S7 E10: "Fit Note for the Last GP" song; Best UTI Abx; Kidney Failure Risk Tool & Death; Phone Empathy & Outcomes

Welcome to the Hot Topics podcast from NB Medical with Dr Neal Tucker. More new research to discuss for the world of general practice.

First, which antibiotic is actually best for managing uncomplicated UTI - is UK guidance offering the best choice to women?

Second, are you using the Kidney Failure Risk Equation in your patients with CKD? New research on how your risk of death may be much more important than your risk of end-stage renal disease.

Finally, does empathy work in telephone consultations, and can it improve important hard outcomes such as symptom control?

References

Lancet Abx for UTI

BJGP Kidney Failure Risk Equation, Death and ESRD

Kidneyfailurerisk.co.uk

BJGP Empathy and the telephone

CARE measure

www.nbmedical.com/podcast

Transcript

Neal Tucker 0:16

*Song*

Neal Tucker 3:46

I've realized having recorded that song and listening to it back, not only are the vocals a little bit sketchy, particularly at the start, but also what started off as really a musical expression of a thought experiment based in general practice actually ends up feeling like a bit of a downer. So it is time to raise the mood and let's enjoy ourselves a little bit because it's Friday, the 15th of May, and this is the Hot Topics Podcast.

Neal Tucker 4:24

Welcome to the Hot Topics Podcast from NB Medical, Neal Tucker here, as usual, to take you through the next 20 minutes or so of what's new in the world of medical research relevant to us in general practice. And as usual, we've got three papers to have a look at.

Neal Tucker 4:39

First, one in the Lancet, that's on what's the best first-line antibiotic for uncomplicated lower urinary tract infection? Such a common problem. Are UK guidelines recommending the best treatment for our patients? Second, we've got a paper in this month's BJGP on the use of the kidney failure risk equation score. Is this something on your radar? And finally, final paper also in the BJGP on the role of GP empathy in telephone consultations.

Neal Tucker 5:13

First, what's going on with NB Medical? Well, we've got lots of live webinars coming up, of course. In fact, right now as I'm recording this, my colleagues are running the hot topics in mental health in primary care course. So if you're interested in knowing what's new or upskilling in mental health, that's the one for you to go for. You'll be able to see that on demand on the website anytime from the any point from the time that you're probably listening to this podcast. In two weeks' time, we've got the Managing Obesity and Overweight course with the fabulous Stephanie de Giorgio. I'll be the wing person for that one. So do join us on Thursday, the 28th of May. Shortly after, we've got our advanced clinical practice course as well. So if you are an advanced practitioner in general practice looking to stay up to date or upskill yourself, then that's the course for you. That's on Friday, the 29th. And then going into June, we've got our latest hot topics course as an online live webinar. Also, diabetes and dermatology updates as well, all coming before the summer. So do check out the website and remember there's loads more courses as well. If you sign up to NB Plus for just £340 a year, you can come on all of those with lots of extras as well.

Neal Tucker 6:26

Now, recently I have been skipping the non-clinical medical news because let's be honest, it's generally just a bit depressing, but it seems remiss of me not to mention something. It's been a very tumultuous week for the current government. Wes Streeting has just resigned as health secretary. Meanwhile, at least in England, reforms continue at a pace with the King, no less, introducing the NHS Modernisation Bill this week. In his words, or rather the words of some bureaucrat that wrote the speech for him, the bill puts power and resources in the hands of frontline NHS organisations by abolishing NHS England and stripping back national bureaucracy. Well, as we've learned from his very successful trip to the States, where he very successfully navigated some difficult diplomatic choppy waters with Trump, he is rather deft at turning a joke. One suspects he might have been chuckling internally a little bit as he was reading that one out.

Neal Tucker 7:23

Meanwhile, the BMA in England have recommended GP practices engage in collective action. It's just no one is sure what that actually means this time, and no one in power seems to think it will have any effect anyway. All of which has led to stronger cries once again that GP should be going the way of the dentists. Well, it might not help health inequalities in the UK, but at least it would boost the German economy through sales of BMW and Audi SUVs. Who knows where it's all going to end up? Not me. Answers on a postcard or in an email hottopics@nbmedical.com. The good news is that we do have some actual solid answers to this month's research, so let's get on with the medicine.

Neal Tucker 8:04

Okay, we're going to start off with this paper in the Lancet with the title Clinical and Bacteriological Effectiveness of Three Different Short Course Antibiotic Regimes and Single Dose Fosfomycin for Uncomplicated Lower Urinary Tract Infections in Women. Bracket Scout S C O U T. Close Brackets. That's presumably the name of the trial, the Scout trial. Now I'm struggling to make that acronym. Short course SC antibiotic No. Now that may be one that's lost in translation, but the rest of the paper was in English and was quite interesting. So this was a pragmatic, multi-center, open label randomised control trial conducted in Spanish primary care between 2022 and 2024. Cards on the table, Spanish UTI guidelines, are a little bit different from UK UTI guidelines. They recommend either nitrofurantoin, 100 milligrams three times a day for five to seven days. You'd have thought that's gonna knock that UTI for six, or a single dose of Fosfomycin. Beta-lactams and kefs are an alternative, so they're second line, and then trimethoprim, not really on the radar at all. There's a note in the guidelines saying co-trimoxazole isn't recommended due to high resistance rates, which by which they mean greater than 20%.

Neal Tucker 9:28

So this research is really looking at whether these Spanish guidelines are optimal for patients, but of course, it also gives us lots of information about whether our UK guidelines are also optimal. And I've been thinking about UTI management quite a lot in the past week because I was presenting the urgent care course a few days ago, and on that we talked about UTI guidelines. If you want to see that course, go on the nbmedical.com website, it's all available on demand. And I was reviewing the underlying data for the NICE guidelines and nice quote antibiotic resistance rates. So trimethaprim is around 30% in the UK, which is staggeringly high, whereas nitrofurantoin is around 2%, which is why we typically use nitrofurantoin. And in case you want all the figures, the quoted rates for resistance to Pivmecillinam was around 7.5%, for keflexin around 10%. What about Fosfomycin? Well, I don't know because they don't give any figures. Perhaps they just weren't available at the time, but it would be interesting to know. It's a third line option in the nice guidance, but it's a single dose. That's very convenient. It seems to be quite well tolerated in the patients I've used it in, and it doesn't have the, at least as far as we know, or as far as I know, tell me if you know something different, doesn't seem to have the associations with potentially really nasty side effects that we've seen with nitrofurantoin, you know, respect to things like respiratory and hepatic reactions.

Neal Tucker 11:01

The other thing I've noticed sometimes with nitrofurantoin, and I don't know if this is just me or if you've seen this as well, is that sometimes even when you have a positive urine culture and you know it's susceptible to the drug, for some people it doesn't seem to work, even when they've got normal renal function. Nitrofurantoin's action is for it to be absorbed by the body, filtered through the kidneys into the urine where it concentrates and then has a direct bacteriocidal effect on the organisms within the bladder. If you don't get sufficient concentration, it's not as effective. And I wonder if perhaps there's a lot more natural variation than we might think here. And I don't know if you know the answer to this. If you do, maybe this is your area, then please do get in touch. As ever, hottopics @nbmedical.com. Send me an email. Other factors also influence its effectiveness, so it needs to be an acidic environment to work. Maybe that's an issue for some people, and its bioavailability is improved if you take it with food, so perhaps that can affect things as well. Perhaps none of this is real and it's just my own cognitive bias.

Neal Tucker 12:10

Well, let's see what the data shows. So, what they did in the study, they recruited women 18 years and older with at least one UTI-specific symptom, all the classics that you would think of, plus a positive dipstick for nitrites or leukocytes. They then randomised them to one of four treatment groups, so either a single 3 gram dose of Fosfomycin or two 3 gram doses of Fosfomycin taken 24 hours apart, or nitrofurantoin 100 milligrams three times a day for five days, or pivmycillinin 400 milligrams three times a day for three days, which is slightly higher than the UK guidelines. The primary outcome was the proportion of patients with clinical resolution at day seven. 768 patients were recruited, split evenly between these four groups, median age was 48 years old. And the results showed that good old nitrofurantoin came out top. It had the highest rate of clinical resolution at 74% of patients, Piv mycillin was close behind at 70%, and Fosfomycin further down the list at 59% with a single dose, but a bit better at 67% if you use that two-dose regime. There was a secondary outcome, which was antimicrobial resistance rates, and interestingly for nitrofurantone and Fosfomycin, they quoted this as around 10%, and then a little bit higher for Pivmecillinam at 16%. All of which suggests that there's something more than just the organism's sensitivity to the individual antibiotic that determines the likelihood of success of the treatment. This idea is further supported by the authors looking at the patients who had a positive culture, who were then treated with the appropriate first-line antibiotic, and Pivmecillinam actually came out as the one that required the least additional causes of antibiotics afterwards. If you don't look at the urine cultures, which is what you and I would do because in day-to-day practice we don't have them before we're actually going to start treating the patient, we're just going to crack on with it, then nitrofurontoin and Pivmecillinam came out equal in terms of treatment success or rather treatment failure with 16% of patients requiring further prescriptions.

Neal Tucker 14:36

But that was much better than the 30% for those who were using a single dose of Fosfomycin. Just a quick mention about adverse effects. They were reported in between 1 in 4 and 1 in 5 women, depending on the regime, pretty close between all of the different antibiotics used, and they were mild and self-limiting, mostly gastrointestinal, so no surprises there. The authors concluded that nitrofurantoin was the most effective treatment and single-dose Fosfomycin the least effective treatments for UTIs in women. What lesson should we take away from this data regarding UK guidelines? Well, the data certainly supports nitrofurantoin as a first-line treatment, despite my own personal observations, which probably have a bit of confirmation bias in there, because let's be honest, the ones that get better, they don't phone us back. It also supports the use of Pivmecillinam as a second-line treatment, a drug which I suspect most of us are still not hugely familiar with, but seems to be very effective and well tolerated. And it shows that there is a role for Fosfomycin, but NICE guidelines suggest just a single dose, whilst this data suggests you can improve symptom resolution if you give a second dose after 24 hours. Now, perhaps the downside of the drug is that a single dose, a single sachet costs seven pounds or so, so it is pretty expensive, and maybe that's factored into NICE's recommendations because they do look at cost effectiveness. But if you've got a patient who's on their third antibiotic already, and maybe we just want them to get the best possible outcome, it might be adding a second dose is a thing that makes the difference.

Neal Tucker 16:20

Okay, on to our next paper in the BJGP, and this is looking at the kidney failure risk equation. It's got the title Use of the Kidney Failure Risk Equation, a regional retrospective primary care cohort study in England. Now, what it isn't looking at is how many of us actually use the kidney failure risk equation. We're talking about chronic renal disease on our latest hot topics course, and at a couple of recent face-to-face courses, I asked how many people in the room have used this tool, and I reckon maybe five percent of people's hands went up. So if you're sat there thinking, well, I've never used a kidney failure risk equation score before, Neal, then don't worry, you are not alone. This is something that doesn't seem to be, despite being introduced by NICE five years ago, recommended for everyone who's got a diagnosis of chronic kidney disease. It's not been widely adopted in general practice just yet. And if it's completely new to you, you've not come across it before, it is a pretty neat tool. It estimates your two and five year risk of developing end-stage renal failure. So chronic renal disease that's genuinely going to affect you. And you only need four metrics age, sex, eGFR, and albumin to creatinin ratio.

Neal Tucker 17:36

As far as I'm aware, it's not integrated into our clinical systems just yet. So you have to go to the kidney failure risk equation website, so kidney failurerisk.co.uk. I'll put the link in the podcast description, is open access and it's free to use. Now there are some limitations of the kidney failure risk tool. Not being integrated is a big barrier, I think. It's the kind of thing crying out to be automated, and I'm not going to use the word AI because what does that really mean? Um, but this is the kind of thing that a computer would be better at doing than a human. Much faster, and actually, it would do it rather than just simply not doing it. There's also an issue that despite the fact it's recommended in national guidelines, we actually don't know how many people are likely to be considered high risk. NICE recommends referral to nephrology if someone's five-year risk is greater than 5%, but we don't know in day-to-day real-world terms how much of our practice population and therefore how much workload for both us and nephrology that actually means. And then also it doesn't account for ethnicity, and I think that's important because you will have definitely noticed if you've got South Asian populations, black populations, they are much more likely to have end-stage renal failure than if you've got a large white population, and a quick internet search shows that the risk is something like three to five times higher than Caucasian counterparts.

Neal Tucker 19:07

Some of that risk may be captured just by looking at the EGFR and the albumin creatinine ratio, but because of underrepresentation of ethnic minority groups in the original research, there's still some uncertainty around here, which NICE actually sets out in a research question in their guidelines. The other big issue, as one of the delegates pointed out on a face-to-face course I did a week or so ago, was that whilst the kidney failure risk equation looks at your chance of end stage renal failure, it doesn't look at your risk of death from other causes. And of course, you are much more likely to die of something like cardiovascular disease if you've got CKD than you are actually of the renal disease itself. Sounds pretty important then, and that is one of the key aims of this BJGP paper to measure the association between kidney failure risk equation scores and the probability of death compared to renal replacement therapy, so end stage renal disease. They also wanted to quantify the number of patients who would actually have a risk of end-stage renal disease greater than 5%, because that's going to tell us a little bit more about the workload implications for us and the burden on neprology services.

Neal Tucker 20:22

This then was a retrospective observational cohort study conducted between 2018 and 2023 using the electronic health records to assess 2.85 million patients from the greater Manchester area across their general practices. They looked at adult patients with CKD stage 3 to 5, defined using EGFR and albumin creatinine ratios as per NICE guidelines. The primary outcome was the risk of death or the need for renal replacement therapy at various different kidney failure risk equation scores, and they had three groups here. So less than 5% five-year risk, 5 to 20% risk, or greater than 20% risk. 100,000 patients were included with CKD stage 3 to 5. 28% of those had an albumin creatinine ratio measured during 2018 and 2019 at the start of the study, which allowed them then to have five to six years of follow-up. And that was the group that was then included in their multi-nominal regression analysis to examine these differences between those kidney failure risk equation risk categories. Sensible to just have a think about the study population because this isn't differentiated in the main results. That's all about that kidney failure risk equation risk threshold. So 65% of that group were male. The average age was 74, so quite old. A third had obesity, a third had overweight. About 80% were white, 8% were Asian ethnicity, 3% black ethnicity, and just under 10% were described as other ethnic groups. And a much higher proportion of those were from high deprivation areas, as perhaps we might expect. And then in terms of comorbidities, hypertension was present in about three quarters, diabetes in about half, and a quarter already had coronary heart disease, and a quarter had depression.

Neal Tucker 22:30

Okay, on to the results then. First up, the percentage of people that had a kidney failure risk equation score of greater than 5%. These are the people that we are recommended by NICE to refer to nephrology for further assessment. And that was about 10% over the course of the study. That's about 10% of people with CKD 3 to 5. To put that into context, that comes out at about 1,800 per year out of nearly 3 million across 433 different practices. So maybe what's that, about four per practice, which doesn't sound like too much. Now that may be an underestimate, and I spent a long time, believe me, trying to get my head around the maths here. And for the record, I'm still not completely sure that I've got it all right. But I think we're probably only looking at about 40% of the patients here with CKD stage three to five because the others didn't have an albumin creatinine ratio, so weren't included in the sort of final calculations that give us the key figures. So it may be that there's more patients that may merit being referred, but even then, it probably wouldn't be huge. You know, we're talking maybe eight or nine or ten or something like that on a whole practice basis on an individual GP level. That's going to be really, really rather small. What it does show us is the importance of measuring that ACR because it's such an important marker of renal disease, and without it, really, we're just guessing it's a really, really big factor in establishing whether you're likely to get long-term significant renal disease. About 40% of the study population, so they've been coded as having CKD stage three to five, had no recorded albumin creatinine ratio for the whole five years of the study. That sounds like a really big gap. And if we wanted to improve CKD outcomes in our patients, just trying to make sure that we actually manage to get the appropriate tests, that's a really good place to start.

Neal Tucker 24:40

This data also shows us that the number of people that need an intervention, as in like the number of people needed to be referred by us from general practice, is much, much smaller than the number of people that need to be assessed. And so that's really quite a big workload for general practice. If we have to sit down and put all of our patients' data into an equation on a website, it really needs to be automated. And until that happens, adoption of this tool I think is going to be really slow, and identification of patients who are genuinely at high risk of future renal disease, renal failure is going to be impaired.

Neal Tucker 25:28

Now, second up, we've got the actual figures around how many people are likely to need renal replacement therapy, or indeed may die. So over the five to six year follow-up period, if you've got patients with CKD stage three to five, average age, remember in this cohort of 74, there was a 1% chance of needing renal replacement therapy. Sounds good, right? But there was a 20% chance of dying from something else. Sounds bad. Remember, most of these patients also had other metabolic diseases. How does the actual kidney failure risk equation score influence any of this? Well, if you're in the low risk group, so less than 5%, the group that we're not going to be referring for, and that is 90% of people remember with CKD stage 3 to 5, the overall chance of needing renal replacement therapy is 0.1%. Presumably, actually using the risk equation here would nuance that even more. There's going to be a big difference between someone who's got CKD stage 3 and 5, which is not accounted in these sort of gross figures in the paper, but would be accounted for by using the risk tool.

Neal Tucker 26:44

But even in that low risk group, your risk of death in the next five years is still 20%. That sounds pretty high. This goes up as your kidney failure risk equation score goes up as well. So at 5 to 20% risk, then the chance of death increases to 35% and 40% chance of death if your kidney risk equation score is greater than 20%. The learning point from all of this, it's probably not the renal disease per se that is going to kill you. And everything the patient and we can do to improve on those other risks: blood pressure and glucose control, statin, smoking cessation, exercise, all of those kind of things is going to be really, really important. Finally, they touch on ethnicity, and Asian and black patients had approximately double the relative risk of needing renal replacement therapy compared with white ethnicity, highlighting that these are a high risk group that definitely merit us doing this kidney failure risk equation. The authors conclude the probability of death was generally greater than renal replacement therapy across kidney failure risk equation estimates. Useful for clinicians to consider when making shared decision making and management decisions. Sounds about right.

Neal Tucker 28:03

Okay, on to our final paper: The Role of GP Empathy on Patient Reported Outcomes in Telephone Consultations, a cross-sectional study with validation of the consultation and relational empathy measure, the care measure. You'll remember back in our Christmas special six months ago when I spoke to Andy Ward, a GP in Leicester, who chatted about the benefits of empathy in general practice and the data that supports it. You might think it all sounds a bit wishy-washy, but this paper looks at objective measures in association to empathy when doing telephone consultations. And I've probably talked about this before. Lots of what we do these days is on the phone. Actually, this isn't anything new, but perhaps we've got better at offering it as part of our routine day-to-day consultations rather than it being part of that unmeasured work after hours when you finally get around to those abnormal blood results or tricky prescriptions.

Neal Tucker 28:57

Anyway, I'm fine doing consultations on the phone, but I'd much rather do them in person. I don't find the phone faster, probably the opposite. And I feel like you're potentially losing that visual part of communication, those visual cues, which can make consulting much more difficult and ultimately might reduce patient perceived empathy, which ultimately can affect patient outcomes. So the question the researchers are trying to answer here by using a validated measure of empathy is how do telephone consultations compare against face-to-face consultations? So this was done via postal surveys from 12 selected practices in Scotland. 6,000 surveys sent out, 1,000 return. That's about par for the course. They collected data on GP empathy using the care measure. So this is a 10-point questionnaire asking how good the practitioner was at various aspects, including making you feel at ease, letting you tell your story, understanding your concerns, showing care and compassion and so forth. If you're interested, I'll link the care measure, the website where it's on to the in the podcast description, so you can check it out. And they then compared this against patient-reported outcomes, including patient enablement, satisfaction, and symptom improvement for both telephone and face-to-face consultations.

Neal Tucker 30:19

The data showed that the care measure was valid and reliable across both consultation modalities. Levels of perceived empathy were similar on the phone to face-to-face consultations, and they found that in phone consultations, I think perhaps there's data showed before, compared with low care scores, high scores, so consultations with lots of perceived empathy, actually translated into better enablement, better satisfaction, and even better reported symptom control. That last one had an odds ratio of about six. I don't really know how to interpret that into the real world, but it sounds pretty good. So good news all around, you can be empathetic on the phone, that's good to know. This can improve outpatient outcomes, that's also good to know. The authors do suggest areas for future research, so perhaps we could explore how empathy can be effectively fostered beyond the person and phone-based consultations into the digital realm, ensuring empathy on a text reply to an online triage form or even a practice-based AI chat box. Now that's going to be an interesting piece of research.

Neal Tucker 31:34

That is all for today, folks. Thank you for joining us on the podcast as ever. I will leave you to bathe in a sea of empathy because I really understand you've had a busy week and you all deserve a fantastic weekend. Don't forget you can always get in touch, hottopics @nbmedical.com or via social media. Look after yourselves. We'll be back in four weeks. Take care. Bye bye.