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Antibiotic prescribing for acute respiratory tract infections 12 months after internet-based training in communication skills and using CRP: a multi-national randomised trial

Antibiotic prescribing for acute respiratory tract infections 12 months after internet-based training in communication skills and using CRP: a multi-national randomised trial
Antibiotic prescribing for acute respiratory tract infections 12 months after internet-based training in communication skills and using CRP: a multi-national randomised trial
Purpose. C-Reactive-Protein (CRP) has diagnostic utility for lower respiratory tract infections (RTI). A large international trial documented that internet-based training in communication skills, CRP point-of-care-test (POCT), or both, reduced antibiotic prescribing at 3 months (risk ratios (RR) 0.68, 0.53, 0.38, respectively). We report the longer-term impact.
Methods. 246 general practices in 6 countries were cluster-randomised to: 1) Usual care (n=61); Internet-based training for 2) CRP POCT (n=62), or 3) enhanced communication skills and interactive booklet (n=61), or 4) combined interventions (n=62). Outcome: antibiotic prescribing for RTIs audited after 12 months (12m).
Results. Of 228 practices providing 3m data, 168 (74%) provided 12m data (n=40,39,41,48, respectively) with no demonstrable attrition bias. Prescribing had reduced in usual care (3m 58% (508/870); 12m 51% (613/1194)), but increased for CRP (3m 35% (368/1062), 12m 43% (456/1052); adjusted RR compared to usual care at 12 months 0.75 (95%CI 0.51-1.00)) and combined groups (3m 32% (476/1170), 12m 45% (641/1410), RR 0.70 compared to usual care at 12 months (0.49-0.93)). Reductions for communication training were maintained (3m 41% (476/1170), 12m 40% (465/1166), RR 12m 0.70 (0.49-0.94)). Despite being freely provided, CRP POCT was hardly used at 12m, and booklets sparingly. Enhanced communication, but not CRP, remained effective for lower RTIs (RRs 0.71 (0.45-0.99), 0.76 (0.47-1.06), respectively), whereas both remained effective for upper RTIs (0.60 (0.37-0.94, 0.58 (0.36-0.92)).
Conclusion. Internet-based training in enhanced communication skills remains effective in the longer-term. The effect of CRP training wanes and becomes ineffective for LRTI, the only current indication for using CRP.
1544-1709
125-132
Little, Paul
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Stuart, Beth
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Francis, Nick
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Douglas, Elaine
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Tonkin-Crine, Sarah
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Anthierens, Sibyl
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Cals, Jochen W.
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Melbye, Hasse
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Santer, Miriam
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Moore, Michael
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Coenen, Samuel
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Butler, Christopher C.
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Hood, Kerenza
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Kelly, Mark J.
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Godycki-Cwirko, Maciek
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Mierzecki, Artur
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Torres, Antoni
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Llor, Carl
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Davies, Melanie J.
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Mullee, Mark
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O'reilly, Gillian
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van der Velden, Alike
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Geraghty, Adam
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Goossens, Herman
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Verheij, Theo J. M.
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Yardley, Lucy
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Little, Paul
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Stuart, Beth
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Francis, Nick
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Douglas, Elaine
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Tonkin-Crine, Sarah
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Anthierens, Sibyl
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Cals, Jochen W.
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Melbye, Hasse
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Santer, Miriam
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Moore, Michael
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Coenen, Samuel
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Butler, Christopher C.
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Hood, Kerenza
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Kelly, Mark J.
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Godycki-Cwirko, Maciek
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Mierzecki, Artur
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Torres, Antoni
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Llor, Carl
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Davies, Melanie J.
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Mullee, Mark
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O'reilly, Gillian
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van der Velden, Alike
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Geraghty, Adam
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Goossens, Herman
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Verheij, Theo J. M.
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Yardley, Lucy
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Little, Paul, Stuart, Beth, Francis, Nick, Douglas, Elaine, Tonkin-Crine, Sarah, Anthierens, Sibyl, Cals, Jochen W., Melbye, Hasse, Santer, Miriam, Moore, Michael, Coenen, Samuel, Butler, Christopher C., Hood, Kerenza, Kelly, Mark J., Godycki-Cwirko, Maciek, Mierzecki, Artur, Torres, Antoni, Llor, Carl, Davies, Melanie J., Mullee, Mark, O'reilly, Gillian, van der Velden, Alike, Geraghty, Adam, Goossens, Herman, Verheij, Theo J. M. and Yardley, Lucy (2019) Antibiotic prescribing for acute respiratory tract infections 12 months after internet-based training in communication skills and using CRP: a multi-national randomised trial. Annals of Family Medicine, 17 (2), 125-132. (doi:10.1370/afm.2356).

Record type: Article

Abstract

Purpose. C-Reactive-Protein (CRP) has diagnostic utility for lower respiratory tract infections (RTI). A large international trial documented that internet-based training in communication skills, CRP point-of-care-test (POCT), or both, reduced antibiotic prescribing at 3 months (risk ratios (RR) 0.68, 0.53, 0.38, respectively). We report the longer-term impact.
Methods. 246 general practices in 6 countries were cluster-randomised to: 1) Usual care (n=61); Internet-based training for 2) CRP POCT (n=62), or 3) enhanced communication skills and interactive booklet (n=61), or 4) combined interventions (n=62). Outcome: antibiotic prescribing for RTIs audited after 12 months (12m).
Results. Of 228 practices providing 3m data, 168 (74%) provided 12m data (n=40,39,41,48, respectively) with no demonstrable attrition bias. Prescribing had reduced in usual care (3m 58% (508/870); 12m 51% (613/1194)), but increased for CRP (3m 35% (368/1062), 12m 43% (456/1052); adjusted RR compared to usual care at 12 months 0.75 (95%CI 0.51-1.00)) and combined groups (3m 32% (476/1170), 12m 45% (641/1410), RR 0.70 compared to usual care at 12 months (0.49-0.93)). Reductions for communication training were maintained (3m 41% (476/1170), 12m 40% (465/1166), RR 12m 0.70 (0.49-0.94)). Despite being freely provided, CRP POCT was hardly used at 12m, and booklets sparingly. Enhanced communication, but not CRP, remained effective for lower RTIs (RRs 0.71 (0.45-0.99), 0.76 (0.47-1.06), respectively), whereas both remained effective for upper RTIs (0.60 (0.37-0.94, 0.58 (0.36-0.92)).
Conclusion. Internet-based training in enhanced communication skills remains effective in the longer-term. The effect of CRP training wanes and becomes ineffective for LRTI, the only current indication for using CRP.

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Accepted/In Press date: 1 January 2019
e-pub ahead of print date: 1 March 2019

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Local EPrints ID: 429611
URI: https://eprints.soton.ac.uk/id/eprint/429611
ISSN: 1544-1709
PURE UUID: f0aa19cf-eb45-4fc9-8122-9c07d91b9995
ORCID for Miriam Santer: ORCID iD orcid.org/0000-0001-7264-5260
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509
ORCID for Lucy Yardley: ORCID iD orcid.org/0000-0002-3853-883X

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Date deposited: 01 Apr 2019 16:30
Last modified: 17 Sep 2019 01:04

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Contributors

Author: Paul Little
Author: Beth Stuart
Author: Nick Francis
Author: Elaine Douglas
Author: Sarah Tonkin-Crine
Author: Sibyl Anthierens
Author: Jochen W. Cals
Author: Hasse Melbye
Author: Miriam Santer ORCID iD
Author: Michael Moore ORCID iD
Author: Samuel Coenen
Author: Christopher C. Butler
Author: Kerenza Hood
Author: Mark J. Kelly
Author: Maciek Godycki-Cwirko
Author: Artur Mierzecki
Author: Antoni Torres
Author: Carl Llor
Author: Melanie J. Davies
Author: Mark Mullee
Author: Alike van der Velden
Author: Adam Geraghty
Author: Herman Goossens
Author: Theo J. M. Verheij
Author: Lucy Yardley ORCID iD

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