Risk assessment and antibiotic prescribing decisions in children presenting to UK primary care with cough: a vignette study
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Supporting information
Published version
Author(s)
Nurek, Martine
Delaney, Brendan C
Kostopoulou, Olga
Type
Journal Article
Abstract
Objectives: The validated “STARWAVe” clinical prediction rule (CPR) uses seven variables to guide risk assessment and antimicrobial stewardship in children presenting with cough(Short illness duration, Temperature, Age, Recession, Wheeze, Asthma,Vomiting). We aimed to compare General Practitioners’ (GPs) risk assessments and prescribing decisions to those of STARWAVe, and assess the influence of the CPR’s clinical variables. Setting: Primary care. Participants: 252 GPs, currently practising in the UK. Design: GPs were randomly assigned to view four (of a possible eight) clinical vignettes online. Each vignette depicted a child presenting with cough, who was described in terms of the seven STARWAVe variables. Systematically, we manipulated patient age (20 months vs. 5 years), illness duration (3 vs. 6 days),vomiting (present vs. absent) and wheeze (present vs. absent), holding the remaining STARWAVe variables constant. Outcome measures:Per vignette, GPs assessed risk of hospitalisation and indicated whether they would prescribe antibiotics or not. Results: GPs overestimated risk of hospitalisationin 9% of vignette presentations (88/1008) and underestimated it in 46% (459/1008). Despite underestimating risk, they overprescribed: 78% of prescriptions were unnecessary relative to GPs’ own risk assessments (121/156), while 83% were unnecessary relativeto STARWAVe risk assessments (130/156). All four of the manipulated variables influenced risk assessments, but only three influenced prescribing decisions: a shorter illness duration reduced prescribing odds (OR 0.14, 95% CI 0.08-0.27, p<0.001), while vomiting and wheeze increased them (ORvomit2.17, 95% CI 1.32-3.57, p=0.002; ORwheeze8.98, 95% CI 4.99-16.15, p<0.001). Conclusions: Relative to STARWAVe, GPs underestimated riskof hospitalisation, overprescribed, and appeared to misinterpret illness duration (prescribing for longer rather than shorter illnesses). It is important to ascertain discrepancies between CPRs and current clinical practice. This has implications for the integration of CPRs into the electronic health record and the provision of intelligible explanations to decision maker.
Date Issued
2020-07-20
Date Acceptance
2020-05-28
Citation
BMJ Open, 2020, 10
ISSN
2044-6055
Publisher
BMJ Journals
Journal / Book Title
BMJ Open
Volume
10
Copyright Statement
© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ. https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
License URL
Sponsor
National Institute for Health Research
Grant Number
n/a
Subjects
health informatics
medical education & training
primary care
public health
respiratory infections
1103 Clinical Sciences
1117 Public Health and Health Services
1199 Other Medical and Health Sciences
Publication Status
Published
Article Number
ARTN e035761
Date Publish Online
2020-07-20