General Practice

Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice

Commentary: What can we learn from narratives of implementing evidence?

Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice

Toby Lipman, general practitioner ^{a b},  Dawn Price, prescribing adviser ^b. 

^a Westerhope Medical Group, Newcastle upon Tyne NE5 2LH, ^b Blyth Valley Primary Care Group, Blyth, Northumberland NE24 2JN

Correspondence to: T Lipman toby{at}tobylipm.demon.co.uk

	Abstract

Top Abstract Introduction Methods Results Discussion References

Objectives: To describe a group general practice's implementation of a decision to prescribe 3 day courses of 200 mg trimethoprim twice daily for urinary tract infections in women and to compare 3 day courses with 5 and 7 day courses.
Design: Record review, audit of trimethoprim prescribing for urinary tract infections, and critical appraisal of evidence originally presented in support of 3 day course.
Setting: Group general practice in Newcastle upon Tyne.
Data sources: The records of all female patients aged 12 years and older who were prescribed trimethoprim for uncomplicated urinary tract infections during a 12 month period were reviewed. 271 valid records were identified.
Data extraction: Prescribing rates for different courses of trimethoprim, rates of patients returning for second consultations, rates of urine cultures, results of cultures, results of critical appraisal of evidence.
Results: 114 of 271 (42%) prescriptions written at the first visit were for 3 day courses. 16 of 114 (14%) patients who had had a 3 day course of treatment returned for a second consultation compared with 6/83 (7.2%) of those who had had a 5 day course and 8/74 (11%) who had had a 7 day course. The difference between 3 day and 5 day courses in rates of returning for second consultations was 6.8% (95% CI 1.7% to 12.6%) and between 3 day and 7 day courses was 3.2% (3.6% to 10.0%). Appraisal of the original evidence on which the practice based its recommendations showed that it was flawed. Additional evidence was found in the Cochrane Library.
Conclusions: Our original decision, made by consensus at a meeting of the practice's partners, had not led to a consistent change in practice. We did not find a significant increase in treatment failures among patients treated with the 3 day regimen.

	Introduction

Top Abstract Introduction Methods Results Discussion References

Successful programmes for implementing effective healthcare interventions have often developed from projects on single topics that have been carried out in local areas but organised outside individual general practices.¹ Of necessity these programmes address only one aspect of health care at a time, yet practices need continuously to re-examine their policies on many topics if they want to improve clinical effectiveness and cost effectiveness. It is unrealistic to expect large scale projects to be implemented to assess each aspect of health care, therefore practices must rely on their own resources to make decisions about most changes in clinical management. Westerhope Medical Group benefited from the services of a qualified pharmacist (DP) for one session per week who facilitated this process. She presented reports on the practice's prescribing patterns and made recommendations based on local policy and evidence selected by local experts. Until the events described in this paper decisions about changes in prescribing were made at meetings of the practice's partners (which she attended), taking into account her reports and advice.

At one meeting we decided to use 3 day courses of trimethoprim (200 mg twice daily) as the first line treatment for uncomplicated lower urinary tract infection occurring in adult women. Evidence from local experts supported this regimen.² The partners did not critically appraise the evidence before implementing the decision; it was made by consensus after a brief discussion.

More than a year later, soon after we had introduced fortnightly multidisciplinary educational sessions,³ a practice nurse claimed, during a session devoted to questions from everyday practice, that the change to the 3 day course had led to more treatment failures. At that point some general practitioners claimed not to have heard of the new policy, and we realised that it was not being implemented consistently.

We decided to obtain and critically appraise the articles cited in support of the policy and to search for new evidence. At the same time we would also audit the prescribing of trimethoprim for urinary tract infections and the investigations and second visits associated with its use. Merely returning for a second visit does not necessarily indicate that a treatment has failed but was a practicable outcome measure given that patients in routine clinical practice are not likely to be followed up as systematically as in clinical trials. However, we felt that we would be justified in reviewing our policy if the audit found that there was a significantly higher rate of reconsultation among patients who had been given 3 day courses of trimethoprim compared with those who had been given 5 or 7 day courses.

	Methods

Top Abstract Introduction Methods Results Discussion References

Critical appraisal
Copies of all the articles cited were obtained and critically appraised using checklists from standard texts.^4-9 Critical appraisal took less than an hour, and most articles did not meet the essential criteria given in the checklists which would have allowed them to be classed as methodologically rigorous studies.

Literature search
A 10 minute search of the Cochrane Library found a meta-analysis of randomised trials of single dose treatment with antibiotics, randomised trials of 3 day courses of co-trimoxazole compared with 7 day courses for urinary tract infections in women, 3 day courses of co-trimoxazole and pivmecillinam compared with 10 day courses, treatment with a single dose of an antibiotic compared with 3 day and 7 day courses (including a single dose of co-trimoxazole compared with a 3 day course), and treatment with 3 days of co-trimoxazole compared with 10 days.^10-14

Audit
Electronic medical records were searched by DP to identify all prescriptions for trimethoprim written in the 12 months after the decision had been made to use a 3 day course as first line treatment. The records of children younger than 12 years were excluded. Both the paper and the electronic records were retrieved and examined. The length of the first prescription for trimethoprim in days (3, 5, or 7) was recorded, whether the patient returned with similar symptoms within 2 weeks, whether a urine culture was performed at the time of the first or second consultation, the result of the culture (no growth, sensitive to trimethoprim, sensitive to other antibiotic), the sex of the patient, and the general practitioner who wrote the prescription.

	Results

Top Abstract Introduction Methods Results Discussion References

Critical appraisal and literature search
Four reviews were cited and their critical appraisals are summarised in table 1.^6-9 None is a full systematic review: no details are given of search strategies and only one outlines the criteria used to evaluate the quality of trials (which are described as modest) for inclusion in the review.⁸ The other reviews are expert reviews which cannot be relied on. ^{6 7 9 15}

Audit
Altogether, 302 prescriptions of trimethoprim written for symptoms of urinary tract infections were identified. Thirty one records were incomplete or missing or the patients had complex problems such as an indwelling catheter or pyelonephritis; these records were not included in the audit, leaving 271 records for analysis (table 3).

	Discussion

Top Abstract Introduction Methods Results Discussion References

Although these results are reassuring in that 3 day courses of trimethoprim for uncomplicated lower urinary tract infections do not seem to increase the rate of treatment failure, they raise a number of important issues.

Quality of evidence
Firstly, we were disappointed by the quality of the evidence offered by apparently authoritative sources. The evidence cited to support the use of a 3 day course of trimethoprim was scanty, and using Eccles et al's classification, was rated category C at best: it was based on extrapolated evidence from randomised controlled trials (which were of mediocre quality).²³ The only way to be sure that 3 day courses of trimethoprim are as effective as 5 or 7 day courses would be if results from well designed randomised controlled trials in general practice were available; however, such trials have yet to be carried out.

Uncertainty and compromise
Secondly, given that the quality of the evidence was poor, would we make the same decision now given the same circumstances? It was easy to find evidence in the Cochrane Library suggesting that 3 day courses of co-trimoxazole are as effective as longer courses, that trimethoprim alone is as effective as co-trimoxazole,¹² that the recommendation is supported by expert consensus, and that it has biological plausibility. In the real world we have to accept compromises and, despite a degree of uncertainty, would probably have made the same decision. In future we would question any recommendation or guideline and, at the very least, assess its validity by critically appraising it before agreeing to implement it.

Dissemination and implementation
Thirdly, even in a practice that was well motivated enough to employ a pharmaceutical adviser and that had an explicit policy of reviewing its prescribing, the original decision was not well disseminated and only partially implemented. All of the general practitioners prescribed courses of 3, 5, and 7 days even though they had been party to and supportive of the original decision. In general practice doctors deal with hundreds of different problems in a short time and are not likely to remember every guideline or regimen for each condition that they treat.²⁴ Implementation of practice policies requires reinforcement using strategies such as computerised reminders, having regularly revised loose leaf practice manuals at each desk, and providing educational activities within the practice. At an educational session after the audit, the team used our findings to produce a practice guideline which is based both on the best external evidence (including evidence about diagnosis )²⁵ and the audit described here (box). Copies have been distributed to each team member and placed at the telephone triage desk, and the audit will be repeated in 12 months.

Conclusions
Clinical audit is now firmly established as a key quality assurance method and our experience shows its value in answering the question "are we doing what we're supposed to be doing?" and "what is the effect of what we're doing?"²⁶ It is important that general practitioners identify and address relevant questions and implement changes according to the best evidence available. We have described the often messy and uncoordinated process whereby we have tried to improve our practice. We are always busy, always have to get through the next surgery, and struggle to find time and effective ways to evaluate and improve our performance. Decisions must be made quickly using the best evidence and data, and we must often trade methodological rigour for practicability and speed. Making this particular decision in a partners' meeting based on external advice did not lead to a consistent change in practice. However, we were able to use multidisciplinary educational methods in a small group to identify and address an important question. Active educational methods in the practice setting are more effective in achieving a sustained change in practice than passive methods (such as lectures or dissemination of information on paper).²⁷ The small group educational process worked better for us than the administrative process of the partners' meeting. It is now therefore our preferred method of identifying the need for review or change in our practice, examining the evidence, and addressing the details of implementation.

	Acknowledgments

   Contributors: TL carried out the critical appraisal, searched for new evidence, calculated the statistics, and wrote the text. TL will act as guarantor for the paper. DP obtained the original articles for critical appraisal, carried out the audit, and collated the figures.

	Footnotes

Funding: None.

Competing interests: None declared.

	References

Top Abstract Introduction Methods Results Discussion References

1.	Dunning M, Abi-Aad G, Gilbert D, Hutton H, Brown C. Experience, evidence and everyday practice: creating systems for delivering effective health care. London: King's Fund, 1999.
2.	The treatment of uncomplicated lower urinary tract infection. NHS Northern and Yorkshire Regional Drug and Therapeutics Newsletter 1994; 5: 17-18.
3.	Lipman T. Structure and process before outcome: evidence-based learning in the primary health care team. In: Hungin APS, ed. Royal College of General Practitioners and NoReN annual research presentation days: abstracts of presentations and posters. Eaglescliffe: Northern Primary Care Research Network, 1998.
4.	Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London: BMJ Publishing, 1997.
5.	Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone, 1997.
6.	Bailey RR. Management of lower urinary tract infections. Drugs 1993; 45(suppl 3): 139-144.
7.	Neu HC. Urinary tract infections. Am J Med 1992; 92(suppl 4A): 63-70S.
8.	Norrby SR. Short-term treatment of uncomplicated lower urinary tract infection in women. Rev Infect Dis 1990; 12: 458-467[Medline].
9.	Powers RD. New directions in the diagnosis and therapy of urinary tract infections. Am J Obstet Gynecol 1991; 164(5 Pt 2): 1387-1389[Medline].
10.	Leibovici L, Wysenbeek AJ. Single-dose antibiotic treatment for symptomatic urinary tract infections in women: a meta-analysis of randomized trials. Q J Med 1991; 78: 43-57[Abstract/Free Full Text].
11.	Trienekens TA, Stobberingh EE, Winkens RA, Houben AW. Different lengths of treatment with co-trimoxazole for acute uncomplicated urinary tract infections in women. BMJ 1989; 299: 1319-1322.
12.	Gordin A, Kalima S, Makela P, Antikainen R. Comparison of three- and ten-day regimens with a sulfadiazine-trimethoprim combination and pivmecillinam in acute lower urinary tract infections. Scand J Infect Dis 1987; 19: 97-102[Medline].
13.	Greenberg RN, Reilly PM, Luppen KL, Weinandt WJ, Ellington LL, Bollinger MR. Randomized study of single-dose, three-day, and seven-day treatment of cystitis in women. J Infect Dis 1986; 153: 277-282[Medline].
14.	Fair WR, Crane DB, Peterson LJ, Dahmer C, Tague B, Amos W. Three-day treatment of urinary tract infections. J Urol 1980; 123: 717-721[Medline].
15.	Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Boston: Little Brown, 1991.
16.	Co-trimoxazole use restricted. Drug Ther Bull 1995; 33: 92-93[Abstract/Free Full Text].
17.	Brumfitt W, Hamilton-Miller JM. Combinations of sulphonamides with diaminopyrimidines: how, when and why? J Chemother 1995; 7: 136-139[Medline].
18.	Iravani A. Multicenter study of single-dose and multiple-dose fleroxacin versus ciprofloxacin in the treatment of uncomplicated urinary tract infections. Am J Med 1993; 94(suppl 3A): 89-96S.
19.	Osterberg E, Aberg H, Hallander HO, Kallner A, Lundin A. Efficacy of single-dose versus seven-day trimethoprim treatment of cystitis in women: a randomized double-blind study. J Infect Dis 1990; 161: 942-947[Medline].
20.	Saginur R, Nicolle LE. Single-dose compared with 3-day norfloxacin treatment of uncomplicated urinary tract infection in women: Canadian Infectious Diseases Society Clinical Trials Study Group. Arch Intern Med 1992; 152: 1233-1237[Abstract/Free Full Text].
21.	Elwood M. Critical appraisal of epidemiological studies and clinical trials. 2nd ed. Oxford: Oxford University Press, 1998.
22.	Managing urinary tract infection in women. Drug Ther Bull 1998; 36: 30-32[Abstract/Free Full Text].
23.	Eccles M, Clapp Z, Grimshaw J, Adams PC, Higgins B, Purves I, et al. North of England evidence based guidelines development project: methods of guideline development. BMJ 1996; 312: 760-762[Free Full Text].
24.	Lipman T. Discrepancies exist between general practitioners' clinical work and a guidelines implementation programme. BMJ 1998; 317: 604[Free Full Text].
25.	Winkens RA, Leffers P, Trienekens TA, Stobberingh EE. The validity of urine examination for urinary tract infections in daily practice. Fam Pract 1995; 12: 290-293[Abstract/Free Full Text].
26.	Houghton G. From audit to effectiveness: an historical evaluation of the changing role of medical audit advisory groups. J Eval Clin Pract 1997; 3: 245-253[CrossRef][Medline].
27.	Onion CW, Bartzokas CA. Changing attitudes to infection management in primary care: a controlled trial of active versus passive guideline implementation strategies. Fam Pract 1998; 15: 99-104[Abstract/Free Full Text].

(Accepted 7 December 1999)

Commentary: What can we learn from narratives of implementing evidence?

Trisha Greenhalgh, senior lecturer. 

Unit for Evidence Based Practice and Policy, Department of Primary Care and Population Sciences, Royal Free and University College Medical Schools, London N19 3UA

This paper is engaging for the story it tells. Once upon a time there was an enthusiast, and this is what befell him. The evidence itself is unremarkableindeed, one of the twists in the tale is that it is found to be flawedbut if you kept reading till the bitter end, it was probably to discover the fate of the brave pioneer who embarked on a crusade of implementation in a practice where (we infer) the language of evidence based health care was not universally spoken.

Downing has argued that the process of change necessarily centres on human characters whose moves are interpreted, told, and retold by others within and outside the organisation.¹ Human behaviour is driven by feelings, and stories of organisational change tend to follow one of four basic plots: romance (the hero-adventurer meets and overcomes a series of challenges to earn his ultimate reward), tragedy (the hero works hard for a just cause but is pitched from success to danger and ultimate humiliation), melodrama (a polarised struggle between hero and villain, often with a climactic battle towards the end) and irony (the hero is exposed as incompetent, corrupt or a fool; the heroic actions are reinterpreted as a scam).²

Most published accounts of implementing evidence based practice are presented as teamwork-romance ("we pulled together, worked hardand look what we've produced"), resource-tragedy ("we did our best but were beaten by constraints [usually financial] beyond our control"), or political melodrama ("key stakeholders had too much to lose and blocked our efforts"). ^{3 4} Lipman and Price's story follows what is probably the commonest but least publicised plot of all: the irony of misplaced values.

In this basic storyline, the hard liners for the evidence based agenda come to discover that their academic value systemwith its emphasis on experiment, rigour, precision, and reproducibilityserves them poorly in the untidy and unpredictable environment of service delivery. Furthermore, the value system espoused by their service colleagueswith its emphasis on using available data and information systems, maintaining harmony and job fulfilment among staff, responding flexibly to individual needs, and keeping the customer satisfiedmay be better able to initiate and sustain positive changes within the organisation.

The story of implementing best evidence in Lipman's practice is as yet unfinished. We are left on a cliffhanger in which our humbled hero (or, perhaps, the heroic dyad of GP-enthusiast and complicit pharmacist) have sensibly abandoned their efforts to table clinical epidemiology as "any other business" in administrative meetings. They have revised their claims for the invincibility of research evidence and (we suspect) have put in work backstage to muster support for the idea of multidisciplinary practice education. The stage is set for real progress. Watch out for the next exciting instalment.

	References

1.	Downing SJ. Learning the plot: emotional momentum in search of dramatic logic. Management Learning 1997; 28: 27-44[Abstract].
2.	Gorman P. Managing multidisciplinary teams in the NHS. London: Kogan Page, 1998.
3.	Dunning M, Abi-Aad G, Gilbert D, Hutton H, Brown C. Experience, evidence, and everyday practice: creating systems for delivering effective health care. London: King's Fund, 1999.
4.	Evans D, Haines A. Evidence, effectiveness and the experience of implementation: working to achieve evidence based changes in the real world. Oxford: Radcliffe Publications, (in press).

	Acknowledgments

The importance of exploring different value systems when identifying barriers to change was suggested by Dr Charlotte Humphrey in relation to another project.

	Footnotes

Competing interests: None declared.