Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial

Abstract

Background: Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. We evaluated the effect of DECISION+2, a shared decision-making training program, on the percentage of patients who decided to take antibiotics after consultation with a physician or resident.

Methods: We performed a randomized trial, clustered at the level of family practice teaching unit, with 2 study arms: DECISION+2 and control. The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making. The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation. We also recorded patients' perception that shared decision-making had occurred. Two weeks after the initial consultation, we assessed patients' adherence to the decision, repeat consultation, decisional regret and quality of life.

Results: We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group, and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group. The percentage of patients who decided to use antibiotics after consultation was 52.2% in the control group and 27.2% in the DECISION+2 group (absolute difference 25.0%, adjusted relative risk 0.48, 95% confidence interval 0.34-0.68). DECISION+2 was associated with patients taking a more active role in decision-making (Z = 3.9, p < 0.001). Patient outcomes 2 weeks after consultation were similar in both groups.

Interpretation: The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections. This reduction did not have a negative effect on patient outcomes 2 weeks after consultation. ClinicalTrials.gov trial register no. NCT01116076.

Figure 1:

Flow diagram of the DECISION+2 trial. In the DECISION+2 group, 11 of the 189 eligible physicians who were not available during the first phase of patient recruitment were recruited (completed the baseline questionnaire) after DECISION+2 training began and therefore were not included in the final analysis. Out of 162 (151 + 11), 103 completed both the online tutorial and the interactive workshop, 16 completed only the interactive workshop, 15 completed only the online tutorial, and 28 completed none of the training components. Thus, 72.8% (118/162) completed the online tutorial, and 73.5% (119/162) completed the interactive workshop. In the control group, 9 of the 144 eligible physicians who were not available during the first phase of patient recruitment were recruited (completed the baseline questionnaire) after DECISION+2 training began; these physicians were included in the follow-up.

Figure 2:

Patient perceptions of how much they participated in decision-making during consultation with A) any participating physician (Z = 3.9; p < 0.001), B) a teaching physician (Z = 3.7; p < 0.001) or C) a resident (Z = −4.7918; p = 0.03). The perceptions were grouped as follows 1) I made the decision alone; 2) I made the decision but considered the opinion of my doctor; 3) My doctor and I decided equally; 4) My doctor made the decision but considered my opinion; 5) My physician made the decision alone.