This study of the effectiveness of internet training to modify antibiotic prescribing for respiratory-tract infections followed a period of careful intervention development across major language, cultural, and health-system boundaries. Our findings suggest that these interventions are transferable between very different primary-care settings.
The practices involved in the study had previously shown no interest in their levels of antibiotic prescribing and many were research naive. The prescribing rate at baseline (55·3%) was similar to that in a previous observational study,5
where most patients were given antibiotics. Although recruitment was not complex, some practices did not include the minimum number of patients in the baseline audit, which supports the everyday nature of those practices. The baseline prescribing rate in the usual-care group was similar to those in the other groups, which suggests minimum attrition bias. Control for patients' characteristics only slightly altered estimated prescribing rates and remained similar in all intervention groups, which indicates minimum confounding. The limited change in prescribing rate in the usual-care group, and the slightly worse symptomatic outcomes in the intervention groups, which were in line with evidence from placebo-controlled trials,4,6
suggest that the reductions in antibiotic prescribing in intervention groups were genuine. We assessed adherence to training but did not observe consultations to avoid introducing bias to clinicians' behaviour. The long-term effects of our study interventions on behaviour are unknown, although similar interventions have had lasting effects.10,16,25
The efficacy of the multifactorial enhanced-communication intervention supports evidence that interactive methods, rather than simply providing educational information, are most effective.12,14
In the STAR trial,16
a 4% reduction in global antibiotic use was noted, but that trial was much more intensive than ours (five online training phases vs
one in this study, plus expert-led outreach seminars). Our intervention caused slightly less reduction in prescribing rates than that used in the IMPAC3T study. The risk ratio for antibiotic prescribing was 0·49 for communication training in IMPAC3T, compared with 0·68 in our study,10
but that intervention was also more intensive than ours (outreach visits plus peer review of consultations). Despite our interventions predominantly addressing lower-respiratory-tract infections, prescribing rates fell for upper-respiratory-tract infections, which suggests further modifications of the booklet and training to better address upper-respiratory-tract infections could improve efficacy. Although the diagnostic value of CRP testing has been questioned in systematic reviews,8,26
our findings are similar to those in intensive Dutch trials10,11
and suggest that internet-based training on CRP testing promotes non-antibiotic management strategies when the findings of qualitative work support the quantitative findings.17
In view of the additional resources needed for CRP testing (training, equipment, and time for testing and discussion of results) the cost-effectiveness of this intervention remains to be shown.
No intervention affected symptom severity in the first few days, but the median time to resolution of moderately severe or worse symptoms was slightly longer in the enhanced-communication group than in the usual-care group (by 1 day). The risk of new or worsening symptoms was also raised in the combined group (appendix pp 6–7
), which lessens the likelihood that training in CRP training protects against symptom progression. These findings might have been due to the 12% rate of symptom reporting in the usual-care group. However, this rate is lower than that in the placebo group of a previous large trial6
and requires confirmation. Symptom control might be worse in patients with upper-respiratory-tract infections than in those with lower-respiratory-tract infections, but this finding should be interpreted cautiously as it was a secondary outcome and the interaction term was not significant. The IMPAC3T trial10
provided little evidence of poor symptom control, although the duration of severe symptoms and the rates of new or worsening symptoms were not reported. Symptom control was also not reported in a previous trial of internet-based communication training with an accompanying booklet.13
The perception of worse symptoms could have been due to expectations about the effectiveness of antibiotics in an open trial, although similar open trials have not reported such effects.10,27,28
The use of the interactive booklet might have led to increased re-consultation rates by emphasis of the long natural history of respiratory-tract infections and the raising of awareness of symptoms for which re-consultation is recommended. Likewise, although an increased rate of hospital admission could have indicated a negative effect with the CRP intervention, it might have reflected appropriate management. The slightly worse symptom control in the enhanced-communication group highlights the paucity of high-quality evidence for effective treatments.29
Improved symptom control should become a research priority. The risk of potential intervention-related harm (possibility of worse symptom control or increased rate of hospital admissions) must be balanced by the potential benefits (reduced antibiotic prescribing, demedicalisation of self-limiting illness,6,19
reduced risk of antibiotic-associated side-effects, and reduced risk of antibiotic resistance; panel
Panel. Research in context
Arnold and Straus12
searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (supplemented by the bibliographies of studies found in the register and the Science Citation Index), and identified 39 randomised studies and quasirandomised studies. They found that multifaceted interventions were most successful in reducing the rate of antibiotic prescribing. We searched Medline, Embase, and The Cochrane Library for articles published from January, 1990, to July, 2009, with several combinations of the following keywords: “antibiotic”, “primary care”, “intervention”, “respiratory tract infection”, and specific MeSH terms for respiratory-tract-infection diagnoses. We manually screened reference lists to identify further articles of interest. Inclusion criteria for articles were an intervention primarily targeted at physicians in a primary care setting aiming to improve antibiotic prescription for respiratory-tract infections, studies done in high-income countries, presentation of a standardised outcome of first-choice prescription measured in defined daily dosage, prescriptions or rates, and publication in the English language. Relevance of studies was screened by assessments of titles, keywords, abstracts, and full texts, independently by two reviewers. Disagreements were resolved by consensus or arbitration by a third person. The main reasons for exclusion were a lack of standardised outcomes or a clear description of intervention features. We identified 58 studies describing 87 interventions in primary care related to antibiotic prescribing for respiratory-tract infections, and confirmed that multiple interventions containing at least educational material for physicians were most frequently effective. This finding underscored promising evidence for communication-skills training and near-patient testing.15
Patients' outcomes, however, were rarely reported, the participants and settings were generally restricted, and outreach interventions used highly trained staff at research centres of excellence and, therefore, the generalisability of interventions seemed poor. Only one trial had used the internet for intervention delivery. In a study that involved 246 primary-care practices in six European countries with different languages, cultures, and health systems, we aimed to assess the effect of internet-based training in the use of a C-reactive protein point-of-care test and in enhanced communication skills, supported by an interactive booklet for patients.
Both types of training were associated with notable reductions in antibiotic prescribing rates, but the two training methods combined had the greatest effect (C-reactive-protein intervention risk ratio 0·53, 95% CI 0·36–0·74; enhanced-communication intervention 0·68, 0·50–0·89; combined intervention 0·38, 0·25–0·55). We found evidence of slightly lengthened duration (1 day) of symptoms rated moderately bad or worse with the enhanced-communication training, and increased hospital admissions with C-reactive-protein training (22 vs
eight with usual care), but these outcomes may be balanced against the potential benefits (reduced antibiotic prescribing, demedicalisation of self-limiting illness,6,19
reduced risk of antibiotic-associated side-effects, and reduced risk of antibiotic resistance). The easily accessible format of internet-based intervention delivery and the success of the interventions across national language and cultural boundaries suggest that these interventions could be implemented widely in many health systems.
Internet-based training in how to use a CRP point-of-care test or in enhanced communication skills plus use of an interactive information booklet achieved important reductions in antibiotic prescribing for respiratory-tract infections in several countries. These interventions, therefore, can be disseminated widely and maintain efficacy. Effective symptom-control strategies are needed to support reductions in antibiotic prescribing.