Little, Paul, Stuart, Beth, Francis, Nick, Douglas, Elaine, Tonkin-Crine, Sarah, Anthierens, Sibyl, Cals, Jochen W.L., Melbye, Hasse, Santer, Miriam, Moore, Michael, Coenen, Samuel, Butler, Chris C., Hood, Kerenza, Kelson, Mark, Godycki-Cwirko, Maciek, Mierzecki, Artur, Torres, Antoni, Llor, Carl, Davies, Melanie, Mullee, Mark, O'Reilly, Gilly, van der Velden, Alike, Geraghty, Adam W.A., Goossens, Herman, Verheij, Theo and Yardley, Lucy (2019) Antibiotic prescribing for acute respiratory tract infections 12 months after communication and CRP training: a randomized trial. Annals of Family Medicine, 17 (2), 125-132. (doi:10.1370/afm.2356).
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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