• Paul Little, Beth Stuart, Nick Francis, Elaine Douglas, Sarah Tonkin-Crine, Sibyl Anthierens, Cals Jochen W L JWL Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, , Hasse Melbye, Miriam Santer, Michael Moore, Samuel Coenen, Chris C Butler, Kerenza Hood, Mark Kelson, Maciek Godycki-Cwirko, Artur Mierzecki, Antoni Torres, Carl Llor, Melanie Davies, Mark Mullee, Gilly O'Reilly, Alike van der Velden, Geraghty Adam W A AWA Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Herman Goossens, Theo Verheij, Lucy Yardley, and GRACE consortium.
• 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). p.little@soton.ac.uk.
• Ann Fam Med. 2019 Mar 1; 17 (2): 125-132.

PurposeC-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.MethodsA 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.ResultsOf 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).ConclusionsInternet-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.© 2019 Annals of Family Medicine, Inc.

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