A multi-country qualitative study of clinicians' and patients' views on point of care tests for lower respiratory tract infection

Wood, Fiona; Brookes‐Howell, Lucy; Hood, Kerenza; Cooper, Lucy; Verheij, Theo; Goossens, Herman; Little, Paul; Godycki-Cwirko, Maciek; Adriaenssens, Niels; Jakobsen, Kristin; Butler, Christopher Collett

doi:10.1093/fampra/cmr031

Cited by 66 publications

(91 citation statements)

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“…Qualitative work with both patients and HCPs across Europe suggests both patients and HCPs may be willing to use CRP (C reactive protein) as a point-of-care test in lower respiratory tract infection, but major issues for HCPs are questionable test performance, problems interpreting results, a detraction from clinical reasoning, costs, time and patients not wanting, or demanding, the tests. 53 We are unaware of any qualitative research that has documented and explored HCPs' or patients' perceptions of RADTs.…”

Section: Introductionmentioning

confidence: 99%

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Little

Hobbs

Moore

et al. 2014

Health Technol Assess

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Background Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. Objective This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. Design The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. Setting The setting was UK primary care general practices. Participants Participants were patients aged ≥ 3 years with acute sore throat. Interventions An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. Main outcome measures The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2–4 days). Results The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (–0.33; 95% confidence interval –0.64 to –0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (–0.30; –0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals’ concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. Conclusions Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals’ concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians’ perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. Trial registration Current Controlled Trials ISRCTN32027234. Source of funding This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.

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Section: Introductionmentioning

confidence: 99%

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Little

Hobbs

Moore

et al. 2014

Health Technol Assess

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“…Previous international studies found that clinicians value POCTs as an intervention to help reduce unnecessary antibiotic prescribing. 18,19 However, these studies asked about hypothetical, rather than actual, use.…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2014

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BACKGROUND: Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority. OBJECTIVE: We aimed to explore clinicians' experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs). DESIGN: We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions. PARTICIPANTS: General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study. APPROACH: Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis. KEY RESULTS: Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician's own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics. CONCLUSION: Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.

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“…Wood et al (2011) conducted a multi-country qualitative study to gather clinician and patient views in regards to POCT for CRP. The primary concerns for clinicians included questionable accuracy of tests and over reliance on CRP results, thereby detracting from the clinician's clinical skills.…”

Section: Clinicians' Perspectivesmentioning

confidence: 99%

Point-of-care testing for C-reactive protein in acute cough presentations

Searle-Barnes¹,

Phillips

2017

Journal of Paramedic Practice

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Acute cough is one of the most common illnesses in the UK with an estimated 48 million cases per annum. The majority of these presentations are thought to be of viral aetiology and self-limiting in nature, yet some studies report antibiotic prescription rates of approximately 65% in the UK. Clincians' decision-making process can be influenced by both patient expectations and difficulty in differentiating between viral and bacterial aetiologies by clinical examination alone. Despite warnings about antimicrobial resistance (AMR) from the World Health Organization, clinicians in the UK continue to have high prescription rates for acute cough presentations in comparison to other developed health care systems. This article will consider the feasibility, efficacy, benefits and limitations of using point-of-care testing (POCT) of C-reactive protein (CRP) within primary care in the United Kingdom to help inform management of acute cough.

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A multi-country qualitative study of clinicians' and patients' views on point of care tests for lower respiratory tract infection

Abstract: Acceptability of POCTs to clinicians is likely to be improved if tests perform well on accuracy, time to result, simplicity and cost. Including POCTs in the routine management of acute cough/LRTI is likely to be acceptable to most patients.

Cited by 66 publications

References 12 publications

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

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

Point-of-care testing for C-reactive protein in acute cough presentations

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