Education to improve timeliness of shingles diagnosis in primary care: a cluster randomised study within a trial with nested qualitative study

Abstract

Background: Herpes zoster (shingles) is normally diagnosed clinically. Timely diagnosis is important so that antiviral treatment can be started soon after rash onset.

Aim: To assess whether a practice-level educational intervention, aimed at non-clinical patient-facing staff, improves the timely assessment of patients with shingles.

Design and setting: This was a cluster randomised study within a trial (SWAT) with nested qualitative study in general practices in England.

Method: Practices were cluster randomised 1:1, stratified by centre and minimised by practice list size and Index of Multiple Deprivation score. Intervention practices were sent educational materials, highlighting the common presenting features of shingles and what action to take if suspected. The primary and secondary outcomes were the mean proportion of patients per practice seen within 72 and 144 h of rash onset, respectively. Comparison between groups was conducted using linear regression, adjusting for randomisation variables. Semi-structured interviews with practice staff in intervention practices explored views and opinions about the intervention.

Results: In total, 67 practices were enrolled; 34 randomised to the intervention and 33 to the control. The mean difference in proportion of patients seen within 72 and 144 h was -0.132 (95% confidence interval [CI] = -0.308 to 0.043) and -0.039 (95% CI = -0.158 to 0.080), respectively. In intervention practices, 90.9% reported distributing the educational materials; however, engagement with these was suboptimal. Twelve participants were interviewed, and the poster component of the intervention was said to be easiest to implement.

Conclusion: Our educational intervention did not improve the timely assessment of patients with shingles. This may be the result of poor intervention engagement.

Keywords: diagnosis; general practice; herpes zoster; interprofessional education.

Figure 1.

Timeline of all contacts (all via email) with intervention practices (black text) and methods used to evaluate use of the intervention materials, that is, process evaluation measures (blue text). Both evaluation surveys asked practices to confirm the number of posters and desktop backgrounds on display. Video usage data were obtained using YouTube analytics software.

Figure 2.

CONSORT flow diagram for GP practices enrolled in the SWAT. ^aOne GP practice was unable to participate in the SWAT because of absence of the GP Principal Investigator at the time of randomisation. ^b Thirty-four intervention practices were made up of 20 individual practice sites, six groups of practices that were randomised as a whole group, and eight practice sites that were part of a larger practice group but randomised individually for the purposes of the SWAT. ^cThe 33 control practices were made up of 20 individual practice sites, four groups of practices that were randomised as a whole group, and nine individual practice sites that were part of a larger practice group but randomised individually for the purposes of the SWAT. SWAT = study within a trial.