Recording of presentation introducing narrative analysis, outlining what it is, why it can be a useful approach, how to do it and where to find out more. Presentation given at methods@manchester seminar at University of Manchester on 4 March 2010.

What is Narrative Analysis

Infectious Diseases Society of America.

Urinary tract infections (UTIs) are among the most common bacterial infections acquired in the community and in hospitals. In individuals without anatomical or functional abnormalities, UTIs are generally self limiting, but have a propensity to recur. Uropathogens have specialized characteristics, such as the production of adhesins, siderophores and toxins that enable them to colonize and invade the urinary tract, and are transmitted between individuals both through person-to-person contact and possibly via food or water. Although generally self limiting, treatment of UTIs with antibiotics leads to a more rapid resolution of symptoms and is more likely to clear bacteriuria, but also selects for resistant uropathogens and commensal bacteria and adversely affects the gut and vaginal microbiota. As uropathogens are increasingly becoming resistant to currently available antibiotics, it may be time to explore alternative strategies for managing UTI.

The epidemiology of urinary tract infection

Long-term diseases are today the leading cause of mortality worldwide and are estimated to be the leading cause of disability by 2020. Person-centered care (PCC) has been shown to advance concordance between care provider and patient on treatment plans, improve health outcomes and increase patient satisfaction. Yet, despite these and other documented benefits, there are a variety of significant challenges to putting PCC into clinical practice. Although care providers today broadly acknowledge PCC to be an important part of care, in our experience we must establish routines that initiate, integrate, and safeguard PCC in daily clinical practice to ensure that PCC is systematically and consistently practiced, i.e. not just when we feel we have time for it. In this paper, we propose a few simple routines to facilitate and safeguard the transition to PCC. We believe that if conscientiously and systematically applied, they will help to make PCC the focus and mainstay of care in long-term illness.

Person-Centered Care — Ready for Prime Time:

Clinical presentation helps differentiate between upper and lower urinary tract infections (UTIs). UTIs are classified as either complicated or uncomplicated. A complicated UTI is associated with an underlying condition that increases the risk of failing therapy. Primary laboratory tests for UTIs consist of urinalysis and urine culture. The most common pathogen for uncomplicated cystitis and pyelonephritis is Escherichia coli. Nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are first-line therapies for acute uncomplicated cystitis. Decisions regarding antibiotic agents should be individualized based on patients' allergies, tolerability, community resistance rates, cost, and availability.

https://www.primarycare.theclinics.com/article/S0095-4543(13)00067-5/pdf

Urinary tract infections.

SUMMARY Background: Urinary tract infections (UTI) are among the leading reasons for treatment in adult primary care medicine, accounting for a considerable percentage of antibiotic prescriptions Because this problem is so common and so significant in routine clinical practice, a high level of diagnostic accuracy is essential Antibiotics should not be prescribed excessively, particularly in view of the increasing prevalence of antibiotic resistance Method: Systematic review of relevant articles that were retrieved by a search of the Medline, Embase, and Cochrane Library databases The recommendations of selected international guidelines were also taken into account, as were the German national quality standards for microbiological diagnosis Results: The diagnosis of UTI by clinical criteria alone has an error rate of approximately 33% The use of refined diagnostic algorithms does not completely eliminate uncertainty Conclusion: With the aid of a small number of additional diagnostic criteria, antibiotic treatment for UTI can be provided more specifically and thus more effectively Differentiating UTI from asymptomatic bacteriuria, which usually requires no treatment, can lower the frequency of unnecessary antibiotic prescriptions

/pdf/the-diagnosis-of-urinary-tract-infection-a-systematic-review-n9sph4zsg4.pdf

The Diagnosis of Urinary Tract Infection: A Systematic Review

Study question  Can treatment of the symptoms of uncomplicated urinary tract infection (UTI) with ibuprofen reduce the rate of antibiotic prescriptions without a significant increase in symptoms, recurrences, or complications? Methods  Women aged 18-65 with typical symptoms of UTI and without risk factors or complications were recruited in 42 German general practices and randomly assigned to treatment with a single dose of fosfomycin 3 g (n=246; 243 analysed) or ibuprofen 3×400 mg (n=248; 241 analysed) for three days (and the respective placebo dummies in both groups). In both groups additional antibiotic treatment was subsequently prescribed as necessary for persistent, worsening, or recurrent symptoms. The primary endpoints were the number of all courses of antibiotic treatment on days 0-28 (for UTI or other conditions) and burden of symptoms on days 0-7. The symptom score included dysuria, frequency/urgency, and low abdominal pain. Study answer and limitations  The 248 women in the ibuprofen group received significantly fewer course of antibiotics, had a significantly higher total burden of symptoms, and more had pyelonephritis. Four serious adverse events occurred that lead to hospital referrals; one of these was potentially related to the trial drug. Results have to be interpreted carefully as they might apply to women with mild to moderate symptoms rather than to all those with an uncomplicated UTI. What this paper adds  Two thirds of women with uncomplicated UTI treated symptomatically with ibuprofen recovered without any antibiotics. Initial symptomatic treatment is a possible approach to be discussed with women willing to avoid immediate antibiotics and to accept a somewhat higher burden of symptoms. Funding, competing interests, data sharing  German Federal Ministry of Education and Research (BMBF) No 01KG1105. Patient level data are available from the corresponding author. Patient consent was not obtained but the data are anonymised and risk of identification is low. Trial registration No  ClinicalTrialGov Identifier NCT01488955.

http://www.allgemeinmedizin.med.uni-goettingen.de/de/media/project_kinderwunsch/2015_Gagyor_Hummers_urinary_tract_infection.pdf

Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial

Background Older people consume an increasing amount of medication. Polypharmacy is associated with an elevated risk of adverse health outcomes resulting in hospitalizations and sometimes death. Objectives To describe the prevalence of prescribed and over-the-counter (OTC) medications among older general practice patients living in the community. To determine predictors of polypharmacy (five or more prescribed drugs) from a variety of patient- and doctor-related factors. Methods Sixty-seven randomly selected practices in two areas of Germany and 466 of their older patients (70+ years) were recruited for a geriatric assessment study. A cross-sectional analysis of health problems, GPs' awareness and their interventions was conducted. In this post hoc analysis, we assessed the medication use as reported by older patients and compared it with doctors' perceived medication regimens for their respective patients. The detailed assessment of patients' health and well-being enabled us to explore a variety of predictors of polypharmacy using logistic regression analysis with forward selection. Results Study participants consumed an average of 3.7 prescribed medicines and an additional 1.4 OTC drugs. In all, 26.7% of patients used five and more chronically prescribed drugs. A set of five determinants predicted polypharmacy best: breathlessness, hypertension, dependency on instrumental activities of daily living, low subjective health and medication disagreement between doctors and patients. Conclusion This older general practice population in Germany is among the top pharmaceutical user group of European study samples. Apart from disease-specific determinants, GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.

/pdf/prevalence-and-predictors-of-polypharmacy-among-older-57udpt09xd.pdf

Prevalence and predictors of polypharmacy among older primary care patients in Germany

Objective To examine the attitude of patients towards generic drugs and prescriptions containing generic drugs as an alternative to brand-name products, with a special focus on information on patients attitude to generic drugs provided by their general practitioners (GPs). Methods A total of 804 patients in 31 general practices were surveyed using a self-questionnaire. The influence of age, sex, education, disease, knowledge of generic drugs, experience with generic substitution and information provided by the GP on patient attitudes towards generic drugs and substitutions were examined. Results Nearly two thirds of the patients (509/804) stated that they knew of the difference between brand-name drugs and generics; of these, one third were not satisfied with the information given by their GPs and 37% of patients expressed general skepticism towards generic drugs because of their lower price. This attitude was more frequent among those who felt that generic prescribing was "invented" to solve the financial crisis in the German health insurance system at their expense (odds ratio (OR): 6.2; 95% confidence interval: 4.0 - 9.8) and those who had not been confronted personally with a generic substitution (OR: 1.8; 1.3 3.0). Patients who had been skeptical when first confronted with a generic substitution were more frequently among those who considered inexpensive drugs to be inferior (OR: 4.5; 2.0 10.4) and they were frequently not satisfied with the information on substitution provided by their GP (OR: 2.7; 1.2 - 5.9). Conclusion GPs are in an ideal position to inform their patients adequately about the equivalence of brand-name and generic drugs. However, the patient view that inexpensive drugs must be inferior may be difficult to rectify in the short term.

http://www.allgemeinmedizin.med.uni-goettingen.de/en/media/2005_Himmel_GenericDrugs.pdf

What do primary care patients think about generic drugs

Background Non-participation of general practitioners (GPs) is a serious source of bias for practice-based studies. Objective. To elucidate doctors' motives for non-participation in, and subjective barriers to, general practice research. Methods German GPs that had opted out of a quality assessment project involving electronic patient records (EPRs) were mailed a questionnaire regarding their attitudes towards general practice research and their specific objections to the current project. A sub-sample of doctors was interviewed. Their statements were coded and classified with regard to the reasons given for non-participation and possible motivating factors. Results The survey response rate was 37% (96/263); 21 GPs completed an additional qualitative interview. Nearly all respondents (88/96) considered general practice research to be important, but 58% had not previously participated in research projects and 56% would not do so in the future. Nearly half (47/96) were opposed to having data extracted from their EPRs. The qualitative analysis revealed deep concerns related to the collection of EPRs (e.g. potential misuse of data, being subject to control or resulting computer problems). Some GPs expressed concerns about recruiting their own patients for the study. Some doctors complained of not being sufficiently recognized as a partner or not having a voice in the research process. Conclusion Doctors' negative attitudes, concerns and ambivalent feelings should be addressed in recruitment strategies, especially when the analysis of EPRs or direct patient contact is required. Some doctors do not participate in research out of principle and will be very difficult to convince.

http://www.allgemeinmedizin.med.uni-goettingen.de/en/media/2008_HummersPradier_GPsParticipation.pdf

Eva Hummers-Pradier

Papers

The Diagnosis of Urinary Tract Infection: A Systematic Review

Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial

Prevalence and predictors of polypharmacy among older primary care patients in Germany

What do primary care patients think about generic drugs

Simply no time? Barriers to GPs' participation in primary health care research