An interactive booklet reduces antibiotic use for children with respiratory tract infections

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:b2885.

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Question 

Among children with respiratory tract infections, does the use of an interactive booklet reduce return visits for the same illness episode and reduce antibiotic use, while maintaining satisfaction with care?

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Design 

Cluster randomized controlled trial.

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Setting 

61 general practices in Wales and England.

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Participants 

558 children, ages 6 months to 14 years, who presented to primary care with an acute respiratory tract infection with ≤7 days of symptoms. Children with suspected pneumonia, asthma, or a serious concomitant illness or needing immediate hospital admission were excluded.

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Intervention 

Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during visits with recruited patients. Control-group clinicians provided their standard care.

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Outcomes 

The proportion of children who had a return visit for the same illness during the 2-week follow-up period. Secondary outcomes included antibiotic use, parental intentions for future evaluation for similar illnesses, and parental satisfaction, reassurance, and enablement.

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Main Results 

528 patients participated (3 withdrawals, 27 lost to follow-up). Return visits occurred in 12.9% of children in the intervention group and 16.2% in the control group (absolute risk reduction, 3.3%; 95% confidence interval, −2.7% to 9.3%; P = .29). Using multilevel modeling (at the practice and individual level) to account for clustering, no significant difference in return visits was noted (odds ratio, 0.75; 0.41 to 1.38). Antibiotics were prescribed at the initial visits to 19.5% of children in the intervention group and 40.8% of children in the control group (absolute risk reduction, 21.3%; 95% confidence interval, 13.7 to 28.9), P < .001; number needed to treat [NNT] = 5). A significant difference was still present after adjusting for clustering (odds ratio, 0.29; 0.14 to 0.60). There was also a significant difference in the proportion of parents who said they would seek care in the future if their child developed a similar illness (55.3% vs 76.4%, NNT = 5). Satisfaction, reassurance, and parental enablement scores were not significantly different between the 2 groups.

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Conclusions 

Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to seek care in the future for a similar illness without reducing satisfaction with care.

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Commentary 

This is a large, well-designed and conducted study of a complex intervention and merits consideration of its implications for practice. The selected population of children 6 months to 14 years old with a short history of respiratory infection will be familiar to primary care practitioners and poses a commonly encountered management problem. By excluding those with serious illness, we are left with a group with a favorable outlook (7/588 admissions overall), and yet 40% in the control group were given antibiotics. It is of great interest that the intervention resulted in a significant fall in both antibiotic prescription at the initial consultation and in overall antibiotic consumption without any significant effect on re-visit rates. It is not clear which part of the intervention, the clinician training or use of the leaflet, was responsible for the change nor how it was mediated because satisfaction, reassurance, enablement, and usefulness of information received during the consultation did not differ between intervention and control. Because the use of leaflets alone in other studies appears to have small or modest effect, one can speculate the larger effect observed on prescribing must have arisen from either the training or an interaction between the training and the booklet use within the visit. Practitioners wishing to use the intervention should not assume that the passive addition of a leaflet to the visit will have the desired effect. We need to remember that we have no information regarding the persistence of the effect because each practitioner was limited to only 10 consecutive visits, and it would seem prudent to both confirm the result and distill the active part of the intervention in further studies.