Objective: To explore evidence on the links between patient experience and clinical safety and effectiveness outcomes. Design: Systematic review. Setting: A wide range of settings within primary and secondary care including hospitals and primary care centres. Participants: A wide range of demographic groups and age groups. Primary and secondary outcome measures: A broad range of patient safety and clinical effectiveness outcomes including mortality, physical symptoms, length of stay and adherence to treatment. Results: This study, summarising evidence from 55 studies, indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It demonstrates positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care (such as health-promoting behaviour, use of screening services and immunisation); and resource use (such as hospitalisation, length of stay and primary-care visits). There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations. Conclusions: The data presented display that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. It supports the argument that the three dimensions of quality should be looked at as a group and not in isolation. Clinicians should resist sidelining patient experience as too subjective or mood-oriented, divorced from the ‘real’ clinical work of measuring safety and effectiveness.

https://bmjopen.bmj.com/content/bmjopen/3/1/e001570.full.pdf

A systematic review of evidence on the links between patient experience and clinical safety and effectiveness

Patient-centered communication in cancer care: Promoting healing and reducing suffering

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

/pdf/the-diagnosis-and-management-of-acute-otitis-media-19nbk33eyw.pdf

The Diagnosis and Management of Acute Otitis Media

Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are due to breakdown in the doctor-patient relationship. However, many doctors tend to overestimate their ability in communication. Over the years, much has been published in the literature on this important topic. We review the literature on doctor-patient communication.

Doctor-patient communication: a review.

BACKGROUND: There is evidence that chronic inflammation may promote atherosclerotic disease. We tested the hypothesis that acute infection and vaccination increase the short-term risk of vascular events. METHODS: We undertook within-person comparisons, using the case-series method, to study the risks of myocardial infarction and stroke after common vaccinations and naturally occurring infections. The study was based on the United Kingdom General Practice Research Database, which contains computerized medical records of more than 5 million patients. RESULTS: A total of 20,486 persons with a first myocardial infarction and 19,063 persons with a first stroke who received influenza vaccine were included in the analysis. There was no increase in the risk of myocardial infarction or stroke in the period after influenza, tetanus, or pneumococcal vaccination. However, the risks of both events were substantially higher after a diagnosis of systemic respiratory tract infection and were highest during the first three days (incidence ratio for myocardial infarction, 4.95; 95 percent confidence interval, 4.43 to 5.53; incidence ratio for stroke, 3.19; 95 percent confidence interval, 2.81 to 3.62). The risks then gradually fell during the following weeks. The risks were raised significantly but to a lesser degree after a diagnosis of urinary tract infection. The findings for recurrent myocardial infarctions and stroke were similar to those for first events. CONCLUSIONS: Our findings provide support for the concept that acute infections are associated with a transient increase in the risk of vascular events. By contrast, influenza, tetanus, and pneumococcal vaccinations do not produce a detectable increase in the risk of vascular events.

/pdf/risk-of-myocardial-infarction-and-stroke-after-acute-35uuflusub.pdf

Risk of Myocardial Infarction and Stroke after Acute Infection or Vaccination

# Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial {#article-title-2}

Objectives : To identify which children with acute otitis media are at risk of poor outcome and to assess benefit from antibiotics in these children.

Design : Secondary analysis of randomised controlled trial cohort.

Setting : Primary care.

Participants : 315 children aged 6 months to 10 years.

Intervention : Immediate or delayed (taken after 72 hours if necessary) antibiotics.

Main outcome measure : Predictors of short term outcome: an episode of distress or night disturbance three days after child saw doctor.

Results : Distress by day three was more likely in children with high temperature (adjusted odds ratio 4.5, 95% confidence interval 2.3 to 9.0), vomiting (2.6,1.3 to 5.0), and cough (2.0, 1.1 to 3.8) on day one. Night disturbance by day three was more likely with high temperature 2.4 (1.2 to 4.8), vomiting (2.1,1.1 to 4.0), cough (2.3,1.3 to 4.2), and ear discharge (2.1, 1.2 to 3.9). Among the children with high temperature or vomiting, distress by day three was less likely with immediate antibiotics (32% for immediate v 53% for delayed, χ2=4.0; P=0.045, number needed to treat 5) as was night disturbance (26% v 59%, χ2=9.3; P=0.002; number needed to treat 3). In children without higher temperature or vomiting, immediate antibiotics made little difference to distress by day three (15% v 19%, χ2=0.74; P=0.39) or night disturbance (20% v 27%, χ2=1.6; P=0.20). Addition of cough did not significantly improve prediction of benefit.

Conclusion : In children with otitis media but without fever and vomiting antibiotic treatment has little benefit and a poor outcome is unlikely.

# Commentary: research directions for treatment for acute otitis media {#article-title-17}

https://www.bmj.com/content/bmj/325/7354/22.full.pdf

Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial

Sore throat is one of the commonest reasons for visiting general practitioners yet little is known about what factors are important in its natural course. This is important since people with prolonged illness after the consultation—the 36% with illness lasting more than five days after seeing the doctor (the median)—are much more likely to reattend.1 Providing patients with information about duration of illness can reduce expectation and reattendance.2 We studied factors that affect duration of sore throat and assessed whether satisfaction with the consultation independently predicts duration of illness.3

The methods are reported in full elsewhere.3 General practitioners documented the clinical characteristics of 716 patients presenting with sore throat, who were then randomised to one of three prescribing strategies (antibiotics, no antibiotics, delayed antibiotics). Patients recorded satisfaction with the consultation and how well their concerns had been dealt with on four point Likert scales (very, …

https://www.bmj.com/content/bmj/319/7212/736.full.pdf

Clinical and psychosocial predictors of illness duration from randomised controlled trial of prescribing strategies for sore throat.

Design Randomised (unclear allocation concealment), unblinded, controlled trial with about 1 week of follow up. Setting General practices in south west UK. Patients 315 children aged 6 months to 10 years (59% >3 y) who had acute otalgia and otoscopic evidence of acute inflammation of the ear drum. Exclusion criteria were otoscopic appearances consistent with crying or fever alone (pink ear drum only), appearances more suggestive of OM with effusion and chronic suppurative OM, serious chronic disease, use of antibiotics for ear infections in the previous 2 weeks, previous complications, or if the child was too unwell to be left to wait and see. 285 children (90%) were included in the analysis. Intervention All patients were prescribed amoxicillin syrup, 125 mg in 5 ml, 3 times daily, 100 ml in total, except for patients allergic to penicillin who were prescribed erythromycin, 125 mg in 5 ml, 4 times daily for 1 week. 164 children were allocated to delayed prescription of antibiotics. Their parents were asked to wait for 72 hours before considering using their prescription. If, after that time, their child still had substantial otalgia or fever or was not getting better, parents were instructed to then pick up the prescription from the office. Parents could, however, pick up the prescription before 72 hours. 151 children were allocated to immediate prescription of antibiotics. Main outcome measures Main outcome was duration of symptoms (earache, ear discharge, night disturbance, and crying). Other outcomes included number of missed school days, daily episodes of distress, daily consumption of paracetamol (acetaminophen), daily pain scores, number of children who actually took antibiotics, and adverse effects. Data were obtained from daily diaries kept by parents. Main results Analysis was by intention to treat. Children allocated to delayed antibiotics had more days of earache (mean difference [MD] 1.10 d, 95% CI 0.54 to 1.48), ear discharge (MD 0.66 d, CI 0.19 to 1.13), night disturbance (MD 0.72 d, 0.30 to 1.13), and crying (MD 0.69 d, CI 0.31 to 1.08), and higher daily paracetamol consumption (MD 0.52 spoonfuls, CI 0.26 to 0.79) than children allocated to immediate antibiotics. The groups did not differ for number of school days missed, daily episodes of distress, and daily pain scores. Fewer children allocated to delayed prescription actually took the antibiotics compared with children allocated to immediate prescription (table). Fewer children allocated to delayed prescription had diarrhoea (9% v 19%, p=0.02).

Clare Gould

Papers

Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial

Clinical and psychosocial predictors of illness duration from randomised controlled trial of prescribing strategies for sore throat.

Delayed prescribing of antibiotics increased duration of acute otitis media symptoms in children but reduced diarrhoea