Background: The“STARWAVe” clinical prediction rule (CPR) uses seven factors to
guide risk assessment and antibiotic prescribing in children with cough (Short illness
duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting).
Aim: To assess the influence of STARWAVe factors on General Practitioners’ (GPs)
unaided risk assessments and prescribing decisions. We also explored two methods
of obtaining risk assessments and tested the impact of parental concern.
Design and setting: Experiment comprising clinical vignettes administered to 188 UK
GPs online.
Method: GPs were randomly assigned to view 32 (of 64) vignettes depicting children
with cough. Vignettes varied the STARWAVe factors systematically. Per vignette, GPs
assessed risk of deterioration in one of two ways (sliding scale vs. risk category
selection) and indicated whether they would prescribe antibiotics. Finally, they saw an
additional vignette, suggesting that the parent was concerned. Using mixed-effects
regressions, we measured the influence of STARWAVe factors, risk elicitation
method, and parental concern on GPs' assessments and decisions.
Results: Six STARWAVe risk factors correctly increased GPs’ risk assessments
(bssliding-scale0.66, ORscategory-selection1.61, ps0.001) while one incorrectly reduced
them (short duration: bsliding-scale=-0.31, ORcategory-selection=0.75, ps0.039). Conversely,
one STARWAVe factor increased prescribing odds (fever: OR=5.22, p<0.001) while
the rest either reduced them (short duration, age, recession: ORs0.70, ps<0.001) or
had no significant impact (wheeze, asthma, vomiting: ps0.065). Parental concern
increased risk assessments (bsliding-scale=1.29, ORcategory-selection=2.82, ps0.003) but
not prescribing (p=0.378).
Conclusion: GPs use some, but not all, STARWAVe factors when making unaided
risk assessments and prescribing decisions. Such discrepancies must be considered
when introducing CPRs to clinical practice.