Medicalising illness Delayed prescription The trial evidence Systematic reviews of trials The cohort evidence Barriers What next OUTLINE RULE of THUMB ½ week 1 week 2 weeks 3 weeks ID: 916871
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Slide1
Slide2Brief intro/context
Overall benefit from antibiotics & the natural history
Medicalising illness?Delayed prescription:The trial evidenceSystematic reviews of trialsThe cohort evidenceBarriers?What next?
OUTLINE
Slide3RULE of THUMB: ½ week, 1 week, 2 weeks, 3 weeksOverall do ABs help Symptoms?
NOT MUCH!
Evidence from RCTs & Systematic reviews
Slide4BUT…
It’s Friday pm, you are running late…
A young man in his 20s comes in with his partner“I had antibiotics last year for tonsillitis and I have got tonsillitis again doctor”Would you say no to antibiotics?They attended because they believe antibiotics caused it to settle last time- i.e. Medicalised
Slide5HOW IMPORTANT IS MEDICALISING ILLNESS?
Slide6The potential problem with Medicalisation:
THE ICEBERG
Secondary care: 1:3300
General Practice 1:9
Pharmacy/NHS Direct
Self Care
Photo The_Circumference by kaplanmyrth https://www.flickr.com/photos/kaplanmyrth/2602542187/
Slide7THE PLACE OF DELAYED OR
‘BACK-UP’ PRESCRIPTION?
Slide8Open trial of prescribing strategies:
- No offer of antibiotics
- Immediate antibiotic prescription- Delayed prescriptionAN OLD CHESTNUT!SORE THROAT TRIAL
Slide9%
P < 0.001
P < 0.001
MAIN RESULTS UK
SORE THROAT TRIAL (N=715)
Slide10Even one antibiotic prescription is strongly medicalising
…Fuelling
reconsultations, antibiotic use…
Slide11ANTIBIOTIC PRESCRIPTIONS
VS
ANTIBIOTICS USED
Time trend in antibiotic prescribing in UK general practice children 1993-2004 from national prescribing data and the IMS GP prescribing database (1993=100)
Slide12OTHER STUDIES
Slide13OTITIS MEDIA
Cumulative percent
Advice packageDuration of EaracheLast day of earache
Cumulative percent
Antibiotics
Delayed
Slide14LEVEL OF PAIN
1=NO PAIN…10=EXTREME
Similar for distressImmediate antibiotics did reduce: night disturbance (-0.72 days)crying (-0.69 days)but children only using 2 spoons of Paracetamol per day
Slide15Days
(Or diary
Score)
Cough duration
overall
Cough
‘Moderately
bad’ duration
Diary score
for days 2-4
LRTI PRESCRIBING STRATEGIES: DELAYED OR IMMEDIATE
VS
NONE
Slide16Re attendance within 2 weeks was less in the delayed:
odds ratio 0.3 (0.1 to 1.0), immediate 0.7 (0.3 to 1.6).
CONJUNCTIVITIS
Slide17HOW TO DO IT
It’s easy, but needs to be done properly
(and will then reduce antibiotic use)Remember the 6 R’s (most simply good practice!)ReassuranceReasons not to use antibiotics (side effects/allergy/AMR)Relief: support Paracetamol (v limited use of NSAIDS)
Realistic natural history
[1/2 week OM, 1 week throat, 2 wks. sinus), 3 wks. (chest)]
Reinforce key message:
only
use if getting worse or not even
starting
to settle in the expected average time
Rescue
(safety netting)
Slide18HOW TO DO IT: II
? Re contact
? Post date? Ask to collect? Give it
Slide19No
Ab
Re contact
Postdate
Collect
Patient-led
LR chip
Sx
Severity
1.62
1.60
1.82
1.68
1.75
0.6
Duration
days mod bad
Symps
(median)
3
4
4
4
4
0.3
Belief in Abs
71%
74%
73%
72%
66%
0.8
Ab
Use
26%
37%
37%
33%
39%
0.3
Vsatisfied
79%
74%
80%
88%
89%
0.8
Symptom
severity1
o
outcome:
0
= no problem…6 as bad as it could be; alpha 0.71-0.79; srm 1.6
WHICH WAY TO DELAY?
PIPS TRIAL
Slide20OVERALL
Delayed or ‘back-up’ prescription
Is effective in reducing antibiotic use, if done properlyChanges beliefs and behaviour effectivelyOverall symptom control in most patients similar to having an immediate antibiotic
Slide21WHAT ABOUT MY PARTICULAR PATIENT?
TARGETING ANTIBIOTICS AND THE FLEXIBLE USE OF DELAYED PRESCRIPTION
Slide22Otitis media:
IPD meta-analysis (Lancet): <2y, pus, bilateral: NNTs 4-5 Benefit measured at days 3-7 when symptoms much milderUK trial: children with temperature (>37.5) or vomiting NNTs 3-5, for night disturbance, distressv. safe to wait 72 hours (24 h < 2’s) cohort 7000 children If more florid symptoms halve waiting time (36 h)Sinusitis: Individual Patient Data meta-analysis (Lancet): NNT 15 Patients with purulent discharge in pharynx NNT 8
MORE BENEFIT IN UNWELL INDIVIDUALS
Unwell patients still settle: ? shorten the wait if using back-up antibiotic prescription
Slide232 History: breathless, no coryza
2 Chest signs:
bronchial, crackles2 Vital signs: pulse >100, temp. >37.80 = 1% Have consolidation on X-Ray1-2 = 5% (most people we see …)3 = 20% - consider immediate short delaySIMPLE STRATIFICATION FOR CHEST INFECTIONS: PRESCRIBING PNEUMONIA
Slide24FeverPAIN
(AUC 0.70):
* Fever last 24h PUS* Attend rapidly (<=3 DAYS)* Severely inflamed tonsils No cough or coryza (i.e. pharyngeal illness)* = univariate and multivariate in both cohortsSIMPLE STRATIFICATION IN SORE THROAT: PREDICTING A/C/G STREPTOCOCCI
Slide25Does better diagnosis/targeting of delayed prescriptions lead to better outcome?
Yes – better symptom control and fewer antibiotics used
Slide26Only 3 studies comparing no/delayed!
Reconsultation
and complications: underpoweredNICE modelling: delayed prescribing most efficientDECARTE cohort…COCHRANE REVIEW OF DELAYED PRESCRIBING: Is no prescribing better?
6 studies
Antibiotic use
Satisfaction
Immediate
93%
92%
Delayed
28-30%
87%
No
4%
83%
Slide27Does delayed prescribing prevent complications and
reconsultations
?DESCARTE sore throat cohort >13,000 patients!
Slide28No antibiotics
Antibiotics
Delayed
Antibiotics
Complications:total
73/4536 (1.6%)
75/5750(1.3%)
16/1664 (1.0%)
Quinsy
11/4,536 (0.2%)
30/5750 (0.5%)
4/1,664 (0.2%)
Sinusitis
23/4,536(0.5%)
10/5750(0.2%)
2/1,664 (0.1%)
Otitis media
30/4,536(0.7%)
26/5750 (0.5%)
10/1,664 (0.6%)
Celluliltis
/impetigo
10/4,536(0.2%)
9/5750 (0.2%)
0/1,664 (0.00%)
Symptom severity primary outcome:
0=no problem….6 as bad as it could be; alpha 0.71-0.79; SRM 1.6
RESULTS:
Complications are uncommon
Slide29No antibiotics
Immediate antibiotics
Delayed
antibiotics
Stratified
Propensity score
(Multiple imputation)
1.00
0.61
(0.40;0.94)
0.55
(0.31,0.98)
(Adjusted RRs All controlled for clustering)
Symptom severity primary outcome:
0=no problem….6 as bad as it could be; alpha 0.71-0.79; SRM 1.6
DELAYED / BACK-UP
PRESCRIBING COMPLICATIONS
Delayed prescribing prevents complications as effectively as Immediate antibiotics
Slide30Symptom severity primary outcome:
0=no problem….6 as bad as it could be; alpha 0.71-0.79; SRM 1.6
…And lowers
reconsultations
more effectively than immediate antibiotics
No antibiotics
Immediate antibiotics
Delayed
Antibiotics
Stratified
Propensity score
(Multiple imputation)
1.00
0.76
(0.68;0.86)
0.58
(0.49,0.67)
(Adjusted RRs All controlled for clustering)
DELAYED / BACK-UP
PRESCRIBING COMPLICATIONS
Slide31So complications are uncommon
But if considering an antibiotic, consider back-up / delayed prescribing
- Prevents complications, reduces re consultations- At least as effective as immediate antibioticsDESCARTE SORE THROAT COHORT
Slide32Patients will just go out and use it?
Some will but low prescription rates if used with clear advice: 6 Rs
It is giving mixed messages?
No evidence of that if done clearly
The message is
you do not need antibiotics now
and will get side effects if you do; Very occasionally people will need to use it and ONLY use this in the following situations…..
COMMON CONCERNS 1?
Slide33It is not as effective as no offer of a prescription?
Yes slightly higher rates of antibiotic use, but fine
It will reduce number of patients who come back to see you by 1/3
Medico-legal consequences?: complications
Similar reduction in complications compared with an immediate antibiotics
Two very large cohorts to show that this the case
It takes more time?
Most of the 6 Rs you should be doing anyway
The key difference is advice about when to consider cashing in
COMMON CONCERNS 2?
Slide34www.rcgp.org.uk/TARGETantibiotics
READ CODES:
Delayed:8CAk, Leaflet: 8CE
All sections can be personalised and added to by the GP
“Usually lasts” section educates patients about when to consult
Safety netting
Back-up prescription
Information about antibiotics & resistance
TARGET: PATIENT TREAT YOUR INFECTION LEAFLETS
Slide35Try it: patients like it and you will get quicker
It’s easy, but do it properly
(and will then reduce antibiotic use) Remember the 6rs (most of which are simply good practice!):Reassurance; Reasons not to use antibioticsRelief: paracetamol (v limited NSAIDs)Realistic natural history 1/2 week (OM), 1 wk. (throat), 2 wks. (sinus) 3 wks. (chest)Reinforce key message: ONLY use if getting worse or not even STARTING to settle in the expected average time
R
escue (Safety netting)
Aim to keep it for the 20-30% where you are unsure
Audit to check how often you are using it
It will reduce complications and save you time
Fewer complications than no prescription;
Fewer repeat consultations compared with no prescription or immediate
WHAT NEXT?
Slide36THANK YOU