text analysis complementing that of quantitative data. DISCUSSION: The benefits and limitations of the selected methodology are discussed, in view of contributing useful information to help anticipate and manage health issues among hospital staff who have been victims of traumatic events.

[How to raise awareness about antibiotics and vaccination among French teenagers?] / Antibiotiques et vaccinations : comment sensibiliser les adolescents français ?

Introduction: Bacterial resistance to antibiotics is a growing concern in Europe, vaccination coverage is inadequate, and young adults, who are the highest antibiotic consumers, have the lowest level of knowledge. Extension of the e-Bug project, a European educational school programme concerning microbes, antibiotics and vaccination, to 15-18-year-olds implies the development of educational resources based on social marketing to promote sustainable behavioural changes. The objectives of the present study, which is part of the needs assessment in France, are to explore the attitudes, knowledge and behaviour of 15-18-year-olds concerning antibiotics and vaccination and their health education needs. Methods: Individual semi-structured interviews were conducted using purposeful sampling of 15- to 18-year-olds, until data saturation, and were transcribed and analysed. Results: The results confirm that teenagers are high antibiotic consumers with poor knowledge. They are interested in their health, but less so in antibiotics and vaccination. Health information is mainly obtained from the Internet, but tends to be criticised. General practitioners play an important role in terms of health information and are also influenced by peers and family. Teenagers believe school should play an important role in health education, which they would prefer to be more interactive: debates, case-stories, sharing experience with peers, parents and health professionals, based on relevant concrete examples, via new technologies. Conclusion: Knowledge gaps revealed among young people during this survey confirm that this age-group should be targeted by a specifically tailored approach. Responders are receptive to information provided by reliable and easily accessible sources. High schools, as well as general practitioners, play an important role in health education in general for this age-group and particularly concerning antibiotics and vaccinations. The Internet is a relevant medium for disseminating information. Teaching should be interactive and take social influences (peers, family) into account.

Attitudes and behaviours of adolescents towards antibiotics and self-care for respiratory tract infections: a qualitative study.

BACKGROUND: To understand attitudes and behaviours of adolescents towards antibiotics, antimicrobial resistance and respiratory tract infections. DESIGN: Qualitative approach informed by the Theory of Planned Behaviour. Semi-structured interviews and focus groups were undertaken. We aimed to inform the development of an intervention in an international setting to improve antibiotic use among adolescents; therefore on completion of thematic analysis, findings were triangulated with qualitative data from similar studies in France, Saudi Arabia and Cyprus to elucidate differences in the behaviour change model and adaptation to diverse contexts. SETTING: 7 educational establishments from the south of England. PARTICIPANTS: 53 adolescents (16-18 years) participated in seven focus groups and 21 participated in interviews. RESULTS: Most participants had taken antibiotics and likened them to other common medications such as painkillers; they reported that their peers treat antibiotics like a 'cure-all' and that they themselves were not interested in antibiotics as a discussion topic. They demonstrated low knowledge of the difference between viral and bacterial infections.Participants self-cared for colds and flu but believed antibiotics are required to treat other RTIs such as tonsillitis, which they perceived as more 'serious'. Past history of taking antibiotics for RTIs instilled the belief that antibiotics were required for future RTIs. Those who characterised themselves as 'non-science students' were less informed about antibiotics and AMR. Most participants felt that AMR was irrelevant to them and their peers. Some 'non-science' students thought resistance was a property of the body, rather than bacteria. CONCLUSION: Addressing adolescents' misperceptions about antibiotics and the treatment of RTIs using a behaviour change intervention should help improve antibiotic awareness and may break the cycle of patient demand for antibiotics to treat RTIs amongst this group. Schools should consider educating all students in further education about antibiotic usage and AMR, not only those taking science.

[Promoting primary care screening for Chlamydia trachomatis infection]. / Promotion du dépistage d'infection à Chlamydia trachomatis en soins primaires.

Background: Lower urogenital tract Chlamydia trachomatis (Ct) infection is the most common bacterial sexually transmitted infection in Europe, especially among young people with multiple partners. Often asymptomatic, its spread and severity are due to delayed diagnosis, highlighting the need for early detection.Objective: Implementation and evaluation of a complex intervention targeting GPs in the Alpes-Maritimes (06) promoting opportunistic screening of Ct infection in young patients.Method: Academic detailing visits provided 105 randomized GPs with tools and patient self-testing kits to include 10 patients over a 6-month period followed by a quantitative (prescribed screenings / reimbursed screenings among visited GPs and all GPs in the Alpes-Maritimes compared to the previous year) and a qualitative assessment (post-interventional interviews with GPs and trainers).Results: In the context of a global increase in screening between the 2013 and 2014 seasons (+15%), the intervention resulted in a significantly higher rate (73%), p = 0.02. Screening was performed in 73 (48%) patients and 12 were PCR-positive. Qualitative analysis of post-interventional interviews with GPs and a focus group of AD visitors highlighted facilitating factors and obstacles to screening. Conclusion: Our intervention, appreciated by the visited GPs, demonstrates its potential impact and feasibility in primary care. GPs used facilitating factors to overcome the identified obstacles. To sustain this intervention, evaluated tools will be available on line to help GPs promote Ct screening as well as for sexual health training targeting GPs.

Identification of cultural determinants of antibiotic use cited in primary care in Europe: a mixed research synthesis study of integrated design "Culture is all around us".

BACKGROUND: Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions. METHOD: A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described. RESULTS: Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception/behaviour, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labelling, work ethos, perception of practitioner) or practitioner-related (RTI management, initial training, antibiotic awareness, legal issues, practice context) or both (antibiotic awareness). DISCUSSION AND CONCLUSION: Cultural factors should be considered as exerting an ubiquitous influence on all the consecutive stages of the disease process and seem closely linked to education. Interactions between determinant categories, cultural dimensions and antibiotic use in primary care are multiple, complex and require further investigation within overlapping disciplines. The context of European projects seems particularly relevant.