What clinicians want from decision aids for children with urinary tract infections (UTI): implications for antibiotic prescribing interventions
Urinary tract infections (UTI) affect around 65,000 children under 5 years in England and Wales annually. It can be difficult to diagnose and if left untreated can cause significant immediate and long term health problems. The Diagnosis of Urinary Tract infection in Young children (DUTY) study produced a clinical decision rule to support the diagnosis of UTI in pre-school children. Clinical decision aids can be difficult to integrate into practice and GPs are coming under increasing pressure to reduce antibiotic prescribing. This qualitative study investigated the credibility and acceptability of the DUTY decision aid and evaluated how it might be used in practice.
We recruited 20 clinicians (GPs and nurses) from primary care sites. Sites were located in urban and rural areas with different levels of deprivation. Clinicians were sent a schema of the DUTY decision rule and out study information sheet in advance of the interviews. Most interviews were conducted by telephone, with one face to face interview. The interviews covered normal management of UTI in children, views of the DUTY decision rule and facilitators and barriers to use of the rule. Interviews were audio-recorded, transcribed and analysed thematically.
Clinicians were generally ambivalent about the DUTY decision rule. There was considerable variation in whether they felt they would use it in practice. However, clear themes emerged regarding the characteristics of decision rules that would be more attractive to clinicians. Clinicians wanted the decision aid to be:1) safe – they wanted to be sure that focussing to those few was a clinically safe course of action; 2) credible – they questioned the symptoms and signs that were included and excluded from the rule; 3) timely and quick – it was going to fit into a normal consultation and not add time unnecessarily; 4) valid and useful – it would help with children about whose management the clinician feels uncertainty; 5) support their sense of professional judgement and clinical autonomy. The clinician’s role and level of experience was an important context for their attitude towards decision rules. Nurses’ attitudes to these aids were more positive than GPs’, because their mode of working involves more use of decision rules. GPs, on the other hand, felt their clinical judgement made the rule irrelevant. Some GPs felt that such rules were only useful for junior, inexperienced clinicians.
When designing interventions and decision support aids, researchers need to take account not just of the immediate requirements for safety and speed, but also ensure the intervention can support clinical decision-making while respecting normal practice, clinical judgement and self-perception.