Research update: Social factors in remote consulting and antibiotic prescribing

Recent research asked if remote consulting increases health inequalities for homeless people, and whether a family’s socioeconomic situation influences the likelihood of antibiotic prescribing to children 

Remote primary care during the Covid-19 pandemic for people experiencing homelessness: a qualitative study

Homelessness is an ongoing and rising problem in England and other countries.¹ Recent evidence shows widening health inequalities for homeless people, who face challenges with acute and ongoing complex mental, social and physical care needs.² The NHS Long Term Plan (2019) aims to close the inequality gap and recommends prioritisation of vulnerable groups in primary care,³ but the pandemic obliged the sector to adapt. Remote consultations were introduced for most patients, including those experiencing homelessness. This may have exacerbated inequality of access to healthcare.

Howells and colleagues⁴ set out to explore the experience and impact of Covid-related changes to healthcare access for people experiencing homelessness. They undertook individual semi-structured interviews with 21 homeless people and 22 clinicians and support workers, from September 2020 until the end of January 2021. The settings were two commissioned primary care services and a community nurse inclusion health service. 

The results showed homeless people faced difficulties due to not always having access to a phone or the means to pay for a phone call. Support workers and clinicians in the community had to further increase their workload by providing or facilitating a face-to-face primary care appointment. 

The participants also felt there were challenges with maintaining a therapeutic relationship remotely. Some felt phone appointments were easier for repeat prescription, but they missed the ability to ‘drop in’ at their GP practice or day centre for a same-day slot. 

The main limitation of the study was the lack of quantitative data, which may have provided evidence on the mode of consultation and number of appointments. 

Overall, this study demonstrates that while there are benefits to remote consultation, it should not be the default approach for all. A patient’s vulnerability and individual needs should be taken into consideration, as a relationship-based approach is important for trust, continuity of care and reducing inequalities.

References

1. Fitzpatrick S et al. The homelessness monitor: England 2019. Link
2. Marmot M et al. Health equity in England: the Marmot review 10 years on. Link
3. NHS England. The NHS long term plan. 2019. Link
4. Howells K et al. Remote primary care during the COVID-19 pandemic for people experiencing homelessness. BJGP.2021.0596. Link

Factors predicting amoxicillin prescribing in primary care among children: a cohort study

One in three children under five is prescribed at least one antibiotic a year,¹ and three-quarters of antibiotics prescribed to children in primary care are for respiratory tract infections (RTIs).^2,3 Antibiotic prescribing contributes to antimicrobial resistance, which is a public health emergency.⁴ A study by Miller and colleagues⁵ aimed to identify factors associated with amoxicillin prescribing and primary care consultations for RTIs in young children. They undertook a cohort study in Bradford, with data collected from 2007-2013 from hospitals and primary care, and air pollution data. They calculated amoxicillin prescribing rates/1,000 child-years to establish risk factors for amoxicillin prescribing and consultation for RTI during the first two years of life. 

The results showed that, among 2,493 children, the amoxicillin prescribing rate was 710/1,000 child-years during the first year and 780/1,000 during the second year. The odds of receiving at least one prescription during year one were higher for infants who were male, those who were socioeconomically deprived  and those with a Pakistani ethnic background. During the second year they were higher for infants with a Pakistani ethnic background and for preterm or early-term infants. Additional risk factors for antibiotic prescribing included caesarean delivery, congenital irregularities, crowded households and attendance at a formal childcare setting. The main limitation of the study was that data were gathered from families living in Bradford, and therefore may not be generalisable throughout the country. 

This study highlights that socioeconomic status and ethnic background are strongly associated with amoxicillin prescribing and primary care consultations for RTI in the first two years of life. Active interventions to prevent the spread of RTIs in household and childcare settings may reduce prescribing and support antimicrobial stewardship in primary care.

References

1. Sun X and Gulliford M. Reducing antibiotic prescribing in primary care in England from 2014 to 2017. BMJ Open 2019;9(7):e023989.
2. Schneider-Lindner V et al. Secular trends of antibacterial prescribing in UK paediatric primary care. J Antimicrob Chemother 2010;66(2):424- 33. 
3. O’Brien K et al. Clinical predictors of antibiotic prescribing for acutely ill children in primary care. Link Br J Gen Pract 2015;65(638):e585-92.
4. World Health Organization. Global Action Plan on Antimicrobial Resistance 2015. Link
5. Miller F et al. Factors predicting amoxicillin prescribing in primary care among children. BJGP 2021.0639. Link

Lucille Kelsall-Knight is a lecturer in children’s nursing at University of Birmingham School of Nursing