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Clinicians’ Views and Experiences of Interventions to Enhance the Quality of Antibiotic Prescribing for Acute Respiratory Tract Infections

Journal of General Internal Medicine volume 30, pages 408–416 (2015)Cite this article

ABSTRACT

BACKGROUND

Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority.

OBJECTIVE

We aimed to explore clinicians’ experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs).

DESIGN

We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions.

PARTICIPANTS

General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study.

APPROACH

Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis.

KEY RESULTS

Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician’s own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics.

CONCLUSION

Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.

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Acknowledgements

We thank all participants, clinicians and patients, who took part in the GRACE INTRO trial. We especially thank all the clinicians who consented to be involved in this qualitative study. We also thank all members of the GRACE INTRO consortium whose hard work made the trial and this study possible.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author Contribution

All authors participated in study concept and design and preparation of the manuscript. SA and STC participated in moderation of interviews, transcript analysis and interpretation, and they take responsibility for the manuscript as a whole. JWC and NAF participated in interpretation of the analysis. PFV, JK, CL, LBH participated in moderation of interviews, checking interpretation and preparation of analysis. All authors read and commented on different versions of the manuscript.

Funding

This GRACE/CHAMP study was supported by the European Commission Framework 6 Programme (grant 518226). The work in the UK was also supported by the National Institute for Health Research and the Research Foundation Flanders (grant G.027408N). The work reported on in this publication has been financially supported through the European Science Foundation (ESF), in the framework of the Research Networking Programme TRACE (www.esf.org.trace).

Prior Presentations

Presented at the General Respiratory Infections Network (GRIN) Annual meeting 2012, Bristol, UK; the South West Society of Academic Primary Care (SW SAPC) conference 2012, Torquay, UK and the 41st Annual Scientific Meeting of the Society of Academic Primary Care (SAPC) 2012, Glasgow, UK. Presentation entitled: “Exploring clinicians’ views across six countries of a near patient test and/or communication skills training as techniques to decrease inappropriate antibiotic prescribing for acute cough”.

Author information

Affiliations

  1. Department of Primary Care and Interdisciplinary Care, University of Antwerp, Universiteitsplein 1, 2016, Wilrijk, Belgium

    Sibyl Anthierens MA, PhD & Samuel Coenen MD, PhD

  2. Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK

    Sarah Tonkin-Crine MSc, PhD & Paul Little MD, PhD

  3. Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands

    Jochen W. Cals MD, PhD

  4. Vaccine & Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerpen, Belgium

    Samuel Coenen MD, PhD & Herman Goossens MD, PhD

  5. Academic Unit of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK

    Lucy Yardley MSc, PhD

  6. Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK

    Lucy Brookes-Howell MA, PhD, Christopher C. Butler MD, PhD & Nick A. Francis MD, PhD

  7. Applied Research in Respiratory Diseases, Hospital Clinic of Barcelona, Barcelona, Spain

    Patricia Fernandez-Vandellos MSc

  8. Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland

    Jaroslaw Krawczyk MD, PhD & Maciek Godycki-Cwirko MD, PhD

  9. Primary Care Centre Jaume I, University Rovira i Virgili, Tarragona, Spain

    Carl Llor MD, PhD

  10. Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

    Theo Verheij MD, PhD

Authors
  1. Sibyl Anthierens MA, PhD
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  2. Sarah Tonkin-Crine MSc, PhD
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  3. Jochen W. Cals MD, PhD
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  4. Samuel Coenen MD, PhD
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  5. Lucy Yardley MSc, PhD
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  6. Lucy Brookes-Howell MA, PhD
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  7. Patricia Fernandez-Vandellos MSc
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  8. Jaroslaw Krawczyk MD, PhD
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  9. Maciek Godycki-Cwirko MD, PhD
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  10. Carl Llor MD, PhD
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  11. Christopher C. Butler MD, PhD
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  12. Theo Verheij MD, PhD
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  13. Herman Goossens MD, PhD
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  14. Paul Little MD, PhD
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  15. Nick A. Francis MD, PhD
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Consortia

on behalf of the GRACE/CHAMP INTRO team

Corresponding author

Correspondence to Sibyl Anthierens MA, PhD.

Appendix: The Interview Schedule Used with Clinicians

Appendix: The Interview Schedule Used with Clinicians

Clinician Interview Schedule

For all clinicians:

  1. 1.

    Could you start by giving me your general impressions of taking part in the study?

    Prompts:

    1. a.

      How was the contact with the study team?

    2. b.

      Did the training meet your expectations? Could you explain why/why not?

    3. c.

      Were there any aspects of the study that you particularly liked? Could you explain why/why not?

    4. d.

      Were there any aspects of the study that you thought were problematic or did not work well? Could you explain why/why not?

  2. 2.

    Did any part(s) of the training help you to increase your knowledge and/or skills during your consultations for LRTI/cough?

For clinicians who had recieved CRP training:

  1. 3.

    I’d now like to ask you a bit more about the CRP training and the use of the CRP test.

    Prompts:

    1. a.

      What were your impressions of the CRP online training?

    2. b.

      Did you complete the CRP online training?

    3. c.

      Did you find it helpful? Why/why not?

    4. d.

      Were there any sections that you found particularly helpful?

    5. e.

      Were there specific things in the training that you did not like or sections you would have liked removed?

    6. f.

      How did the training help you to use the CRP device and interpret the results?

    7. g.

      Were there any barriers to doing what we asked you to do, or to using the CRP test?

    8. h.

      Did the training help you to manage patients with cough/ LRTIs?

    9. i.

      Do you think there are any barriers to implementing the training?

    10. l.

      What was your experience with the length of the training?

  2. 4.

    Did you use the CRP test as a tool within consultations or did somebody else within the practice do the test?

    Prompts:

    1. a.

      If you didn’t use the CRP test, can you tell me why you decided not to use it?

    2. b.

      If yes, can you tell me what it was like using it in the consultation?

      1. i.

        What worked well? What did not work well? How did it influence your consultation?

    3. c.

      How did you use the results of the test in your decision about whether to prescribe antibiotics or not?

    4. d.

      What do you think patients thought of the CRP test?

For clinicians who had received communication skills training:

  1. 5.

    I’d now like to ask you a bit more about the communication skills training and the use of the patient booklet.

    Prompts:

    1. a.

      What were your impressions of the communication skills online training?

    2. b.

      Did you complete the communication skills online training?

    3. c.

      Did you find it helpful? Why/why not?

    4. d.

      Were there any sections that you found particularly helpful?

    5. e.

      Were there specific things in the training that you did not like or sections you would have liked removed?

    6. f.

      How did the training help you to use the patient booklet?

    7. g.

      Were there any barriers to doing what we asked you to do, or to using the booklet?

    8. h.

      Did the training help you to manage patients with cough/ LRTIs?

    9. i.

      Do you think there are any barriers to implementing the training?

    10. j.

      What was your experience with the length of the training?

  2. 6.

    How did you use the booklet as a tool within consultations?

    1. a.

      If not used, can you tell me why you decided not to use it?

    2. b.

      If used, can you tell me what it was like using it in the consultation?

      1. i.

        What worked well? What did not work well? How did it influence your consultation?

    3. c.

      What do you think patients thought of the booklet?

For clinicians who had recieved CRP and communication skills training:

  1. 7.

    In what way have you used both interventions in your practice?

    1. a.

      Have you used them together or separately?

    2. b.

      What influences your choice in using one or both techniques?

    3. c.

      What are the advantages and disadvantages of using them together or separately?

    4. d.

      Have you got a preference for one or the other and why?

For all clinicians:

  1. 8.

    How has participating in the study changed your prescribing behaviour or the way you manage cough or LRTIs?

  2. 9.

    How useful did you find the training and how easy was it to use in daily practice?

  3. 10.

    How do you feel the intervention impacted on the doctor-patient relationship?

  4. 11.

    Do you have any other comments or points you would like to make about managing cough or lower respiratory tract infections or taking part in the study as a whole?

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Anthierens, S., Tonkin-Crine, S., Cals, J.W. et al. Clinicians’ Views and Experiences of Interventions to Enhance the Quality of Antibiotic Prescribing for Acute Respiratory Tract Infections. J GEN INTERN MED 30, 408–416 (2015). https://doi.org/10.1007/s11606-014-3076-6

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KEY WORDS

  • qualitative research
  • decision making
  • antibiotic prescribing
  • communication training
  • point-of-care testing
  • primary care