Electronic Health Records for Intervention Research: A Cluster Randomized Trial to Reduce Antibiotic Prescribing in Primary Care (eCRT Study)

Gulliford, Martin; Staa, Tjeerd van; Dregan, Alexandru; McDermott, Lisa; McCann, Gerard; Ashworth, Mark; Charlton, Judith; Little, Paul; Moore, Michael; Yardley, Lucy

doi:10.1370/afm.1659

Cited by 90 publications

(135 citation statements)

References 25 publications

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“…23 For each CPRD general practice we estimated the rate of RTI consultations per 1000 registered patients, the antibiotic prescribing rate for RTI per 1000 registered patients, and the proportion (%) of RTI consultations with antibiotics prescribed. These prescribing measures were estimated on a sample of CPRD data because it was not feasible and our licence did not allow us to perform the analysis on the entire CPRD database.…”

Section: Methodsmentioning

confidence: 99%

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Gulliford

Moore

Little

et al. 2016

BMJ

123

114

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Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs).Design Cohort study.Setting 610 UK general practices from the UK Clinical Practice Research Datalink.Participants Registered patients with 45.5 million person years of follow-up from 2005 to 2014.Exposures Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients.Main outcome measures Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice.Results From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome were similar in frequency at low prescribing and high prescribing practices.Conclusions General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

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Section: Methodsmentioning

confidence: 99%

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Gulliford

Moore

Little

et al. 2016

BMJ

123

114

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“…80 We have previously conducted cluster RCTs using primary care electronic health records, with the Clinical Practice Research Datalink (CPRD) 81 as the data source. These cluster trials were in implementation research focusing on primary care management and appropriate prescribing for respiratory infections 82 and stroke secondary prevention. 83 Van Staa et al 84 reported on two pilot clinical trials to evaluate statin prescribing for CVD prevention and antibiotic prescribing for chronic obstructive pulmonary disease.…”

Section: Rapid Trials Using Electronic Health Recordsmentioning

confidence: 99%

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

McDermott

Wright

Cornelius

et al. 2016

Health Technol Assess

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BackgroundA national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake.ObjectiveTo evaluate the effectiveness of an enhanced invitation method using the question–behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks.DesignThree-arm randomised trial and cohort study.ParticipantsAll participants invited for a health check from 18 general practices. Individual participants were randomised.Interventions(1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation.Main outcome measuresThe primary outcome was completion of the health check within 6 months of invitation. Ap-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving ‘opportunistic’ health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction.ResultsIn total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) –0.12% to 2.97%;p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI –0.03% to 3.07%;p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was –0.01% (95% CI –1.59% to 1.58%;p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an ‘opportunistic’ health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99;p < 0.001).ConclusionsUptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials.Trial registrationCurrent Controlled Trials ISRCTN42856343.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.

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“…The RECORD statement focuses on observational studies, as an extension to STROBE. However, increasingly, routine data are being used for research that is not observational in nature, including pragmatic randomized controlled trials, where they have the potential for great efficiency and inclusiveness . In future, the RECORD will be modified to encompass interventional studies and other research designs.…”

Section: The Record Statement – Checklist Of Items Extended From Thementioning

confidence: 99%

The need to improve reporting of routinely collected dermatology data for patient benefit

Langan

Benchimol

2016

British Journal of Dermatology

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Electronic Health Records for Intervention Research: A Cluster Randomized Trial to Reduce Antibiotic Prescribing in Primary Care (eCRT Study)

Cited by 90 publications

References 25 publications

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

The need to improve reporting of routinely collected dermatology data for patient benefit

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