Burden of illness and healthcare resource use in United States patients with sporadic inclusion body myositis.

INTRODUCTION: We analyzed the burden of illness of sporadic inclusion body myositis (sIBM) patients and the costs to the healthcare system. METHODS: A retrospective cohort analysis of 333 sIBM patients aged ≥ 50 years was performed using United States (U.S.) claims data. sIBM patients were matched in a 1:5 ratio to randomly selected individuals with ≥1 healthcare encounter within the year of index date. RESULTS: sIBM patients presented with higher rates of disease- and muscle-related conditions, such as myalgia, myositis, muscle weakness, dysphagia, pneumonia, and falls. Use of healthcare resources, including physical therapy, office visits, emergency room (ER) visits, and hospitalizations, was greater in sIBM patients. This was also reflected in significantly higher overall healthcare costs in the sIBM population driven mainly by more all-cause office visits, all-cause ER visits and hospitalizations. CONCLUSIONS: sIBM imposes a substantial burden on U.S. patients in terms of additional healthcare usage and associated costs. Muscle Nerve 56: 861-867, 2017.

A Systematic Review and Meta-Analysis of Prevalence Studies of Sporadic Inclusion Body Myositis.

BACKGROUND: Sporadic Inclusion Body Myositis (sIBM) is a rare and slowly progressive debilitating muscle disease with symptoms generally developing≥50 years of age. OBJECTIVE: To conduct a systematic review and meta-analysis of the prevalence of sIBM literature, including a methodological quality assessment of the selected papers. METHODS: A systematic search of Medline, Embase, Cochrane Database of Systematic Reviews and major Myositis and Neurological conferences was conducted. Articles reporting prevalence and published in English up to March 2017 were assessed for methodology quality using the Loney quality assessment, Downs & Black score, and the Methodological Evaluation of Observational Research checklists. Meta-analyses using random effects were completed on both general population and≥50 years prevalence estimates. RESULTS: 315 articles were retrieved and data were extracted from 10 relevant studies. One study was subsequently excluded due to methodological issues. The meta-prevalence estimate from 9 papers was 24.8/1,000,000 (95% CI: 20.0-29.6). The methodological quality results were consistent across assessment tools with four articles scoring 4 or 5 out of 8 in the Loney assessment. The meta-prevalence of these four articles was 45.6/ 1,000,000 (95% CI: 35.9-55.2). CONCLUSION: There was high variability in reported sIBM prevalence estimates and the quality of the studies conducted. Existing evidence suggests an increase of prevalence estimates over time, which may be explained by growing disease awareness, improvements in diagnostic criteria and study methodologies. Further high quality studies are needed to understand if prevalence varies across geographies or ethnicities.

The cost effectiveness of the SIMPle intervention to improve antimicrobial prescribing for urinary tract infection in primary care.

Background: Antimicrobial resistance is a major public health issue. This study examines the cost effectiveness of the SIMPle (Supporting the Improvement and Management of Prescribing for Urinary Tract Infections (UTI)) intervention to improve antimicrobial prescribing in primary care in Ireland. Methods: An economic evaluation was conducted alongside a cluster randomized controlled trial of 30 general practices and 2560 patients with a diagnosis of UTI. Practices were randomized to the usual practice control or the SIMPle intervention (arm A or B). Data at 6 months follow-up were used to estimate incremental costs, incremental effectiveness in terms of first-line antimicrobial prescribing for UTI and cost effectiveness acceptability curves. Results: The SIMPle intervention was, on average, more costly and more effective than the control. The probability of intervention arm A being cost effective was 0.280, 0.995 and 1.000 at threshold values of €50, €150 and €250 per percentage point increase in first-line antimicrobial prescribing respectively. The equivalent probabilities for intervention arm B were 0.121, 0.863 and 0.985, respectively. Conclusions: The cost effectiveness of the SIMPle intervention depends on the value placed on improving antimicrobial prescribing. Future studies should examine the wider and longer term costs and outcomes of improving antimicrobial prescribing.

Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections.

OBJECTIVES: The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member. DESIGN: Indepth interviews were conducted with GPs, and focus groups were held with community members. SETTING: General practice and community setting. PARTICIPANTS: 15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken. RESULTS: The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available. CONCLUSIONS: Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing. TRIAL REGISTRATION NUMBER: NCT01913860; Pre-results.

Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial.

BACKGROUND: Overuse of antimicrobial therapy in the community adds to the global spread of antimicrobial resistance, which is jeopardizing the treatment of common infections. METHODS: We designed a cluster randomized complex intervention to improve antimicrobial prescribing for urinary tract infection in Irish general practice. During a 3-month baseline period, all practices received a workshop to promote consultation coding for urinary tract infections. Practices in intervention arms A and B received a second workshop with information on antimicrobial prescribing guidelines and a practice audit report (baseline data). Practices in intervention arm B received additional evidence on delayed prescribing of antimicrobials for suspected urinary tract infection. A reminder integrated into the patient management software suggested first-line treatment and, for practices in arm B, delayed prescribing. Over the 6-month intervention, practices in arms A and B received monthly audit reports of antimicrobial prescribing. RESULTS: The proportion of antimicrobial prescribing according to guidelines for urinary tract infection increased in arms A and B relative to control (adjusted overall odds ratio [OR] 2.3, 95% confidence interval [CI] 1.7 to 3.2; arm A adjusted OR 2.7, 95% CI 1.8 to 4.1; arm B adjusted OR 2.0, 95% CI 1.3 to 3.0). An unintended increase in antimicrobial prescribing was observed in the intervention arms relative to control (arm A adjusted OR 2.2, 95% CI 1.2 to 4.0; arm B adjusted OR 1.4, 95% CI 0.9 to 2.1). Improvements in guideline-based prescribing were sustained at 5 months after the intervention. INTERPRETATION: A complex intervention, including audit reports and reminders, improved the quality of prescribing for urinary tract infection in Irish general practice. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT01913860.

Improving antimicrobial prescribing in Irish primary care through electronic data collection and surveillance: a feasibility study.

BACKGROUND: The increase in the spread of antimicrobial resistance (AMR) in bacterial pathogens and limited availability of new antimicrobials places immense pressure on general practitioners (GPs) to prescribe appropriately. Currently, electronic antimicrobial prescribing data is not routinely collected from GPs in Ireland for surveillance purposes to assess regional specific fluctuations or trends in antimicrobial prescribing. The current study aimed to address this issue by assessing the feasibility of remotely extracting antimicrobial prescribing data from primary care practices in Ireland, for the purpose of assessing prescribing quality using the European Surveillance of Antimicrobial Consumption (ESAC) drug specific quality indicators. METHODS: Participating practices (n = 30) uploaded data to the Irish Primary Care Research Network (IPCRN). The IPCRN data extraction facility is integrated within the practice patient management software system and permitted the extraction of anonymised patient prescriptions for a one year period, from October 2012 to October 2013. The quality of antimicrobial prescribing was evaluated using the twelve ESAC drug specific quality indicators using the defined daily dose (DDD) per 1,000 inhabitants per day (DID) methodology. National and European prescribing surveillance data (based on total pharmacy sales) was obtained for a comparative analysis. RESULTS: Antimicrobial prescriptions (n = 57,079) for 27,043 patients were obtained from the thirty study practices for a one year period. On average, study practices prescribed a greater proportion of quinolones (37 % increase), in summer compared with winter months, a variation which was not observed in national and European data. In comparison with national data, study practices prescribed higher proportions of ß-lactamase-sensitive penicillins (4.98 % vs. 4.3 %) and a greater use of broad spectrum compared to narrow-spectrum antimicrobials (ratio = 9.98 vs. 6.26) was observed. Study practices exceeded the European mean for prescribing combinations of penicillins, including ß-lactamase inhibitors. CONCLUSIONS: This research demonstrates the feasibility and potential use of direct data extraction of anonymised practice data directly through the patient management software system. The data extraction methods described can facilitate the provision of routinely collected data for sustained and inclusive surveillance of antimicrobial prescribing. These comparisons may initiate further improvements in antimicrobial prescribing practices by identifying potential areas for improvement.

Willingness to pay for telecare programmes to support independent living: results from a contingent valuation study.

An ageing population provokes an economic interest in the resource allocation questions posed by long-term care and critically, the development of sustainable community-based health and social care models that support independent living. This paper explores Irish citizens preferences and willingness to pay (WTP) for a range of community-based care programmes, including different telecare programmes that support older people to continue living at home. The paper reports on a cross-sectional multi-good contingent valuation survey conducted between April and September 2009 with three representative samples of the Irish population (N = 1214) to identify rankings and preferences for different community care programmes including: family care programme, a state-provided care programme and three different telecare programmes. The survey design permits the identification of strength, direction and relative preferences of different forms of community care provision. We also investigate convergent validity between ranking and willingness to pay results. We find that while people place significant value on formal state care provision and on telecare programmes, willingness to pay (WTP) estimates continue to highlight the importance of family care, which remains the strongest preference of the Irish population for the provision of community-based care for older people in the country. Respondents weakened their ranking preferences in the WTP exercise. However, both the direction of ranking and WTP estimates confirm the importance of family care. While all telecare programmes generated some economic value, telecare associated with social connection had much stronger support than telecare used to support physical or cognitive care needs. This paper offers unique information on societal values for different forms of community care provision, and in particular, the direction of preferences for technology-based approaches.

Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): protocol for a cluster randomized trial.

BACKGROUND: The overuse of antimicrobials is recognized as the main selective pressure driving the emergence and spread of antimicrobial resistance in human bacterial pathogens. Urinary tract infections (UTIs) are among the most common infections presented in primary care and empirical antimicrobial treatment is currently recommended. Previous research has identified that a substantial proportion of Irish general practitioners (GPs) prescribe antimicrobials for UTIs that are not in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The aim of this trial is to design, implement and evaluate the effectiveness of a complex intervention on GP antimicrobial prescribing and adult (18 years of age and over) patients' antimicrobial consumption when presenting with a suspected UTI. METHODS/DESIGN: The Supporting the Improvement and Management of Prescribing for urinary tract infections (SIMPle) study is a three-armed intervention with practice-level randomization. Adult patients presenting with suspected UTIs in primary care will be included in the study.The intervention integrates components for both GPs and patients. For GPs the intervention includes interactive workshops, audit and feedback reports and automated electronic prompts summarizing recommended first-line antimicrobial treatment and, for one intervention arm, a recommendation to consider delayed antimicrobial treatment. For patients, multimedia applications and information leaflets are included. Thirty practices will be recruited to the study; laboratory data indicate that 2,038 patients will be prescribed an antimicrobial in the study. The primary outcome is a change in prescribing of first-line antimicrobials for UTIs in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The study will take place over 15 months with a six-month intervention period. Data will be collected through a remote electronic anonymized data-extraction system, a text-messaging system and GP and patient interviews and surveys. The intervention will be strengthened by the implementation of a social marketing framework and an economic evaluation. TRIAL REGISTRATION: This intervention is registered at ClinicalTrials.gov, ID NCT01913860.