Clinicians views and experiences of implementing a complex intervention to reduce antibiotic prescribing in children with Respiratory Tract Infections in primary care

Problem

Antimicrobial resistance is recognised as one of the most pressing global public health threats of our time. Respiratory Tract Infections (RTIs) in children present major primary care challenge because they are common, costly and ongoing uncertainty regarding diagnosis and management is a major driver of antibiotic prescribing. Improved identification of children at low risk of future hospitalisation could increase confidence of when not to prescribe antibiotics for RTIs. To address this, The CHIldren with Cough Cluster Randomised Controlled Trial (the CHICO RCT) aims to reduce antibiotics prescribing amongst children presenting with acute cough or RTI without increasing hospital admission. The CHICO intervention incorporates a clinician focussed prognostic algorithm to predict hospitalisation in children with RTIs and a carer-focussed personalised advice leaflet recording treatment decisions, care and safety netting information. As part of the CHICO RCT pilot study, we conducted qualitative interviews with clinicians to investigate the actability and feasibility of the CHICO intervention.

Approach

Semi-structured interviews with clinicians to explore views and experiences of the CHICO intervention. Clinicians were sampled to include those from practices with high and low patient list sizes and high and low prescribing rates. Normalisation process theory, which outlines the social processes involved in intervention implementation, informed data collection and thematic data analysis.

Findings

We interviewed 8 GPs and 2 nurses from 8 practices. Clinicians liked the intervention and used it as a supportive aid within consultations, describing it as a “safety net”. It was a way of reassuring themselves and parents of the appropriateness of some treatment decisions. They liked the patient advice leaflet as it helped explain treatment decisions and home care with parents. Most clinicians liked the algorithm template, found it easy and straightforward to use, without adding any more time to consultations. However, a minority of clinicians stopped using the algorithm because they were unclear how to complete the template, which led them to think it wasn’t working. Other issues encountered during the pilot included the use of a ‘hard pop-up’ which launched for all children under 10 years. This limited use of the intervention for some because it was launched at a point too early in the consultation to be useful. Findings were fed back to the Trial Management Group who used the information to make changes to improve the intervention for the main trial. For example, a modified ‘soft pop-up’ in relation to diagnosis read codes was implemented.

Consequences

Clinicians reported the CHICO intervention to be beneficial for supporting clinician’s decision making around antibiotic prescribing for children with cough or RTI and helped discussions with parents. The findings demonstrate the value of conducting qualitative interviews early in trials to identify initial teething problems and inform refinements to study design.