Using BRAN (benefits, risks, alternatives, nothing) to disseminate BMJ 10 minute consultation findings
Dear Editor
Hoffmann et al highlight the importance of shared decision making in management of uncomplicated urinary tract infection (UTI) in women.(1) Shared decision making will be familiar to many patients from previous GP consultations – for example whether to treat a sore throat with antibiotics or simple analgesia and fluids. Expectations around UTIs are likely to be different, whether from previous experience of receiving antibiotics for cystitis symptoms, or worry that the bacterial infection of a UTI may progress. Condensing discussion into a 10-minute GP consultation can be challenging. The Choosing Wisely “BRAN” approach helps structure shared decision making. I have expanded this to “BRAND” below, using Hoffmann et al’s findings:
• BENEFITS: Antibiotics may shorten duration of symptoms (from mean of 4.9 to 3.8 days)
• RISKS: Side effects with antibiotics (e.g. diarrhoea, fungal overgrowth); antibiotic resistance
• ALTERNATIVES: No evidence for cranberry products as treatment. Advise simple analgesia & fluids
• NOTHING: Symptoms will resolve within 7-10 days for 1/3 women with uncomplicated UTIs
• DELAYED PRESCRIPTION: Careful safety netting, explaining likely course of infection and red flags.
This overview summarises key points to aid rapid consulting, but also highlights some of the challenges in shared decision making – e.g. comparing likely duration of symptoms from different studies under the “benefits” and “nothing” headings.
The approach has wider application. In Scotland, patients can access free advice and treatment for UTIs and a range of other conditions through NHS Pharmacy First Scotland.(2) That service is complemented by a website and interactive tool that uses age, sex, symptoms and special circumstances (including pregnancy) to assess risk and signpost accordingly, to either pharmacist or GP.(3) The approach is broadly in line with Hoffmann et al’s findings, though somewhat simplified.
The BRAN approach is simple and memorable, tried and tested with Choosing Wisely and Scotland Chief Medical Officer’s Realistic Medicine reports,(4) and can be used in a range of situations. Summarising future BMJ 10-minute consultation papers in BRAN infographics could bring evidence-based clinical advice to a wider audience.
Rapid Response:
Using BRAN (benefits, risks, alternatives, nothing) to disseminate BMJ 10 minute consultation findings
Dear Editor
Hoffmann et al highlight the importance of shared decision making in management of uncomplicated urinary tract infection (UTI) in women.(1) Shared decision making will be familiar to many patients from previous GP consultations – for example whether to treat a sore throat with antibiotics or simple analgesia and fluids. Expectations around UTIs are likely to be different, whether from previous experience of receiving antibiotics for cystitis symptoms, or worry that the bacterial infection of a UTI may progress. Condensing discussion into a 10-minute GP consultation can be challenging. The Choosing Wisely “BRAN” approach helps structure shared decision making. I have expanded this to “BRAND” below, using Hoffmann et al’s findings:
• BENEFITS: Antibiotics may shorten duration of symptoms (from mean of 4.9 to 3.8 days)
• RISKS: Side effects with antibiotics (e.g. diarrhoea, fungal overgrowth); antibiotic resistance
• ALTERNATIVES: No evidence for cranberry products as treatment. Advise simple analgesia & fluids
• NOTHING: Symptoms will resolve within 7-10 days for 1/3 women with uncomplicated UTIs
• DELAYED PRESCRIPTION: Careful safety netting, explaining likely course of infection and red flags.
This overview summarises key points to aid rapid consulting, but also highlights some of the challenges in shared decision making – e.g. comparing likely duration of symptoms from different studies under the “benefits” and “nothing” headings.
The approach has wider application. In Scotland, patients can access free advice and treatment for UTIs and a range of other conditions through NHS Pharmacy First Scotland.(2) That service is complemented by a website and interactive tool that uses age, sex, symptoms and special circumstances (including pregnancy) to assess risk and signpost accordingly, to either pharmacist or GP.(3) The approach is broadly in line with Hoffmann et al’s findings, though somewhat simplified.
The BRAN approach is simple and memorable, tried and tested with Choosing Wisely and Scotland Chief Medical Officer’s Realistic Medicine reports,(4) and can be used in a range of situations. Summarising future BMJ 10-minute consultation papers in BRAN infographics could bring evidence-based clinical advice to a wider audience.
1) Hoffmann TC, Bakhit M, Del Mar C. Uncomplicated urinary tract infection in women. BMJ 2021;372:n725
2) NHS Pharmacy First Scotland website – Information for patients. https://www.gov.scot/publications/nhs-pharmacy-first-scotland-informatio... accessed 19/4/2021
3) NHS Inform website – Urinary tract infection (UTI) https://www.nhsinform.scot/illnesses-and-conditions/kidneys-bladder-and-... accessed 19/4/2021
4) Recover, Restore, Renew. Scotland’s CMO Annual Report 2020-2021. https://www.realisticmedicine.scot/annual-report-2020-2021-recover-resto... accessed 19/4/2021
Competing interests: No competing interests