20th May 2009
A randomised controlled trial has shown that communication skills training and the use of near-patient C reactive protein (CRP) testing can reduce antibiotic prescribing for patients with lower respiratory tract infection in primary care.
The aim when assessing patients with an acute respiratory tract infection with cough as the predominant symptom is to select out the minority of patients who already have or who may be at higher risk of developing a more serious illness (including pneumonia) from the majority of patients who have a less serious and self-limiting illness.
NICE Guidance on respiratory tract infections advises that antibiotics are prescribed immediately, and/or further appropriate investigation and/or management should be offered, if a patient has signs and symptoms suggestive of pneumonia or is at risk of suffering a prolonged or severe illness or complications. For example, if he/she is systemically unwell or has pre-existing co-morbidities, or is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria: hospitalisation in previous year, type 1 or type 2 diabetes, history of congestive heart failure, or current use of oral glucocorticoids.
If the criteria for serious illness or the risk of serious illness are not met, NICE recommends prescribing either a delayed antibiotic or no antibiotic. The patient’s concerns and expectations should be addressed when agreeing which strategy should be used. Enhanced communication skills and shared decision-making, as used in this study, are key to improving patients’ participation in discussions about their care and achieving evidence-based decisions on prescribing. Near patient tests, including CRP, should not be introduced without a national policy decision involving evaluation of all data on clinical and cost effectiveness.
What does this study claim?
This randomised controlled trial evaluated the effect of GPs using a near-patient test for CRP and being trained in enhanced communication skills, separately and combined, on antibiotic prescribing for lower respiratory tract infection (RTI) and on patient recovery.
The use of near-patient CRP testing and training in enhanced communication skills both significantly reduced antibiotic prescribing at the index consultation for lower RTI (the primary outcome) and antibiotic prescribing during the 28 days’ follow-up period, without affecting clinical recovery, patients’ satisfaction or reconsultations. GPs prescribed antibiotics for 31% of patients in the CRP test group, compared with 53% in the no test group (P=0.02). GPs trained in enhanced communication skills prescribed antibiotics for 27% of patients, compared with 54% in the no training group (P<0.01). Both interventions together produced no statistically significant additional effect to either of the interventions alone (P=0.78).
The study authors state that CRP testing may contribute to safely withholding antibiotics from most people with low CRP values who probably would not benefit from antibiotic treatment. However, CRP near-patient tests are not widely used in the UK and GPs may be inexperienced in interpreting results and using them to guide treatment. In countries where these near-patient tests are available, excessive testing has been reported and could limit the cost-effectiveness of this intervention. A cost-effectiveness analysis of this study is being undertaken. An editorial accompanying the study discusses some other limitations of using CRP testing and points out that a recent systematic review concluded that a CRP test could help rule out community-acquired pneumonia only if the probability of the patient having this condition is more than 10%, and this is more likely after initial selection of patients, for example in emergency departments. The editorial also questions whether CRP testing may increase the long-term likelihood of patients consulting for similar illnesses in the future.
However, this paper supports the NICE approach to managing patients with a delayed or no prescription where this is appropriate. Good communication skills can increase patients’ understanding of prescribing decisions without the feeling of being dismissed. It is important that patients’ concerns and expectations are addressed and they understand that symptoms following a respiratory infection with acute cough as the predominant symptom may last for a number of weeks. Patients should be advised that, for the majority, antibiotics make little difference to symptoms, and may have side effects.
Antibiotics are always indicated for adults and children with suspected pneumonia. They lead to a clinical cure or improvement in 80% or more of people treated in the community or in hospital. But when NICE looked at the evidence for antibiotics to treat acute cough/bronchitis, they found that, although antibiotics had a significant effect on the duration of cough and productive cough, and on feeling ill, the benefits were small – a fraction of a day in an illness lasting several weeks. They concluded that a delayed or no prescribing strategy should be offered to patients with acute cough who are not at an increased risk of suffering a prolonged or serious illness or developing complications.
NICE stress the need for safety-netting approaches in case the patients’ illness worsens or becomes prolonged, either by use of delayed antibiotic prescriptions or by offering a prompt clinical review. If a delayed prescription is given, patients should be given advice on using it if symptoms worsen or aren’t resolving as expected. Similarly, if symptoms worsen despite using the delayed prescription, the patient should be advised to re-consult.
The usual approach to the prescribing of antibiotics for an acute respiratory tract infection with cough as the predominant symptom would require modification in the circumstances of an influenza epidemic or pandemic.
Cals JWL, Butler CC, Hopstaken RM, et al. 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. BMJ 2009;338:b1374, doi: 10.1136/bmj.b1374 (Published 5 May 2009)
Design: Cluster randomised, factorial, controlled trial.
Patients: Forty GPs from 20 practices recruited 431 sequential eligible adults within regular consultation hours during the winters of 2005–6 and 2006–7. Patients were eligible if they had a suspected lower RTI with a cough lasting less than four weeks together with one chest and one systemic symptom.
Intervention: GPs were trained to provide finger prick near-patient CRP tests and/or a communication skills intervention built around 11 key tasks (e.g. exploring patients’ fears and expectations, asking patients’ opinion on antibiotics, and outlining the natural duration of cough in lower RTI) with information exchange throughout based on the elicit-provide-elicit framework from counselling in behaviour change.
Comparison: Patients were randomised to four groups: GP use of CRP testing, training in enhanced communication skills, both, or usual care.
Outcomes: The primary outcome was antibiotic prescribing in the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement. Cost effectiveness is to be reported separately. Patients rated symptoms (cough, phlegm, shortness of breath, disturbance of daily activities, sleeping problems, and generally feeling unwell) on a 7 point scale in a daily diary for 28 days. Antibiotic prescribing and reconsultation data for the 28 days of follow-up were obtained from the participants’ medical records.
Results: GPs in the CRP test group prescribed significantly fewer antibiotics than those in the no test group (31% v 53%, P=0.02). Similarly, those in the communication skills training group prescribed significantly fewer antibiotics than those in the no training group (27% v 54%, P<0.01). The two interventions showed no statistically significant interaction effect (P=0.78). There was no statistically significant difference in reconsultations. Antibiotic prescribing at any point during the 28 days’ follow-up (prescribing rates at the index consultation combined with prescribing rates at reconsultations) remained significantly lower in patients in the CRP test group compared with those in the no test group (45% v 58%, P<0.01) as well as for patients in the communication skills training group compared with patients in the no training group (38% v 63%, P<0.001). Comparable median daily symptom scores were seen for all four groups of patients suggesting that the interventions had no effect on recovery. Overall, satisfaction with the index consultation was high, with no statistically significant differences between treatment groups.
Sponsorship: Netherlands Organisation for Health Research and Development.
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