急性呼吸道感染抗生素处方干预 12 个月后：一项随机试验
Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial.
机构信息
Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye).
出版信息
Ann Fam Med. 2019 Mar;17(2):125-132. doi: 10.1370/afm.2356.
PURPOSE
C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial.
METHODS
A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months.
RESULTS
Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively).
CONCLUSIONS
Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.
目的
C 反应蛋白（CRP）有助于诊断下呼吸道感染（RTIs）。一项大型国际试验证明，基于互联网的 CRP 即时检测培训、增强沟通技巧培训或两者结合培训可降低 3 个月时的抗生素处方率，风险比（RR）分别为 0.68、0.53、0.38。本试验报告了其更长期的影响。
方法
共有 6 个国家的 246 家普通诊所被整群随机分为常规治疗组、基于互联网的 CRP 即时检测培训组、基于互联网的增强沟通技巧培训和互动手册组或两者联合干预组。主要结局是 12 个月时 RTIs 的抗生素处方率。
结果
在提供 3 个月数据的 228 家诊所中，有 74%提供了 12 个月的数据，且无明显的失访偏倚。在 3 个月至 12 个月期间，常规治疗组的 RTIs 抗生素处方率从 58%降至 51%，而 CRP 培训组从 35%升至 43%，两者联合干预组从 32%升至 45%；与常规治疗组相比，12 个月时的调整 RR 分别为 0.75（95%CI，0.51-1.00）和 0.70（95%CI，0.49-0.93）。在 3 个月至 12 个月期间，沟通培训的处方减少仍保持不变（分别为 41%和 40%，12 个月时的 RR 为 0.70[95%CI，0.49-0.94]）。尽管提供了免费的材料，但临床医生很少使用手册，很少使用 CRP 即时检测。沟通培训而非 CRP 培训仍能有效降低下呼吸道 RTIs 的处方率（RR=0.71[95%CI，0.45-0.99]和 RR=0.76[95%CI，0.47-1.06]），而两者都能有效降低上呼吸道 RTIs 的处方率（RR=0.60[95%CI，0.37-0.94]和 RR=0.58[95%CI，0.36-0.92]）。
结论
基于互联网的增强沟通技巧培训在更长期内仍能有效降低抗生素处方率。CRP 培训的早期改善效果减弱，且该培训对下呼吸道 RTIs 无效，而这是目前 CRP 检测的唯一适应证。
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