Higher Consultation Rates Research Articles

Helping parents know when to seek help for an acutely ill child: Evidence based co-development of a mobile phone app using complex intervention methodology

BackgroundAcute illness accounts for the majority of episodes of illness in children under five years of age and is the age group with the highest consultation rate in general practice in the UK. The number of children presenting to emergency care is also steadily increasing, having risen beyond pre-pandemic numbers. Such high, and increasing, rates of consultation have prompted concerns about parents’ level of knowledge and confidence in caring for their children when they are ill, and particularly when and how to seek help appropriately. AimThe ASK SNIFF collaboration research programme identified parents’ need for accurate and accessible information to help them know when to seek help for a sick child in 2010. This paper presents the resulting programme of research which aimed to co-develop an evidence-based safety netting intervention (mobile app) to help parents know when to seek help for an acutely ill child under the age of five years in the UK. MethodsOur programme used a collaborative six step process with 147 parent and 324 health professional participants over a period of six years including: scoping existing interventions, systematic review, qualitative research, video capture, content identification and development, consensus methodology, parent and expert clinical review. ResultsOur programme has produced evidence-based content for an app supported by video clips. Our collaborative approach has supported every stage of our work, ensuring that the end result reflects the experiences, perspectives and expressed needs of parents and the clinicians they consult. ConclusionWe have not found any other resource which has used this type of approach, which may explain why there is no published evaluation data demonstrating the impact of existing UK resources. Future mobile apps should be designed and developed with the service users for whom they are intended.

Acute Gastroenteritis: A Qualitative Study of Parental Motivations, Expectations, and Experiences During Out-of-Hours Primary Care.

Acute gastroenteritis is a common infectious disease in children younger than 6 years of age. Although it is a self-limiting disease, it nevertheless has a high consultation rate in primary care, especially during out-of-hours primary care (OOH-PC). Reasons for this high consultation rate remain unclear. The aim of this qualitative study was to explore parental motivations, expectations, and experiences of OOH-PC contacts for children with acute gastroenteritis. We conducted 14 semistructured interviews with parents who contacted OOH-PC in the Netherlands. Interviews were audio-recorded, transcribed, and analyzed using elements of grounded theory and a constant-comparison approach. Unusual behavior of the sick child, absent micturition, and ongoing vomiting and/or diarrhea, with decreased or no fluid intake, motivated parents to contact OOH-PC. Parents initiated contact to prevent symptom deterioration and to be reassured by a general practitioner (GP), expecting them to perform a thorough physical examination, provide information, and make follow-up plans. Parents reported dissatisfaction if they felt unheard, misunderstood, or not taken seriously, and this increased their likelihood of seeking another consultation. General practitioners did not always meet parental expectations. Multiple factors affect the decision for parents to contact OOH-PC for their child with gastroenteritis. There is a mismatch between parental expectations and actions of the GP. Awareness regarding parental feelings and understanding their expectations can guide GPs in the interaction with parents, which could improve satisfaction with primary health care and OOH-PC specifically.

The interplay of infectious diseases consultation and antimicrobial stewardship in candidemia outcomes: A retrospective cohort study from 2016 to 2019.

To evaluate the need for mandatory infectious diseases consultation (IDC) for candidemia in the setting of antimicrobial stewardship guidance. Retrospective cohort study from January 2016 to December 2019. Academic quaternary-care referral center. All episodes of candidemia in adults (n = 92), excluding concurrent bacterial infection or death or hospice care within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with the EQUAL Candida score. Of 186 episodes of candidemia, 92 episodes in 88 patients were included. Central venous catheters (CVCs) were present in 66 episodes (71.7%) and were the most common infection source (N = 38, 41.3%). The most frequently isolated species was Candida glabrata (40 of 94, 42.6%). IDC was performed in 84 (91.3%) of 92 candidemia episodes. Mortality rates were 20.8% (16 of 77) in the IDC group versus 25% (2 of 8) in the no-IDC group (P = .67). Other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%; P = .17), echocardiography (70.2% vs 50%; P = .26), CVC removal (91.7% vs 83.3%; P = .45), and initial echinocandin treatment (67.9% vs 50%; P = .44). IDC resulted in more ophthalmology examinations (67.9% vs 12.5%; P = .0035). All patients received antifungal therapy. Antimicrobial stewardship recommendations were performed in 19 episodes (20.7%). The median EQUAL Candida score with CVC was higher with IDC (16 vs 11; P = .001) but not in episodes without CVC (12 vs 11.5; P = .81). In the setting of an active antimicrobial stewardship program and high consultation rates, mandatory IDC may not be warranted for candidemia.

Seizures and risks for recurrence in critically ill patients: an observational cohort study

BackgroundTo assess the frequency and clinical characteristics of seizures in adult critically ill patients, to identify predictors of recurrent seizures not transforming into status epilepticus and to characterize their effects on course and outcome.MethodsICU patients at a Swiss academic medical center with seizures not transforming into status epilepticus from 2015 to 2020 were included. Recurrent seizures and associated clinical characteristics were primary, death, and return to premorbid neurologic function were secondary outcomes.ResultsTwo hundred of 26,370 patients (0.8%) with a median age of 65 years had seizures during ICU stay. Seizure semiology was described in 82% (49% generalized; 33% focal) with impaired consciousness during seizures in 80% and motor symptoms in 62%. Recurrent seizures were reported in 71% (36% on EEG) and associated with longer mechanical ventilation (p = 0.031), higher consultation rate by neurologists (p < 0.001), and increased use of EEG (p < 0.001) when compared to single seizures. The use of EEG was not associated with secondary outcomes. Acidosis at seizure onset and prior emergency operations were associated with decreased odds for seizure recurrence (OR 0.43; 95% CI 0.20–0.94 and OR 0.48; 95% CI 0.24–0.97). Epilepsy had increased odds for seizure recurrence (OR 3.56; 95% CI 1.14–11.16).ConclusionsSeizures in ICU patients are infrequent, but mostly recurrent, and associated with higher resource utilization. Whenever seizures are observed, clinicians should be vigilant about the increased risk of seizures recurrence and the need for antiseizure treatment must be carefully discussed. While known epilepsy seems to promote recurrent seizures, our results suggest that both acidosis and previous emergency surgery seem to have protective/antiseizure effects.Trial registrationClinicaltrials.gov (No. NCT03860467).

Using Real World Data (RWD) to Identify Care Needs in an Adolescent and Young Adult (AYA) Lymphoma Population: A Match Cohort Study

Adolescent and young adult (AYA) patients with malignancies are a unique population within oncology with differences in survivorship outcomes as compared to adult and pediatric counterparts. The National Comprehensive Cancer Network (NCCN) identified eight critical domains in AYA care: mental health, cognitive function, physical exercise, fatigue, immunizations/infection prevention, pain, sexual function and sleep disorders. However, it can be difficult to establish a clinical benchmark of these domains at an institutional level without time-consuming chart review. With the advent of real-world data generated from the electronic medical record (EMR), feasible large scale data assessment can be used to identify care needs and direct future prospective studies and interventions.Here we demonstrate the feasibility of a match cohort study using EMR comparing metrics in the above NCCN domains in AYA lymphoma patients within the University of Rochester Medical Center. We identified 172 AYA lymphoma patients diagnosed between 2013 and 2019 and compared them to 516 controls over that time period using 3:1 control matching, both at time of diagnosis and one year post-diagnosis. Controls were identified within the EMR with exclusion criteria of no cancer diagnoses and fewer than an average of ten medical visits per year over the study period to control for other chronic disorders.Demographic characteristics for both groups were matched for age at diagnosis date, sex, and race. The resultant populations had an average age of 29 (SD 6), male predominance (58.72%), and Caucasian predominance (82.56%). The lymphoma group had a slightly higher rate of federally funded insurance as compared to controls (25% vs. 20%).In mental health domains, lymphoma group had a higher rate of depression at baseline (19.77% vs. 1.16%; p <0.0001) but anxiety was at comparable rates (8.72% vs. 10.85% p <0.46) with similar rates of antidepressant medication prescriptions (27.33% vs. 25.97% p < 0.75). At one year post-diagnosis, anxiety and depression rates were near identical but rates of antidepressant prescriptions had increased in the lymphoma group (30.81% vs. 22.65% p < 0.03.)In physical health domains, lymphoma group had similar rates of BMI in the overweight and obese range as compared to controls and less than five percent of the group had a sleep medicine, nutrition, or cognitive assessment at baseline or one year post-diagnosis. Vaccination rates, as measured by influenza and pneumovax adherence, were low both at diagnosis and at one year post- diagnosis in the lymphoma group (18.6% and 21.5%, respectively).In the pain domain, the lymphoma group had similarly low rates of alcohol abuse, opiate abuse and chronic pain diagnoses as compared to controls (between 1 and 4% without statistically significant differences). Interestingly, pain scores recorded at visits on the 0 to 10 scale were noticeably lower for the lymphoma group both at diagnosis and one year post-diagnosis (4.65% vs 11.24% p=0.009; 5.23% vs 11.43% p=0.02) however prescription of any analgesic medication was higher in the lymphoma group (76.16% vs. 40.98% p<0.0001; 63.95% vs. 30.62 p<0.0001).Lastly, in the reproductive and sexual health domain, the lymphoma group had high rates of consultation with reproductive endocrinology at diagnosis as compared to controls (31.40% vs. 1.74% p<0.0001) suggestive of early referral between initial suspicion of cancer and tissue diagnosis. The overall use of the services however were still at relatively low rates. Additionally, long-acting removable contraception rates, while higher in the lymphoma population (11.27% vs. 4.23 p<0.02) were still relatively low. Finally, rates of erectile dysfunction diagnoses were similar in lymphoma cases as compared to controls (0.99 vs. 0.66 p< 0.7128) without significant differences in tadalafil/sildenafil prescriptions at one year post-diagnosis (2.97% vs. 1.32% p<0.15)These data support the feasibility of using the electronic medical record to track institutional level ancillary markers of care for prospective study and population-specific interventions. Future studies will be directed at collaborations to address these care gaps and a prospective survey of AYA patients to identify patient-centered interventions improving care for this critical population. DisclosuresCasulo: Genentech: Research Funding; BMS: Research Funding; Gilead: Research Funding; Verastem: Research Funding.

Cross-sectional analysis of coding, patient characteristics, consultation frequency and pharmacological treatment of adults with severe mental disorders in Irish general practice

BackgroundGeneral practitioners are the gatekeepers of Irish healthcare and they offer continuity of care to patients. Irish general practice is therefore considered appropriate for preventing, diagnosing and managing most mental health problems.AimsThis study sought to establish the coding frequency, consultation frequency, patient characteristics and pharmacological treatment of patients with severe mental disorders (SMDs) in Irish general practice.MethodsA cross-sectional design was used. A finder tool embedded in the practice software assisted general practitioners (GPs) coding adult patients with SMDs. Eleven practices uploaded anonymous data on 2,203 patients. Variables analysed included disease code, consultations, prescriptions, sex, patient status and age.ResultsOverall, 2.9% (n = 2,337) of patients had ever been coded with a SMD, 2.4% (n = 1,964) coded with depressive disorder ever and 0.26% (n = 209) and 0.3% (n = 233) with bipolar disorder and schizophrenia, respectively. Overall, 68.0% (n = 1,336) of patients with depressive disorder were female, and 74.0% (n = 171) of patients with schizophrenia were public patients. The median consultation rate in the previous 3 years was highest for schizophrenia patients at 24.5 visits.ConclusionsCoding of SMDs in Irish general practice appears incomplete. Patients with SMDs have high consultation rates. Patients with depressive disorder are more likely to be female and public patients. This research suggests that the improvement of coding in Irish general practice is the first practical step required to detecting prevalence rates.

Somatic symptom and related disorders in a tertiary paediatric hospital: prevalence, reach and complexity.

Specialist paediatric services manage a variety of presentations of functional somatic symptoms. We aimed to describe the presentation and management of children and adolescents with somatic symptom and related disorders (SSRDs) requiring admission to a tertiary children's hospital with the objective of informing the development of a local clinical pathway. Patients admitted to any hospital department from May 2016 to November 2017 were identified through an electronic medical record (EMR)-linked diagnosis of SSRD. Each record was reviewed for demographic details and admission histories. The frequency of interspecialty consultations and multidisciplinary team (MDT) family meetings were recorded. One hundred twenty-three patients with SSRD were admitted on 203 occasions to 17 different departments. The median (range) age was 14.3 (7.3-18.3) years. Interspecialty consultations occurred in 84.6% of patients, and MDT family meetings occurred in 18.9% patients. SSRD was diagnosed as an inpatient in 79.9% patients, yet only 40.7% of patients, including those with multiple admissions, had SSRD recorded as a discharge diagnosis.Conclusion: Despite high rates of consultation with hospital teams, the frequency of MDT family meetings was low, and less than half the patients had SSRD documented at discharge. This affirms the value of developing a local clinical pathway. What is Known • Functional somatic symptoms are commonly seen in children and adolescents. • Few studies have explored the reach of functional somatic symptoms across a tertiary paediatric hospital; the majority of inpatient studies have focused on a limited set of disorders or cases referred to psychiatry departments. What is New • Symptoms that spanned multiple body systems were the most common presentation of SSRDs in admitted children and adolescents. • Somatic symptom disorders are less likely to be recorded as a discharge diagnosis compared with functional neurological symptom disorder.

Treatment Outcomes and Subsequent Healthcare Utilization Among Patients With Injection Drug Use–Associated Endocarditis

Background: Addiction medicine consultation and medication-assisted treatment (MAT) have been promoted as a way to improve outcomes for patients hospitalized with injection drug use–associated endocarditis (IDU-IE). However, IDU-IE outcomes have not been evaluated in settings where these services are commonplace. Objective: In this study, we evaluated IDU-IE outcomes in a setting where involvement of addiction medicine consultants and use of MAT is well integrated into patient care. Methods: Medical records of patients hospitalized with a diagnosis of bacteremia or infective endocarditis (IE) between October 1, 2015, and December 31, 2017, at a safety-net hospital in Boston were screened for evidence of active injection drug use (IDU) within 6 months of hospitalization (as documented by providers or as supported by urine toxicology assays) for suspected or definite IE using modified Duke criteria. Patients without active IDU or IE were excluded, as were those with a diagnosis of IDU-IE over the 6 months prior to the index hospitalization. Demographic parameters, receipt of antibiotics and MAT, other clinical information, and details of rehospitalizations were recorded. Analyses of descriptive statistics were performed. Results: Of 567 subjects screened for inclusion, 47 patients met inclusion criteria. All had opiate use disorder (OUD); 41 patients (87.2%) had polysubstance abuse. Addiction medicine consultation was completed for 41 patients (87.2%). Of the 47 subjects, 23 patients (54.8%) received MAT (methadone or buprenorphine/naloxone) over their entire hospitalization, and 31 patients (73.8%) received MAT for &gt;75% of the index admission. Moreover, 43 patients (91.5%) survived to discharge, of whom 28 (59.6%) completed antibiotic therapy. Relapsed IDU was observed in 33 patients (76.7%). Relapsed IDU trended toward significance among undomiciled patients (OR, 4.07,; 95% CI, 0.93–17.85; P = .06). Also, 24 patients (55.8%) were rehospitalized within 1 year due to infectious complications of IDU; undomiciled patients were readmitted more frequently (OR, 20.45; 95% CI, 1.09–383.99; P = .04). Completion of IDU-IE antibiotic therapy, relapse of IDU, and rehospitalization were not associated with prior AMA discharges, duration or variety of IDU, receipt of MAT during the index admission, or addiction medicine consultation. The rate of readmission due to an infectious complication of IDU within 1 year was unrelated to the proportion of hospital days where MAT was prescribed. Conclusions: In settings with high rates of addiction medicine consultation and in-hospital MAT administration, inpatient interventions targeting OUD may not necessarily be protective against morbidity and rehospitalization. Focusing on housing instability and outpatient continuation of MAT may be beneficial.Funding: NoneDisclosures: None

Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation.

Examine the relationship between supply of care provided by dental therapists and emergency dental consultations in Alaska Native communities. Explanatory sequential mixed-methods study using Alaska Medicaid and electronic health record (EHR) data from the Yukon-Kuskokwim Health Corporation (YKHC), and interview data from six Alaska Native communities. From the Medicaid data, we estimated community-level dental therapy treatment days and from the EHR data we identified emergency dental consultations. We calculated Spearman partial correlation coefficients and ran confounder-adjusted models for children and adults. Interview data collected from YKHC providers (N=16) and community members (N=125) were content analysed. The quantitative and qualitative data were integrated through connecting. Results were visualized with a joint display. There were significant negative correlations between dental therapy treatment days and emergency dental consultations for children (partial rank correlation = -0.48; p⟨0.001) and for adults (partial rank correlation = -0.18; p=0.03). Six pediatric themes emerged: child-focused health priorities; school-based dental programs; oral health education and preventive behaviors; dental care availability; healthier teeth; and satisfaction with care. There were four adult themes: satisfaction with care; adults as a lower priority; difficulties getting appointments; and limited scope of practice of dental therapy. Alaska Native children, and to a lesser extent adults, in communities served more intensively by dental therapists have benefitted. There are high levels of unmet dental need as evidenced by high emergency dental consultation rates. Future research should identify ways to address unmet dental needs, especially for adults.

Psychosocial characteristics and affective symptomatology associated with patient self‐initiated consultations in Spanish general practice

We aimed to determine the sociodemographic and psychosocial profile, and the associated subclinical affective symptomatology of users above the 95th percentile in the distribution of patient self-initiated, face-to-face consultations. Additionally, we sought to determine the contribution of subclinical symptomatology in differentiating between the groups above or below this cut-off point. A total of 16,803 users who self-initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over 1year, were eligible. After discarding those fulfilling exclusion criteria, 129 cases and 109 controls, matched by gender and age, answered the Family APGAR, the Duke-UNC and the Goldberg Anxiety-Depression scale. Both groups did not differ significantly on any of the sociodemographic and psychosocial variables recorded showing a similar percentage distribution. However, users with high self-initiated consultation rates obtained lower scores on the affective social support subscale from the Duke-UNC. Regarding Goldberg scale, the two groups differed significantly on the likelihood of displaying depression and/or anxiety symptoms. Users with a high probability of suffering from depression and/or anxiety were more prevalent among users on the top 5% in the distribution. Altogether, results indicate that these users report a lack of affective social support and have a higher probability of suffering from subclinical depression and/or anxiety. Early detection and treatment of affective symptomatology would temperate this excess in consultation. General practitioners, social workers and psychologists could act as gatekeepers, preventing this overuse of medical services and in turn lowering economical costs, professional burnout and patients' suffering and discontent.

A population-based study on healthcare-seeking behaviour of persons with symptoms of respiratory and gastrointestinal-related infections in Hong Kong

BackgroundStudies on healthcare-seeking behaviour usually adopted a patient care perspective, or restricted to specific disease conditions. However, pre-diagnosis symptoms may be more relevant to healthcare-seeking behaviour from a patient perspective. We described healthcare-seeking behaviours by specific symptoms related to respiratory and gastrointestinal-related infections.MethodsWe conducted a longitudinal population-based telephone survey in Hong Kong. We collected data on healthcare-seeking behaviour specific to symptoms of respiratory and gastrointestinal-related infections and also associated demographic factors. We performed descriptive analyses and estimated the proportion of participants who sought medical consultation, types of services utilized and duration from symptom onset to healthcare seeking, by different age groups. Post-stratification was used to compensate non-response and multiple imputation to handle missing and right-censored data.ResultsWe recruited 2564 participants who reported a total of 4370 illness episodes and 7914 symptoms. Fatigue was the most frequently reported symptom, followed by headache and runny nose, with 30-day incidence rate of 9.1, 7.7, and 7.7% respectively. 78% of the participants who had fever sought medical consultation, followed by those with rash (60%) and shortness of breath (58%). Older adults (aged ≥55y) who had symptoms including fever, sore throat, and headache had a significantly higher consultation rate comparing to the other age groups. The 30-day incidence rates of influenza-like illness (ILI) and acute respiratory illness (ARI) were 0.8 and 7.2% respectively, and the consultation rates among these participants were 91 and 64%. Private general practitioner clinics was the main service utilized by participants for most of the symptoms considered, especially those related to acute illness such as fever, diarrhoea and vomiting. Chinese medicine clinics were mostly likely to be visited by participants with low back pain, myalgia and fatigue. Among participants who have sought medical services, most were within 3 days of symptom onset.ConclusionsHealthcare-seeking behaviour were different by symptoms and age. Characterization of these patterns provides crucial parameters for estimating the full burden of common infectious diseases from facility-based surveillance system, for planning and allocation of healthcare resources.

Association of Variation in Consultant Use Among Hospitalist Physicians With Outcomes Among Medicare Beneficiaries

Evidence is lacking on the consequences of high rates of inpatient consultation. To examine outcomes and resource use of patients cared for by hospitalists who use more inpatient consultation than their colleagues. A retrospective cohort study of medical admissions to hospitalists among fee-for-service Medicare beneficiaries was conducted. Hospitalist consultation tendency was identified from January 1, 2013, to December 31, 2014; admissions were calculated in 2013; and outcomes were measured in 2014. Data were analyzed from January 31, 2017, to May 9, 2019. A total of 711 654 admissions with patients receiving care from 14 584 hospitalists at 737 hospitals were included. Admission to high-consulting hospitalists, considered to be those who were in the top 25% of the distribution of consulting frequency at their own hospital (adjusted for patient case mix). Outcomes included length of stay, Medicare Part B inpatient charges, discharge destination, all-cause 7- and 30-day readmissions, 90-day outpatient specialist visits, and 30-day mortality. The 711 654 hospital admissions included 408 489 women (57.4%); mean (SD) age of the population was 80 (8.5) years. Length of stay of patients cared for by high-consulting hospitalists was longer compared with other hospitalists (adjusted incidence rate ratio, 1.04; 95% CI, 1.03-1.05). The admissions resulted in a mean of $137.91 (95% CI, $118.89-$156.93) more in Medicare Part B charges and were less likely to end with the patient going home (adjusted odds ratio [aOR], 0.96; 95% CI, 0.94-0.98) compared with patients cared for by other hospitalists in the cohort. Patients cared for by high-consulting hospitalists also were 7% more likely than patients cared for by other hospitalists to see an outpatient specialist at 90 days (aOR 1.07; 95% CI, 1.05-1.09), with no significant differences in 30-day mortality (aOR 1.01, 95% CI, 0.98-1.03) or readmissions (7-day readmissions: aOR 1.01; 95% CI, 0.98-1.03; 30-day readmissions: aOR, 1.01; 95% CI, 0.99-1.03). Hospitalists who obtain consultations more than their colleagues at the same institution were associated with greater use of health care resources without apparent mortality benefit. Further investigation should identify whether reducing high rates of consultation can reduce resource use without harming patients.

Consultation prevalence among children, adolescents and young adults with pain conditions: A description of age- and gender differences.

Pain is a common complaint presented in healthcare, but most epidemiological pain research has focused either on single pain conditions or on the adult population. The aim of this study was to investigate the 2017 consultation prevalence of a wide range of pain conditions in the general population of young people. We used the Skåne Healthcare Register, covering prospectively collected data on all healthcare delivered (primary and secondary care) to the population in the region of Skåne, southern Sweden (population 2017 n=1,344,689). For individuals aged 1-24 in 2017 (n=373,178), we calculated the consultation prevalence, stratified by sex and age, and the standardised morbidity ratio (SMR) to assess overall healthcare consultation. A total of 58,981 (15.8%) individuals consulted at least once for any of the predefined pain conditions. Of these, 13.5% (n=7,996) consulted four or more times for pain. Abdominal pain, joint pain/myalgia, headache and back/neck pain were the most common complaints. Overall, females had higher consultation prevalence than males: 17.6% versus 14.1% (p<.0001). SMR was 1.82 (95% CI=1.74-1.87) for females with pain and 1.51 (95% CI=1.42-1.56) for males with pain. Consultation prevalence increased with age, but this pattern varied between sex and pain condition. Among individuals under the age of 25, a significant proportion consult for pain already in early ages, and they also have high healthcare consultation rates for conditions other than pain. The even higher consultation rates among young females need additional attention, both in the clinic and in research. We present comprehensive 1-year healthcare consultation prevalence data covering all levels of care. A significant proportion of children, adolescents and young adults consult for different pain conditions at multiple occasions warranting greater clinical awareness.

Antibiotics use for upper respiratory tract infections among children in rural Anhui: children's presentations, caregivers' management, and implications for public health policy.

Children with upper respiratory tract infections (URTIs) are among the highest receivers of antibiotics. Using a retrospective cross-sectional study, we described clinical management in rural China of recent URTIs in children. We explored antibiotics using behaviors and associations of caregivers' variables and children's symptoms. Children with URTIs had a high consultation rate and a high prescription rate of antibiotics. For the children, some caregivers adopted, without rationale, 'self-medication' with antibiotics. Children with fever were more likely to be taken to a doctor; among those, children with particular symptoms were more likely to receive a prescription for antibiotics. Disseminating knowledge on antibiotics, and on interpretation and management of URTI symptoms will be important targets for caregiver and physician education and should become routine in training for physicians. Our findings also suggest the need to improve communication between doctors and caregivers, to strengthen regulation of drug sales, and to help caregivers learn when over-the-counter drug purchase without medical consultation is reasonable. These activities can help to improve health of a vast population of children in rural China.

Geographic Variation in Antibiotic Consumption-Is It Due to Doctors' Prescribing or Patients' Consulting?

Antibiotic consumption varies greatly between Norwegian municipalities. We examine whether this variation is associated with inhabitants’ consultation rates or general practitioners’ (GP) prescription rates. Our study comprises consultations and antibiotic prescriptions for respiratory tract infections (RTIs) in general practice in all Norwegian municipalities with over 5000 inhabitants in 2014. Data was collected from The Norwegian Prescription Database, The Directorate of Health’s system for control and payment of health reimbursements registry and Norway Statistics. Consultation rates and prescription rates were categorised in age- and gender specific quintiles and the effect on antibiotic consumption was analysed using a Poisson regression model. We found that inhabitants with RTIs received 42% more prescriptions if they belonged to a municipality with high consultation rates compared to low consultation rates [incidence rate ratio (IRR) 1.42 (95% CI 1.41–1.44)] and 48% more prescriptions if they belonged to a municipality with high prescription rates versus low prescription rates [IRR 1.48 (95% KI 1.47–1.50)]. Our results demonstrate that inhabitants’ consultation rates and GPs’ prescription rates have about equal impact on the number of RTI antibiotics prescribed at municipality level. These findings highlight the importance of interventions targeting patients as well as doctors in efforts to reduce unnecessary antibiotic consumption.

Explaining variation in antibiotic prescribing between general practices in the UK.

Primary care practices in England differ in antibiotic prescribing rates, and, anecdotally, prescribers justify high prescribing rates based on their individual case mix. The aim of this paper was to explore to what extent factors such as patient comorbidities explain this variation in antibiotic prescribing. Primary care consultation and prescribing data recorded in The Health Improvement Network (THIN) database in 2013 were used. Boosted regression trees (BRTs) and negative binomial regression (NBR) models were used to evaluate associations between predictors and antibiotic prescribing rates. The following variables were considered as potential predictors: various infection-related consultation rates, proportions of patients with comorbidities, proportion of patients with inhaled/systemic corticosteroids or immunosuppressive drugs, and demographic traits. The median antibiotic prescribing rate was 65.6 (IQR 57.4-74.0) per 100 registered patients among 348 English practices. In the BRT model, consultation rates had the largest total relative influence on antibiotic prescribing rate (53.5%), followed by steroid and immunosuppressive drugs (31.6%) and comorbidities (12.2%). Only 21% of the deviance could be explained by an NBR model considering only comorbidities and age and gender, whereas 57% of the deviance could be explained by the model considering all variables. The majority of practice-level variation in antibiotic prescribing cannot be explained by variation in prevalence of comorbidities. Factors such as high consultation rates for respiratory tract infections and high prescribing rates for corticosteroids could explain much of the variation, and as such may be considered in determining a practice's potential to reduce prescribing.

The impact of a social prescribing service on patients in primary care: a mixed methods evaluation

BackgroundSocial prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use.MethodsWe used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use.ResultsAt 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent.ConclusionChanges in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.

Patient-level and practice-level factors associated with consultation duration: a cross-sectional analysis of over one million consultations in English primary care

ObjectivesConsultation duration has previously been shown to be associated with patient, practitioner and practice characteristics. However, previous studies were conducted outside the UK, considered only small numbers of general practitioner...

Health risk appraisal in older people 7: long-acting benzodiazepine use in community-dwelling older adults in London: is it related to physical or psychological factors?

Long-acting benzodiazepine consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Two models explain benzodiazepine use in this age group, one linked to physical illness and disability and one to psychological factors. Secondary analysis of baseline data from a study of 1059 community-dwelling non-disabled people aged 65 years and over recruited from three general practices in London. For this analysis, use of long-acting benzodiazepines was defined as any self-reported use of diazepam or nitrazepam in the last four weeks. Associations between demographic factors, health service use, and physical and psychological characteristics and benzodiazepine use were investigated. Findings The prevalence of benzodiazepine use in this sample was 3.3% (35/1059). In univariate analyses, benzodiazepine use was associated with female gender, low income, high consultation rates, physical factors (medication for arthritis or joint pain, polypharmacy, difficulties in instrumental activities of daily living, recent pain) and psychological factors (poor self-perceived health, social isolation, and symptoms of anxiety or agitation). In a multivariate logistic regression analysis only two factors retained statistically significant independent associations with benzodiazepine use: receiving only the state pension (OR=4.0, 95% CI: 1.70, 9.80) and pain in the past four weeks (OR=3.79, 95% CI: 1.36, 10.54).

Health Consequences of Typhoon Haiyan in the Eastern Visayas Region Using a Syndromic Surveillance Database.

Introduction: Typhoon Haiyan was the strongest storm recorded in Philippine history. Surveillance in Post Extreme Emergencies and Disasters (SPEED) was activated during the typhoon response. This study analyzes the health impact of different diseases during different timeframes post-disaster during Typhoon Haiyan in 2013 using a syndromic surveillance database.Methods: SPEED reports medical consultations based on 21 syndromes covering a range of conditions from three syndrome groups: communicable diseases, injuries, and non-communicable diseases (NCDs). We analyzed consultation rates for 150 days post-disaster by syndrome, syndrome group, time period, and health facility type for adults as well as for children under the age of five.Results: Communicable diseases had the highest consultation rates followed by similar rates for both injuries and NCDs. While communicable diseases were the predominant syndrome group for children, wounds and hypertension were common syndromes observed in adults. Village health centers had the most consultations amongst health facilities, but also showed the highest variability.Discussion: Children were more vulnerable to communicable diseases compared to adults. Community health centers showing consistently high consultation rates point out a need for their prioritization. The predominance of primary care conditions requires disaster managers to focus on basic health care and public health measures in community health centers that target the young, elderly and impoverished appropriate to the time period.