Work Package 2

Exploring current prevention and management of respiratory tract infections in European primary care and exploring perception, expectations and illness behaviour of primary care patients with respiratory tract infections
 

Work Package leader: Prof. Christopher Butler, Cardiff University
 

 

Objectives

General objective:

  • To describe management of LRTI and selected other common infections in Europe and to achieve a deep understanding of variation in management of these infections.  

Specific aims: 

  • To develop a scenario based questionnaire to elicit clinicians accounts of their management of otitis media, sinusitis, sore throat and urinary tract infections in patients of all age ranges.
  • To obtain national level data on outpatient antibiotic prescribing from the ESAC project.
  • To administer this questionnaire to clinicians involved in the GRACE clinical Platform
  • To compare variation of clinicians accounts of management of common infections with empirical data on the management of LRTI
  • To explore the determinants of reported and actual variation in practice with potential local determinants such as health care system, clinical and practice characteristics.

To broaden the proposed GRACE qualitative study among clinicians and patients to include questions on other common respiratory infections and the management of children in order to achieve a deep understating in the reported and observed variation in management of common infections in Europe.
 

Description of work
1. Quantitative study: In GRACE, there has been no comprehensive exploration of management of common infectious conditions other than LRTI in adults. In CHAMP, we have used six of the existing GRACE Primary Care Networks to administer a vignette based questionnaire to explore variation in management within and between European countries. This questionnaire was filled in by clinicians participating in four GRACE primary care research networks. The questionnaire presented clinicians with 32 brief clinical scenarios in each of four common infections; sore throat, otitis media, sinusitis and LRTI. In response to each scenario, structured around a working week in order also to model the impact off contextual factors, clinicians were asked to report whether they would prescribe an antibiotic, and if so, what would their first choice of antibiotic be. Additional questions were asked about investigation strategies. A pilot of this approach to explore variation in management of urinary tract infection (UTI) had already been done in the UK.
 

The pilot, ‘proof of concept’ study had involved a sample of 293 clinicians in 103 general medical practices in Wales. For some scenarios, virtual unanimity about management prevailed. For other scenarios, wide variation in management had been identified. This pilot therefore showed that a scenario based tool was effective in determining variation in management in common infections in primary care. Additional scenarios have been developed for sore throat, sinusitis and otitis media. This Work package therefore began with the development of an instrument to determine variation in management for a range of important common infections managed in primary care to highlight areas of variation both within countries and between countries. Then the vignettes were distributed among physicians in six networks. Characteristics of clinicians and practice settings and organisation of care were analysed in relation to reported patterns of clinical practices. The analysis was compared to  analyses based on empirical data collected for LRTI in GRACE, allowing judgement of validity.   Analyses have identified potential targets for focused interventions both within and between countries, and these can be refined and better understood through qualitative research outlined below.  
 

2. Qualitative study: The science of behaviour change suggests that interventions are more likely to be successful and behaviour change maintained if interventions are rooted in the reality of those whose behaviour they aim to change. In GRACE, clinicians and adult patients were interviewed about their understanding and behaviour regarding the presentation and management of  LRTI in 4 of the primary care networks. Conducting the qualitative study in all 13 networks would have generated too much data and redundancy. Networks were therefore selected for this further in-depth qualitative study on the basis of ‘maximum variation sampling’, an approach commonly adopted in qualitative research to ensure that data is obtained from typical and important divergent sources. Maximum variation sampling has been based on quantitative analysis of antibiotic prescribing for LRTI observed in the GRACE project. CHAMP has provided resources for these interviews to be broadened and extended to gather data on clinicians’ and patients’ perceptions and understanding of antimicrobial resistance and antibiotic use more generally and of preventive measures, and included focus on a wider rage of conditions and also on the management of common respiratory tract infections in children. Patients and clinicians were selected from each of the 4 networks  based on the principle of maximal variation. A semi structured interview guide was used. A grounded theory approach was used to analyse the data, and a grounded theory was developed to explain variation in practice within and between countries. Barriers and opportunities for change have been identified. The opportunity to interview clinicians and patients in the same study has ensured that multifaceted interventions developed out of this STREP are based on an in-depth analysis of accounts of understating, barriers and opportunities from the perspectives of the target recipients of multifaceted campaigns targeted at both professionals and the public alike.

Exploring current prevention and management of respiratory tract infections in European primary care and exploring perception, expectations and illness behaviour of primary care patients with respiratory tract infections
 

Work Package leader: Prof. Christopher Butler, Cardiff University
 

 

Objectives

General objective:

  • To describe management of LRTI and selected other common infections in Europe and to achieve a deep understanding of variation in management of these infections.  

Specific aims: 

  • To develop a scenario based questionnaire to elicit clinicians accounts of their management of otitis media, sinusitis, sore throat and urinary tract infections in patients of all age ranges.
  • To obtain national level data on outpatient antibiotic prescribing from the ESAC project.
  • To administer this questionnaire to clinicians involved in the GRACE clinical Platform
  • To compare variation of clinicians accounts of management of common infections with empirical data on the management of LRTI
  • To explore the determinants of reported and actual variation in practice with potential local determinants such as health care system, clinical and practice characteristics.

To broaden the proposed GRACE qualitative study among clinicians and patients to include questions on other common respiratory infections and the management of children in order to achieve a deep understating in the reported and observed variation in management of common infections in Europe.
 

Description of work
1. Quantitative study: In GRACE, there has been no comprehensive exploration of management of common infectious conditions other than LRTI in adults. In CHAMP, we have used six of the existing GRACE Primary Care Networks to administer a vignette based questionnaire to explore variation in management within and between European countries. This questionnaire was filled in by clinicians participating in four GRACE primary care research networks. The questionnaire presented clinicians with 32 brief clinical scenarios in each of four common infections; sore throat, otitis media, sinusitis and LRTI. In response to each scenario, structured around a working week in order also to model the impact off contextual factors, clinicians were asked to report whether they would prescribe an antibiotic, and if so, what would their first choice of antibiotic be. Additional questions were asked about investigation strategies. A pilot of this approach to explore variation in management of urinary tract infection (UTI) had already been done in the UK.
 

The pilot, ‘proof of concept’ study had involved a sample of 293 clinicians in 103 general medical practices in Wales. For some scenarios, virtual unanimity about management prevailed. For other scenarios, wide variation in management had been identified. This pilot therefore showed that a scenario based tool was effective in determining variation in management in common infections in primary care. Additional scenarios have been developed for sore throat, sinusitis and otitis media. This Work package therefore began with the development of an instrument to determine variation in management for a range of important common infections managed in primary care to highlight areas of variation both within countries and between countries. Then the vignettes were distributed among physicians in six networks. Characteristics of clinicians and practice settings and organisation of care were analysed in relation to reported patterns of clinical practices. The analysis was compared to  analyses based on empirical data collected for LRTI in GRACE, allowing judgement of validity.   Analyses have identified potential targets for focused interventions both within and between countries, and these can be refined and better understood through qualitative research outlined below.  
 

2. Qualitative study: The science of behaviour change suggests that interventions are more likely to be successful and behaviour change maintained if interventions are rooted in the reality of those whose behaviour they aim to change. In GRACE, clinicians and adult patients were interviewed about their understanding and behaviour regarding the presentation and management of  LRTI in 4 of the primary care networks. Conducting the qualitative study in all 13 networks would have generated too much data and redundancy. Networks were therefore selected for this further in-depth qualitative study on the basis of ‘maximum variation sampling’, an approach commonly adopted in qualitative research to ensure that data is obtained from typical and important divergent sources. Maximum variation sampling has been based on quantitative analysis of antibiotic prescribing for LRTI observed in the GRACE project. CHAMP has provided resources for these interviews to be broadened and extended to gather data on clinicians’ and patients’ perceptions and understanding of antimicrobial resistance and antibiotic use more generally and of preventive measures, and included focus on a wider rage of conditions and also on the management of common respiratory tract infections in children. Patients and clinicians were selected from each of the 4 networks  based on the principle of maximal variation. A semi structured interview guide was used. A grounded theory approach was used to analyse the data, and a grounded theory was developed to explain variation in practice within and between countries. Barriers and opportunities for change have been identified. The opportunity to interview clinicians and patients in the same study has ensured that multifaceted interventions developed out of this STREP are based on an in-depth analysis of accounts of understating, barriers and opportunities from the perspectives of the target recipients of multifaceted campaigns targeted at both professionals and the public alike.

Christopher Butler