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A PAPER THAT CHANGED MY PRACTICE

A PAPER THAT CHANGED MY PRACTICE. March 2004. Introduction. What changes our practice? Experience with individual patients? Talking to colleagues? Lectures / seminars / learning? Complaints? Reading?. Reading a paper - READER. Relevant? Educational? Does it add anything?

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A PAPER THAT CHANGED MY PRACTICE

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  1. A PAPER THAT CHANGED MY PRACTICE March 2004

  2. Introduction • What changes our practice? • Experience with individual patients? • Talking to colleagues? • Lectures / seminars / learning? • Complaints? • Reading?

  3. Reading a paper - READER • Relevant? • Educational? Does it add anything? • Applicable? Primary-care based? • Discrimination - does it answer the questions it set out to? Any patients excluded? Appropriate design / statistics? Concepts understood – risk, NNT, etc? • Evaluation (oveRall) “RCT of the READER method of critical appraisal in general practice” MacAuley et al, BMJ, 1997, 316, 134 (11th April)

  4. Paper for discussion: • “Open randomised trial of prescribing strategies in managing sore throat” Little et al, BMJ 1997, 314, 722 (8th March) • The objective of this study was to assess three prescribing strategies for sore throat – antibiotics, no antibiotics or deferred prescription for antibiotics

  5. What is the background? • Double blind RCTs suggest antibiotics give only marginal benefit when prescribed for common acute respiratory illnesses • But antibiotics are still widely prescribed in this situation • Is the problem that doctors do not feel that RCTs are applicable to the usual practice setting?

  6. What are the problems? • Prescribing legitimises consultation • Huge costs involved • Huge amounts of time used • Nobody much is empowered by the whole process • Help-seeking behaviour reinforced – What’s this?

  7. The unique potential of each primary care consultation – the tasks: • Dealing with the acute problem • Dealing with chronic problems • Opportunistic health promotion • Modification of help-seeking behaviour (Stott & Davis, BJGP, 1979)

  8. Description of paper - 1 • Objective – to assess three prescribing strategies for sore throat • Open randomised follow-up study – involved discussion with patients • Provides another model for clinical management

  9. Description of paper - 2 • Setting – 11 practices in South and West Region • 716 patients with ST and an abnormal physical sign in the throat – 84% had “tonsillitis” or “pharyngitis” • Patients randomised to three groups: antibiotics for 10/7 (246), no prescription (230), prescription to be used if symptoms were not settling after 3/7 (238) – in fact add to 714

  10. Results - 1

  11. Results - 2

  12. Results - 3 • 69% of patients in deferred group did not use the prescription • Legitimisation of illness for school or work (60%) was an important reason for consultation • Patients who were more satisfied with the way the doctor dealt with them got better more quickly

  13. Conclusion in paper • “Prescribing antibiotics for sore throat only marginally affects the resolution of symptoms but enhances belief in antibiotics and intention to consult in future when compared with the acceptable strategies of no prescription or delayed prescription”.

  14. What this means • Antibiotics are not always needed for sore throat to resolve • Strategy of deferred prescription can reduce antibiotic usage • Patients can be managed in this way and still remain happy with their care

  15. Next steps • Can this idea be generalised? • What about acute cough? • What about conjunctivitis? • What about otitis media? • What about sinusitis? • Other conditions?

  16. Another paper • “A RCT of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care”. Dowell et al, BJGP, 2001, 464, 200 (March) • Reached similar conclusions.

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