Strategies, known as shared decision making, reduced antibiotic prescribing for people with acute respiratory infections by almost 40% in the short term (up to six weeks).
This Cochrane systematic review compared the strategies that promote better discussions between doctor and patient about benefits and harms of treatment in primary care. Interventions were a mix of training healthcare staff (mainly general practitioners) in better communication skills and giving patients structured information. Ten studies of over 1,100 doctors and almost half a million patients were included, but study designs could not eliminate bias, from a lack of blinding, completely. Four studies included in this review were from the UK and the other six were from high-income European countries and Canada, so the findings are applicable to the UK.
There is insufficient evidence about the long term effect (up to one year and beyond) of the strategies used to facilitate shared decision making, so it is not known whether they could reverse community-level antibiotic resistance trends. It is likely that multiple approaches will be needed.
Why was this study needed?
Antibiotic resistance is now seen as an international public health crisis and it is important to avoid unnecessary antibiotic prescribing in primary care. Acute respiratory infections are one of the most common reasons for antibiotic prescribing even though research has shown that antibiotics have little benefits for acute middle ear infections, sinusitis, bronchitis and sore throat. This review aimed to find out whether strategies that facilitate the shared decision making process, which involves a discussion with the patient, can reduce antibiotic prescribing among primary care doctors.
What did this study do?
This was a Cochrane systematic review of randomised controlled trials that compared strategies used to facilitate the shared decision making process in primary care. Nine trials and one follow-up study of over 1,100 doctors and almost half a million patients were included. They compared a range of strategies including clinicians’ skills training and providing information or tools about the options, benefits, harms, or questions about antibiotic prescribing to either patients, or clinicians or both. All studies provided some education and communication skills training for GPs delivered through workshops, seminars or via web-based platforms. Standard systematic review and meta-analysis methods were used. Trial quality was assessed to be moderate or low, because participants in most studies were aware of whether they had received the intervention or not and others had imprecise results, ie had wide confidence intervals.
What did it find?
- Eight of the included studies reporting short-term prescribing outcomes (up to six weeks after the consultation) showed that the various strategies for facilitating the shared decision making process, compared with usual care, reduced antibiotic prescribing by almost 40% (risk ratio [RR] 0.61, confidence interval [CI] 0.55 to 0.68).
- Moderate quality evidence from four trials suggested that the reduction in antibiotic prescribing occurred without an increase in further patient-initiated visits for the same illness episode (RR 0.87, 95% CI 0.74 to 1.03) but the effect was not statistically significant.
- We do not know if there was sustained reduction of antibiotic prescribing in the longer term (up to a year) as the few trials that reported this showed a non-significant trend only.
- The costs of the strategies for improving shared decision making was not reported in most of the studies and was not evaluated in this systematic review.
What does current guidance say on this issue?
The 2008 NICE guideline on self-limiting respiratory tract infections provides recommendations about the options for antibiotic prescribing in specific patient groups and about the shared decision making process. The guideline recommends that patients' or carers' concerns and expectations should be addressed when agreeing the use of the three antibiotic prescribing strategies: no prescribing, delayed prescribing and immediate prescribing. A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, acute cough/acute bronchitis.
Patients with severe infections, and people who are systemically very unwell, or at risk of serious illness and/or complications, and elderly people with some chronic conditions such as diabetes or heart failure can be considered for an immediate antibiotic prescribing strategy.
What are the implications?
There is an increasing interest and growing evidence on shared decision making as an important facet of health care. The studies included in this review were from several high-income European countries, including the UK and Canada so the findings are applicable to the UK. The variety of strategies that were used to facilitate shared decision making made it difficult to determine which components should be used in clinical practice or how to adapt the successful programmes to different primary care settings. There was insufficient data about the long term effect (up to one year and beyond) of the strategies used to facilitate shared decision making so it is not known whether they can reverse community-level antibiotic resistance trends.
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