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Table 3 Characteristics of studies with baseline data and post-intervention measurements

From: Reduction of antibiotic prescriptions for acute respiratory tract infections in primary care: a systematic review

Study, country and study design Inclusion criteria for patients Number of patients (I/C)*; average age of patients (I/C)*; number of physicians (I/C*) Intervention and control group* Data collection periods Number of adverse events (e.g. hospitalisations, deaths) or side effects
Bjerrum et al. 2006
Spain
Two-armed cluster-randomised controlled intervention study
> 14 years
Consultation due to upper/lower RTI
T0: 1114/not performed; n.r.
T1: 1674/2462; n.r.
Physicians on T0: 52
Physicians on T1: 17/35
IG: training for physicians + feedback and reflection of baseline—Abx prescription rate + introduction to POCT (CRP and RADT)
CG: care as usual
Abx prescription rate right after initial consultation:
T0: only for IG (Dec.–Feb. 02/03)
T1: 1 year after I (Dec.–Feb. 04/05)
n.r.
Altiner et al. 2007
Germany
Two-armed cluster-randomised controlled intervention study
> 16 years
First episode of acute cough (no cough for the previous 8 weeks)
T0: 753/898; 42.2/42
T1: 675/885; 44.9/43.9
T2: 787/920; 41.7/41.8
Physicians on T0: 104
Physicians on T1: 42/44
Physicians on T2: 28/33
IG: communication training for physicians + handouts for patients and waiting room poster
CG: care as usual
Abx prescription rate right after initial consultation:
T0: Nov.–Jan. 03/04
T1: 6 weeks after I (Feb.–Apr. 2004)
T2: 1 year after I (Jan.–Mar. 2005)
n.r.
Gonzales et al. 2013
USA
Three-armed cluster-randomised controlled intervention study
13–64 years
Consultation due to uncomplicated acute bronchitis (ICD-9-CM code 466.0; ICD-9-CM code 490)
(No RTI consultation in the last 30 days)
T0:
Arm 1: 3639; n.r.
Arm 2: 2974; n.r.
Arm 3: 3195; n.r.
T1:
Arm 1: 1001; n.r.
Arm 2: 1017; n.r.
Arm 3: 950; n.r.
11 “practice centres” for each study arm
Arm 1: 68 physicians
Arm 2: 41 physicians
Arm 3: 46 physicians
IG 1:
1) Training for physicians (via “clinical champion”)
2) Patient brochure
3) Examination room poster with clinical algorithm for acute bronchitis
IG 2:
1) and 2)
instead of 3) ➔ clinical algorithm integrated in practice software
CG: care as usual
Abx prescription rate right after initial consultation:
T0: baseline (3 successive winter periods from Oct. to Mar. 2007–2009)
T1: Oct. 2009–Mar. 2010
Hospitalisations and emergency room visits occurred rarely in all study arms (no published data)
Gjelstad et al. 2013**
Norway
Two-armed cluster-randomised controlled intervention study
> 13 years
Consultation due to acute RTI
Number of RTI consultations on T0 for patients > 13 years: 43880/46518
Number of RTI-consultations on T1 for patients > 13 years: 47522/47868
Number of physicians on T0:
39 education groups (202 physicians); n.r./41 education groups (232 physicians); n.r.
Number of physicians on T1:
39 education groups (183 physicians); 48.3/40 education groups (199 physicians); 49.7
IG 1:
1) Meeting: guidelines for RTI and strategy of delayed prescribing; installation of additional program for 2 of 4 practice software (reminders to document the number of days for delayed prescribing)
2) Meeting: feedback on prescribing rates based on individual data
3) 1-day seminar: reinforcement of intervention
IG 2:
Training regarding adequate pharmacotherapy on patients > 70 years in 2 group meetings and 1-day peer visit, based on individual prescribing rates; antibiotic therapy was not content
2 data collection periods for Abx prescription rate:
T0: (Abx prescription rate during 1 year before I by retrospective data analysis with special software)
I: Dec. 2005–May 2006
T1: Abx prescription rate during 1 year (after I)
n.r.
Little et al. 2013
Belgium, Spain, Wales, Great Britain, Poland, Netherlands
Multinational cluster-randomised controlled intervention study, factorial study design
> 18 years
First episode of acute cough (max. of 28 days)
First episode of upper/lower RTI
T0: 6771; 49.6
T1: 4264
Arm 1 = CG: 870
Arm 2 = IG 1: 1062
Arm 3 = IG 2: 1170
Arm 4 = IG 3: 1162
Factorial groups:
POCT-CRP-group (arms 2 + 4): 2224; 51.0
CG for CRP-POCT = no CRP-POCT group (arms 1 + 3): 2040; 50.9
CST-group (arms 3 + 4): 2332; 51.1
CG for CST = no CST group (arms 1 + 2): 1932; 50.8
Physicians on T0: 259 practices
Physicians on T1: 228 practices; 372 physicians
CG:
care as usual
IG 1:
Internet-based training for CRP-POCT
IG 2:
Internet-based communication training
IG 3:
Internet-based training for communication training + CRP-POCT
Abx prescription rate right after initial consultation:
T0: Oct.–Dec. 2010
T1: Feb.–May 2011
Deaths: none
Hospitalisations:
CG: 2
IG 1: 10
IG 2: 6
IG 3: 12
Difference in hospitalisation rate between cumulative CRP group and cumulative non-CRP group: 22/8 (OR* = 2.91, 95% CI 0.96–8.85, p = 0.06)
Cluster-adjusted: OR* = 2·61, 95% CI 1.07–6.35, p = 0.034
Andreeva et al. 2014
Russia
Two-armed cluster-randomised controlled intervention study
Patients ≥ 18 years with first episode of acute cough/lower RTI (including acute bronchitis, pneumonia and infectious exacerbations of COPD or asthma) T0 for subgroup of 13 GPs: 47/34; n.r.
T1 for subgroup of 13 GPs: 81/62; n.r.
T1: 101/78; 50.8/50.8
Physicians: a total of 18 GPs participated, but only 13 GPs participated in baseline and intervention period
IG:
1) Registration of patient’s symptoms, clinical examination and therapy in electronic case report form
2) 2 training sessions concerning the CRP test, guidelines about the interpretation of CRP results, discussion about paper cases of patients with different RTIs and different CRP values
CG: 1)
Abx prescription rate during I period (12 weeks—from 30 January to 30 April 2010)
T0: only for 13 GPs 2 months before data collection
T1: Abx prescription rate right after initial consultation
T2: Abx prescription rate 2 weeks after initial consultation
n.r.
Gulliford et al. 2014
UK
Two-armed cluster-randomised controlled intervention study
Patients aged 18–59 years consulting for RTI T0: 292,398/264,137; n.r.
T1: 294,929/263,895; n.r.
50 family practices were allocated to IG, and 50 practices were allocated to CG
IG: decision support tool including a summary of antibiotic prescribing recommendations and research evidence concerning no antibiotic or delayed antibiotic prescribing strategies + a single-sided patient information sheet, information on the definite indications for antibiotic prescription
CG: care as usual
Abx prescription rate during two 12-month data collection periods:
T0: 12-month period before I
T1: 12-month period after I
n.r.
Meeker et al. 2016
USA
Cluster-randomised controlled intervention study, 2 × 2 × 2 factorial design
Patients ≥ 18 years with no visit for acute RTI within the prior 30 days No. of patients: 14,753/16,959
No. of patients T0/T1 for each study group:
IG 1: 2132/2388
IG 2: 1491/1979
IG 3: 1236/1620
IG 1 + 2: 1977/2131
IG 1 + 3: 1511/2014
IG 2 + 3: 2362/2240
IG 1 + 2 + 3: 2178/2492
CG: 1866/2095
No. of practices/physicians for T0 and T1: 47/248
No. of practices/physicians/mean age of patients for each study group:
IG 1: 6/42/48
IG 2: 7/35/53
IG 3: 4/20/47
IG 1 + 2: 6/34/50
IG 1 + 3: 6/35/48
IG 2 + 3: 6/27/49
IG 1 + 2 + 3: 6/28/43
CG: 6/27/49
7 IGs:
I1: “Suggested alternatives”—EHR-based intervention (resembling CDSS) triggered by a RTI. User gets a list of alternative treatment (e.g. over-the-counter medicine)
I2: “Accountable justification”—EHR-based I triggered by antibiotic prescriptions. User must explicitly justify the treatment decision.
I3: “Peer comparison”—monthly e-mail with individual number and proportion of adequate and inadequate antibiotic prescriptions for acute RTI compared with other physicians
I4: I1 + I2
I5: I1 + I3
I6: I2 + I3
I7: I1 + I2 + I3
CG: care as usual
Abx prescription rate for inadequate antibiotic prescriptions for acute RTI
T0: 18-month baseline for each practice
T1: 18-month period (beginning Nov. 2011 to Oct. 2012, ending for the last practice in Apr. 2014)
Return visit rate within 30 days after initial consultation in which no antibiotics were prescribed:
Among CG practices: 0.43% (95% CI 0.25–0.70)
Among I2 and I3 practices: 1.41% (95% CI 1.06–1.85, p < 0.001)
Among return visits, a random sample of 33 cases across all study groups was monitored for complications/hospitalizations:
11 cases of pneumonia, 1 otitis media, 1 pneumonia + otitis media
1 hospitalisation for pneumonia
  1. *Abx prescription rate antibiotic prescription rate, CRP C-reactive protein, CDSS clinical decision support systems, CG control group, EHR electronic health record, IG intervention group, n.r. not reported, POCT point-of-care-testing, RADT rapid antigen detection test, RTI respiratory tract infection
  2. **Unpublished data for patient sample ≥ 13 years, provided by Gjelstad et al.