Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial

Abstract

Objective: To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.

Design: Pragmatic, 2x2 factorial, cluster randomised controlled trial.

Setting: 20 general practices in the Netherlands.

Participants: 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.

Main outcome measures: The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days' follow-up, reconsultation, clinical recovery, and patients' satisfaction and enablement.

Interventions: General practitioners' use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.

Results: General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days' follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients' recovery and satisfaction were similar in all study groups.

Conclusion: Both general practitioners' use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients' recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.

Trial registration: Current Controlled Trials ISRCTN85154857.

Fig 1 Trial profile. *Three general practitioners went on maternity leave halfway through study. It was not feasible for general practitioners to keep a log of those eligible patients not approached or those approached who declined and the reasons for declining

Fig 2 Median symptom scores (%) for treatment groups (see web extra figure for full four level corrected recovery slopes). Treatment groups had identical clinical recovery despite fewer antibiotics prescribed in intervention groups