Paul Little1, Beth Stuart2, Nick Francis2, Elaine Douglas2, Sarah Tonkin-Crine2, Sibyl Anthierens2, Jochen W L Cals2, Hasse Melbye2, Miriam Santer2, Michael Moore2, Samuel Coenen2, Chris C Butler2, Kerenza Hood2, Mark Kelson2, Maciek Godycki-Cwirko2, Artur Mierzecki2, Antoni Torres2, Carl Llor2, Melanie Davies2, Mark Mullee2, Gilly O'Reilly2, Alike van der Velden2, Adam W A Geraghty2, Herman Goossens2, Theo Verheij2, Lucy Yardley2. 1. Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye). p.little@soton.ac.uk. 2. Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye).
Abstract
PURPOSE:C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial. METHODS: A total of 246 general practices in 6 countries were cluster-randomized tousual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months. RESULTS: Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively). CONCLUSIONS:Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.
RCT Entities:
PURPOSE:C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial. METHODS: A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months. RESULTS: Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively). CONCLUSIONS: Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.
Authors: M Woodhead; F Blasi; S Ewig; J Garau; G Huchon; M Ieven; A Ortqvist; T Schaberg; A Torres; G van der Heijden; R Read; T J M Verheij Journal: Clin Microbiol Infect Date: 2011-11 Impact factor: 8.067
Authors: Alike W van der Velden; Eefje J Pijpers; Marijke M Kuyvenhoven; Sarah K G Tonkin-Crine; Paul Little; Theo J M Verheij Journal: Br J Gen Pract Date: 2012-12 Impact factor: 5.386
Authors: M A O'Brien; S Rogers; G Jamtvedt; A D Oxman; J Odgaard-Jensen; D T Kristoffersen; L Forsetlund; D Bainbridge; N Freemantle; D A Davis; R B Haynes; E L Harvey Journal: Cochrane Database Syst Rev Date: 2007-10-17
Authors: Paul Little; Beth Stuart; Michael Moore; Samuel Coenen; Christopher C Butler; Maciek Godycki-Cwirko; Artur Mierzecki; Slawomir Chlabicz; Antoni Torres; Jordi Almirall; Mel Davies; Tom Schaberg; Sigvard Mölstad; Francesco Blasi; An De Sutter; Janko Kersnik; Helena Hupkova; Pia Touboul; Kerenza Hood; Mark Mullee; Gilly O'Reilly; Curt Brugman; Herman Goossens; Theo Verheij Journal: Lancet Infect Dis Date: 2012-12-19 Impact factor: 25.071
Authors: Raymond Oppong; Richard D Smith; Paul Little; Theo Verheij; Christopher C Butler; Herman Goossens; Samuel Coenen; Sue Jowett; Tracy E Roberts; Felix Achana; Beth Stuart; Joanna Coast Journal: J Antimicrob Chemother Date: 2018-11-01 Impact factor: 5.790
Authors: Sibyl Anthierens; Sarah Tonkin-Crine; Elaine Douglas; Patricia Fernandez-Vandellos; Jaroslaw Krawczyk; Carl Llor; Jochen W L Cals; Nick A Francis; Lucy Yardley; Samuel Coenen; Theo Verheij; Herman Goossens; Paul Little Journal: BMC Fam Pract Date: 2012-10-11 Impact factor: 2.497
Authors: C C Butler; K Hood; T Verheij; P Little; H Melbye; J Nuttall; M J Kelly; S Mölstad; M Godycki-Cwirko; J Almirall; A Torres; D Gillespie; U Rautakorpi; S Coenen; H Goossens Journal: BMJ Date: 2009-06-23
Authors: Paul Little; Beth Stuart; Nick Francis; Elaine Douglas; Sarah Tonkin-Crine; Sibyl Anthierens; Jochen W L Cals; Hasse Melbye; Miriam Santer; Michael Moore; Samuel Coenen; Chris Butler; Kerenza Hood; Mark Kelly; Maciek Godycki-Cwirko; Artur Mierzecki; Antoni Torres; Carl Llor; Melanie Davies; Mark Mullee; Gilly O'Reilly; Alike van der Velden; Adam W A Geraghty; Herman Goossens; Theo Verheij; Lucy Yardley Journal: Lancet Date: 2013-07-31 Impact factor: 79.321
Authors: Leon D'Hulster; Steven Abrams; Robin Bruyndonckx; Sibyl Anthierens; Niels Adriaenssens; Chris C Butler; Theo Verheij; Herman Goossens; Paul Little; Samuel Coenen Journal: JAC Antimicrob Resist Date: 2022-06-29
Authors: Rita Mangione-Smith; Jeffrey D Robinson; Chuan Zhou; James W Stout; Alexander G Fiks; Madeleine Shalowitz; Jeffrey S Gerber; Dennis Burges; Benjamin Hedrick; Louise Warren; Robert W Grundmeier; Matthew P Kronman; Laura P Shone; Jennifer Steffes; Margaret Wright; John Heritage Journal: Patient Educ Couns Date: 2022-03-14
Authors: Aleksandra J Borek; Marta Wanat; Anna Sallis; Diane Ashiru-Oredope; Lou Atkins; Elizabeth Beech; Susan Hopkins; Leah Jones; Cliodna McNulty; Karen Shaw; Esther Taborn; Christopher Butler; Tim Chadborn; Sarah Tonkin-Crine Journal: Antibiotics (Basel) Date: 2019-10-31
Authors: Nahara Anani Martínez-González; Ellen Keizer; Andreas Plate; Samuel Coenen; Fabio Valeri; Jan Yvan Jos Verbakel; Thomas Rosemann; Stefan Neuner-Jehle; Oliver Senn Journal: Antibiotics (Basel) Date: 2020-09-16
Authors: Aleksandra J Borek; Anne Campbell; Monsey McLeod; Sarah Tonkin-Crine; Elle Dent; Christopher C Butler; Alison Holmes; Michael Moore; A Sarah Walker Journal: BMC Fam Pract Date: 2021-01-23 Impact factor: 2.497