Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial

Abstract

BackgroundTo reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners’ (GPs’) and patients’ attitudes.MethodsGPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics.ResultsGPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful.ConclusionsOur findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.

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

“…Intervention content was based on theories of behaviour change and particularly focused on increasing self-efficacy, one's belief that one can carry out a particular behaviour at a given time. 16,17 Clinicians reported being more confident in diagnosing an infection when using the CRP test and in explaining a nonprescribing decision to patients, and this appeared to be a result of training videos provided within interventions. Clinicians' expectations of the outcome of a consultation are also likely to have changed.…”

“…[23][24][25] Lastly, the results supported the quantitative evaluation of GRACE INTRO, which indicated that clinicians perceived reducing prescribing as less risky following the intervention, and clinicians in the communication group reported increased confidence to reduce prescribing. 17 Previous qualitative work has also explored clinicians' views of communication skills training as a way to promote prudent prescribing. The STAR study evaluated a multifaceted educational intervention delivered through both online and outreach visit training, and was centred on communication skills.…”

“…The STAR study evaluated a multifaceted educational intervention delivered through both online and outreach visit training, and was centred on communication skills. [16][17][18][19][20][21][22][23][24][25][26] Clinicians reported that communication skills training gave them an additional insight into their patients' agendas, which they felt would reduce future unnecessary consultations, but required an initial investment of longer consultations. The current study found that only a minority of clinicians specifically mentioned the advantage of the communication skills and most concentrated on the benefits of the patient booklet.…”

Comparative Effectiveness of Three Anxiolytics for Acute Respiratory Infections: Antibiotics, C-Reactive Protein Point-of-Care Testing, and Improved Communication

“…8 Communication group patients had lesser belief in the necessity of antibiotics and greater belief in the harms of antibiotics. In contrast, patients in the CRP group had lower enablement scores.…”

“…8 Physicians used CRP testing more selectively, for 38 % of patients. Beyond the reliability of implementation, physicians in the communication group gained confidence in their ability to reduce antibiotic prescribing, and physicians in the CRP group lost confidence.…”