What are clinician’s views and experiences of implementing a complex intervention to inform antibiotic prescribing in children with respiratory tract infections in primary care?

Conference:

SAPC ASM 2022 - UCLan

Talk Code:

1B.6

Presenter:

Clare Clement

Twitter:

@clareclement

Co-authors:

Jenny Ingram2, Christie Cabral3, Pete Blair2, Patricia Lucas4, Alastair Hay3, Penny Seume3, Jeremy Horwood3

Author institutions:

1 Bristol Trials Centre, Bristol Medical School, University of Bristol 2 Centre for Academic Child Health, Bristol Medical School, Population Health Sciences, University of Bristol 3 Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol. 4 School for Policy Studies, University of Bristol

Problem

Respiratory tract infections (RTIs) in children are common, lead to unnecessary antibiotic use and antimicrobial resistance. The CHIldren with COugh (CHICO) intervention incorporates a clinician focussed algorithm (STARWAVe) to predict hospitalisation, explicit elicitation of parental concerns, and a carer-focussed personalised leaflet recording treatment decisions, care, and safety netting information. The CHICO Randomised Controlled Trial (RCT) aimed to assess whether the intervention would result in reductions of antibiotic dispensing without impacting on hospital attendance. As part of the CHICO RCT, we aimed to evaluate how the intervention was implemented by clinicians in practice.

Approach

We conducted semi-structured interviews to explore whether the intervention was acceptable to and used by primary care clinicians from a range of practices with high and low antibiotic prescribing rates. Interviews were conducted in two phases (during the pilot period and after 12 months intervention period) with findings from the pilot phase used to make changes in the main trial. Normalisation Process Theory underpinned data collection and thematic analysis.

Findings

We interviewed 20 GPs and 6 nurses with a range of years’ experience from 24 practices across 13 Clinical Commissioning Groups (CCGs). Most clinicians liked the intervention and used it as a supportive aid within consultations, describing it as a “safety net”. It helped elicit parent concerns and reassure themselves and parents of the appropriateness of some treatment decisions. They liked the advice leaflet as it helped explain treatment decisions and home care with parents. Most clinicians liked the algorithm template and found it straightforward to use, without adding any more time to consultations. However, having to close the patient’s record before the end of the consultation to complete the intervention process did not always align with clinicians’ usual processes and was problematic. Clinicians’ increased familiarisation with the template and algorithm outcomes led to reduced use of the template over time. Changes to practice pathways and consultation conduct and reduced numbers of children presenting with RTIs during COVID-19 waves also impacted use. Some clinicians adapted the intervention to use during remote consultations and to send the advice leaflet to parents digitally. Some clinicians believed the intervention influenced their prescribing behaviour and found it most useful in ‘borderline cases'. However, others believed that it supported rather than changed their prescribing decisions and did not change their behaviour.

Consequences

Clinicians found the CHICO intervention useful, believed that it can help support decision making around antibiotic prescribing for children with RTIs and help discussions with parents about concerns and treatment decisions. The intervention may need to be adapted to align more with clinician’s consultation flow and allow use during remote consultations.

Submitted by:

Clare Clement

Funding acknowledgement:

Funding acknowledgement: This research is funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (funder ref: 16/31/98). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.