• Jochen W L Cals, Christopher C Butler, Rogier M Hopstaken, Kerenza Hood, and Geert-Jan Dinant.
• Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, Netherlands. j.cals@hag.unimaas.nl
• BMJ. 2009 Jan 1;338:b1374.

ObjectiveTo assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.DesignPragmatic, 2x2 factorial, cluster randomised controlled trial.Setting20 general practices in the Netherlands.Participants40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.Main Outcome MeasuresThe primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days' follow-up, reconsultation, clinical recovery, and patients' satisfaction and enablement.InterventionsGeneral practitioners' use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.ResultsGeneral practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days' follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients' recovery and satisfaction were similar in all study groups.ConclusionBoth general practitioners' use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients' recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.Trial RegistrationCurrent Controlled Trials ISRCTN85154857.

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