{'fraction_non_alphanumeric': 0.03207096554077107, 'fraction_numerical': 0.026953258273626747, 'mean_word_length': 5.311087190527449, 'pattern_counts': {'":': 0, '<': 2, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial

Summary Background High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems. Methods After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214. Results The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42–0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54–0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36–0·74, p<0·0001; enhanced communication 0·68, 0·50–0·89, p=0·003; combined 0·38, 0·25–0·55, p<0·0001). Interpretation Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. Funding European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.


Introduction
This section presented information describing the problem of antibiotic resistance for healthcare, its relation to antibiotic use, the medicalization of self-limiting illness creating the 'vicious circle' of encouraging re-consultation during subsequent episodes, and the difficulties in determining what patients presenting with LRTI in primary care may benefit from antibiotic treatment. The introduction discusses common concerns Physicians have when deciding whether or not to prescribe antibiotics and explains how physician training in communication skills and/or physician use of CRP point of care testing could potentially assist in the consultation.

C-Reactive Protein (CRP) point of care testing Training
The aim of the training in the use of point of care CRP was to inform physicians about how a point of care CRP result could assist in differentiating self-limiting from serious LRTI and making antibiotic prescribing decisions for LRTI. Physicians were shown how to interpret specific CRP values and how to use the test in their consultations.
The training starts by giving information on the background of CRP point of care testing and providing evidence to support its use in primary care for LRTI. Physicians were encouraged to use the test to differentiate between serious and self-limiting LRTIs. Common misconceptions were discussed. The module stresses that the test cannot distinguish between viral and bacterial infections in primary care and that it is not a stand-alone test, but should always be used alongside history taking and a physical examination.
Relevant cut off points were provided (see Table below The last section of the CRP training included two short video clips which showed the CRP test procedure, including how to take blood by using a finger prick, running the device and obtaining a result within 4 minutes. The training ends with a page summarising the key points of using point of care CRP testing in LRTI in primary care.

Enhanced Communication skills training and use of patient information booklet
The aim of the communication skills training was to facilitate physicians in using specific patient centred communication skills in the acute cough consultation, using three elements of an effective consultation: to gather information about patient beliefs and expectations, exchange information and agree management, and check patient understanding and concordance. Each of these has steps for the physician to follow (see Figure 1 below). The acronym of these seven steps is CHESTTS which helps ease of recollection in the English version of GRACE INTRO.
Furthermore, it was outlined how a patient booklet could be helpful in the consultation (with a focus on exchanging information and shared decision-making). The web pages presented information, backed by research evidence, to explain how a booklet could help to address patient concerns and maintain patient satisfaction. Physicians were encouraged to make use of tick boxes in the booklet to highlight specific sections which were relevant to individual patients in order to personalise the information. An online discussion forum was also provided for participating physicians but was used by relatively few.

Details of responses in post intervention survey
The sample who completed the post-intervention survey comprised 147 men and 199 women with a mean age of 42.3 (s.d. 8.9), who had practised for a mean of 19.2 (s.d. 9. 6

Variance of Random effects for GP, practice and Network.
Most of the variance in random effects was due to GP and practice while network contributed very little: the model with GP, practice and network was not significantly better than GP and practice model (LR test p=0.960). The ICCs for antibiotic prescribing were 0.13 for physicians 0.13, 0.05 for Practices, and 0.001for Networks when controlling for antibiotic prescribing.