Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial facilitated by Professor Chris Del Mar

Reference:
Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. Can Med Assoc J 2012.

Professor Chris Del Mar presented this cluster RCT – relevant to the CREMARA – together with the ‘Shared Decision Making Support Tools’ (appendix to the paper).

Associate Professor Elaine Beller presented the Study Protocol (BMC Fam Pract 2011) and pilot Protocol (BMC Fam Pract 2007)

Issues:
1 Randomisation after baseline data collected is suboptimal. Although loss from each arm was similar, some baseline characteristics were not balanced (eg Table 3 and Table 4).
An added refinement might be to stratify by prescribing rates (detected in the Baseline phase).

2 The patient recruitment was low: average of 3/physician for the whole season (and some physicians recruited none!). Presumably this was because each patient had to be recruited by the RA in the waiting room. But does this mean that the patients influenced might have been higher – might other patients presenting with ARIs have reduced prescribing rates? IE to what extent is the intervention generalisable (or do we have to intervene with every patients in the waiting room to get this effect)? See 3 below for a possible way of addressing this.

3 Outcomes: ‘intention to use antibiotics’ is clearly a sub-optimal primary outcome because it is so soft. In Australia (and UK) it would be possible to measure actual ABs dispensed. In the meantime, it would be good to know whether there are any measures of harder outcomes, including ABs prescribed. I will write to France Légaré to ask if they have access to these data. (This would also address issue 2 above).

4 What was the intervention? As with all complex interventions, the effective components are sometimes hard to tease out. In this case, was it the ‘epidemiological’ education that did the trick, or the introduction to ‘shared decision-making’?

5 More minor things:

a. More clusters would be better (and easier in Australia where practices appear to be smaller)
b. What’s the commercial influence? It is fee-for-service, or capitation, (or blended) payment systems? (In Australia, GPs might prescribe ABs because they think it makes commercial sense – “It’s what the patients come for, why wouldn’t I give it to them?”)
c. Was there contamination (despite the controls not having access to the Training, because the GPs were academic doctors who may all have known about the trial, its intent, and its hoped for outcome?