Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2015 Nov 12;2015(11):CD010907.
doi: 10.1002/14651858.CD010907.pub2.

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care

Peter Coxeter  1 , Chris B Del Mar, Leanne McGregor, Elaine M Beller, Tammy C Hoffmann
Affiliations
Meta-Analysis

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care

Peter Coxeter et al. Cochrane Database Syst Rev. .

Abstract

Background: Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care.

Objectives: To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care.

Search methods: We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization.

Selection criteria: Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care.

Data collection and analysis: Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available.

Main results: We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms.

Authors' conclusions: Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

PubMed Disclaimer

Conflict of interest statement

Peter Coxeter: none declared Chris B Del Mar: none declared Leanne McGregor: none declared Elaine M Beller: none declared Tammy Hoffmann: none declared

Figures

1
1
PRISMA study flow diagram.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.1 Antibiotics prescribed, dispensed or decision to use (short‐term, index consultation to ≤ 6 weeks).
5
5
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.2 Antibiotics prescribed or dispensed (longer‐term, ≥ 12 months).
6
6
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.3 Antibiotic prescriptions (index consultation) (adjusted odds ratio).
7
7
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.4 Antibiotic prescriptions (index consultation) (adjusted risk ratio).
8
8
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.5 Antibiotic prescriptions (index consultation or population rate per unit of time) (adjusted risk difference).
9
9
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.6 Number or rate of re‐consultations (risk ratio).
10
10
Forest plot of comparison: 1 Shared decision making versus usual care (control), outcome: 1.7 Patient satisfaction with the consultation.
1.1
1.1. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 1 Antibiotics prescribed, dispensed or decision to use (short‐term, index consultation to ≤ 6 weeks).
1.2
1.2. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 2 Antibiotics prescribed or dispensed (longer‐term, ≥ 12 months).
1.3
1.3. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 3 Antibiotic prescriptions (index consultation) (adjusted odds ratio).
1.4
1.4. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 4 Antibiotic prescriptions (index consultation) (adjusted risk ratio).
1.5
1.5. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 5 Antibiotic prescriptions (index consultation or population rate per unit of time) (adjusted risk difference).
1.6
1.6. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 6 Number or rate of re‐consultations (risk ratio).
1.7
1.7. Analysis
Comparison 1 Shared decision making versus usual care (control), Outcome 7 Patient satisfaction with the consultation.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010907

References

References to studies included in this review

Altiner 2007 {published data only}
    1. Altiner A, Brockmann S, Sielk M, Wilm S, Wegscheider K, Abholz HH. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster‐randomized intervention study. Journal of Antimicrobial Chemotherapy 2007;60:638‐44. - PubMed
Briel 2006 {published data only}
    1. Briel M, Langewitz W, Tschudi P, Young J, Hugenschmidt C, Bucher HC. Communication training and antibiotic use in acute respiratory tract infections. A cluster randomised controlled trial in general practice. Swiss Medical Weekly 2006;136:241‐7. - PubMed
Butler 2012 {published data only}
    1. Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, et al. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ 2012;344:d8173. - PMC - PubMed
Cals 2009 {published data only}
    1. Cals JW, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009;338:b1374. - PMC - PubMed
Cals 2013 {published data only}
    1. Cals JW, Bock L, Beckers PJ, Francis NA, Hopstaken RM, Hood K, et al. Enhanced communication skills and C‐reactive protein point‐of‐care testing for respiratory tract infection: 3.5‐year follow‐up of a cluster randomized trial. Annals of Family Medicine 2013;11:157‐64. - PMC - PubMed
Francis 2009 {published data only}
    1. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:b2885. - PMC - PubMed
Légaré 2011 {published data only}
    1. Légaré F, Labrecque M, LeBlanc A, Njoya M, Laurier C, Cote L, et al. Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial. Health Expectations 2011;14(Suppl 1):96‐110. - PMC - PubMed
Légaré 2012 {published data only}
    1. Legare 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. Canadian Medical Association Journal 2012;184:E726‐34. - PMC - PubMed
Little 2013 {published data only}
    1. Little P, Stuart B, Francis N, Douglas E, Tonkin‐Crine S, Anthierens S, et al. Effects of internet‐based training on antibiotic prescribing rates for acute respiratory‐tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 2013;382:1175‐82. - PMC - PubMed
Welschen 2004 {published data only}
    1. Welschen I, Kuyvenhoven MM, Hoes AW, Verheij TJ. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ 2004;329:431. - PMC - PubMed

References to studies excluded from this review

Bourgeois 2010 {published data only}
    1. Bourgeois F, Linder J, Johnson S, Co J, Fiskio J, Ferris T. Impact of a computerized template on antibiotic prescribing for acute respiratory infections in children and adolescents. Clinical Pediatrics 2010;49:976‐83. - PubMed
Gonzales 2013 {published data only}
    1. Gonzales R, Anderer T, McCulloch C, Maselli J, Bloom Jr F, Graf T, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Internal Medicine 2013;173:267‐73. - PMC - PubMed
Pshetizky 2003 {published data only}
    1. Pshetizky Y, Naimer S, Shvartzman P. Acute otitis media‐‐a brief explanation to parents and antibiotic use. Family Practice 2003;20:417‐9. - PubMed
Regev‐Yochay 2011 {published data only}
    1. Regev‐Yochay G, Raz M, Dagan R, Roizin H, Morag B, Hetman S, et al. Reduction in antibiotic use following a cluster randomized controlled multifaceted intervention: the Israeli Judicious Antibiotic Prescription Study. Clinical Infectious Diseases 2011;53:33‐41. - PubMed
Samore 2005 {published data only}
    1. Samore M, Bateman K, Alder S, Hannah E, Donnelly S, Stoddard G, et al. Clinical decision support and appropriateness of antimicrobial prescribing: a randomized trial. JAMA 2005;294:2305‐14. - PubMed
Taylor 2005 {published data only}
    1. Taylor J, Kwan‐Gett T, McMahon Jr E. Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial. Pediatric Infectious Disease Journal 2005;24:489‐93. - PubMed

References to ongoing studies

Altiner 2012 {published data only}
    1. Altiner A, Berner R, Diener A, Feldmeier G, Kochling A, Loffler C, et al. Converting habits of antibiotic prescribing for respiratory tract infections in German primary care‐‐the cluster‐randomized controlled CHANGE‐2 trial. BMC Family Practice 2012;13:124. - PMC - PubMed

Additional references

Ahovuo‐Saloranta 2014
    1. Ahovuo‐Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW Jr, Makela M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database of Systematic Reviews 2014, Issue 2. [DOI: 10.1002/14651858.CD000243.pub3] - DOI - PubMed
Andrews 2012
    1. Andrews T, Thompson M, Buckley DI, Heneghan C, Deyo R, Redmond N, et al. Interventions to influence consulting and antibiotic use for acute respiratory tract infections in children: a systematic review and meta‐analysis. PloS One 2012;7(1):e30334. [PUBMED: 22299036] - PMC - PubMed
Arnold 2005
    1. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database of Systematic Reviews 2005, Issue 4. [DOI: 10.1002/14651858.CD003539.pub2] - DOI - PMC - PubMed
Arroll 2002
    1. Arroll B, Goodyear‐Smith F, Thomas DR, Kerse N. Delayed antibiotic prescriptions: what are the experiences and attitudes of physicians and patients?. Journal of Family Practice 2002;51:954‐9. - PubMed
Boonacker 2010
    1. Boonacker CW, Hoes AW, Dikhoff MJ, Schilder AG, Rovers MM. Interventions in health care professionals to improve treatment in children with upper respiratory tract infections. International Journal of Pediatric Otorhinolaryngology 2010;74(10):1113‐21. [PUBMED: 20692051] - PubMed
Butler 1998
    1. Butler CC, Rollnick S, Kinnersley P, Jones A, Stott N. Reducing antibiotics for respiratory tract symptoms in primary care: consolidating 'why' and considering 'how'. British Journal of General Practice 1998;48:1865‐70. - PMC - PubMed
Butler 2001
    1. Butler CC, Kinnersley P, Prout H, Rollnick S, Edwards A, Elwyn G. Antibiotics and shared decision‐making in primary care. Journal of Antimicrobial Chemotherapy 2001;48:435‐40. - PubMed
Charles 1997
    1. Charles C, Gafni A, Whelan T. Shared decision‐making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 1997;44:681‐92. - PubMed
Chung 2007
    1. Chung A, Perera R, Brueggemann AB, Elamin AE, Harnden A, Mayon‐White R, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. BMJ 2007;335:429. - PMC - PubMed
Costelloe 2010
    1. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta‐analysis. BMJ 2010;340:c2096. - PubMed
Coyne 2013
    1. Coyne I, O'Mathuna DP, Gibson F, Shields L, Sheaf G. Interventions for promoting participation in shared decision‐making for children with cancer. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD008970.pub2] - DOI - PubMed
Duncan 2010
    1. Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD007297.pub2] - DOI - PMC - PubMed
Elwyn 2003
    1. Elwyn G, Edwards A, Wensing M, Hood K, Atwell C, Grol R. Shared decision making: developing the OPTION scale for measuring patient involvement. Quality & Safety in Health Care 2003;12(2):93‐9. [PUBMED: 12679504] - PMC - PubMed
Elwyn 2012
    1. Elwyn G, Frosch D, Thomson R, Joseph‐Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. Journal of General Internal Medicine 2012;27:1361‐7. - PMC - PubMed
Elwyn 2013
    1. Elwyn G, Lloyd A, Joseph‐Williams N, Cording E, Thomson R, Durand MA, et al. Option Grids: shared decision making made easier. Patient Education and Counseling 2013;90:207‐12. - PubMed
Giguere 2012
    1. Giguere A, Legare F, Grad R, Pluye P, Haynes RB, Cauchon M, et al. Decision boxes for clinicians to support evidence‐based practice and shared decision making: the user experience. Implementation Science 2012;7:72. - PMC - PubMed
Gill 2006
    1. Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Family Medicine 2006;38:349‐54. - PubMed
Gillies 2015
    1. Gillies M, Ranakusuma A, Hoffmann T, Thorning S, McGuire T, Glasziou P, et al. Common harms from amoxicillin: a systematic review and meta‐analysis of randomized placebo‐controlled trials for any indication. Canadian Medical Association Journal 2015;187(1):E21‐31. [PUBMED: 25404399] - PMC - PubMed
Gonzales 1997
    1. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901‐4. - PubMed
Gonzales 2001
    1. Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory infections in the United States. Clinical Infectious Diseases 2001;33:757‐62. - PubMed
GRADE Working Group 2004
    1. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490‐4. [DOI: ] - PMC - PubMed
GRADEproGDT 2015 [Computer program]
    1. McMaster University (developed by Evidence Prime, Inc.). GRADEpro Guideline Development Tool [www.guidelinedevelopment.org] [Computer program]. Version 12 August 2015. Hamilton: McMaster University (developed by Evidence Prime, Inc.), 2015.
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Hoffmann 2014
    1. Hoffmann T, Glasziou P, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ (Clinical research ed.) 2014;348:g1687. [PUBMED: 24609605] - PubMed
Kenealy 2013
    1. Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD000247.pub3] - DOI - PMC - PubMed
Kinnersley 2007
    1. Kinnersley P, Edwards A, Hood K, Cadbury N, Ryan R, Prout H, et al. Interventions before consultations for helping patients address their information needs. Cochrane Database of Systematic Reviews 2007, Issue 3. [DOI: 10.1002/14651858.CD004565.pub2] - DOI - PMC - PubMed
Légaré 2013
    1. Légaré F, Moumjid‐Ferdjaoui N, Drolet R, Stacey D, Härter M, et al. Core competencies for shared decision making training programs: insights from an international, interdisciplinary working group. Journal of Continuing Education in the Health Professions 2013;33(4):267‐73. [DOI: 10.1002/chp.21197] - DOI - PMC - PubMed
Légaré 2014
    1. Légaré F, Stacey D, Turcotte S, Cossi MJ, Kryworuchko J, Graham ID, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews 2014, Issue 9. [DOI: 10.1002/14651858.CD006732.pub3] - DOI - PubMed
Makoul 2006
    1. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Education and Counseling 2006;60:301‐12. - PubMed
Prochaska 1992
    1. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors.. American Psychologist 1992;47:1102–14. - PubMed
Ranji 2008
    1. Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Medical Care 2008;46(8):847‐62. [PUBMED: 18665065] - PubMed
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Smith 2014
    1. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2014, Issue 3. [DOI: 10.1002/14651858.CD000245.pub3] - DOI - PubMed
Spatz 2012
    1. Spatz ES, Spertus JA. Shared decision making: a path toward improved patient‐centered outcomes. Circulation: Cardiovascular Quality and Outcomes 2012;5:e75‐7. - PubMed
Spinks 2013
    1. Spinks A, Glasziou PP, Mar CB. Antibiotics for sore throat. Cochrane Database of Systematic Reviews 2013, Issue 11. [DOI: 10.1002/14651858.CD000023.pub4] - DOI - PubMed
Stacey 2014
    1. Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2014, Issue 1. [DOI: 10.1002/14651858.CD001431.pub4] - DOI - PubMed
Thoolen 2013
    1. Thoolen B, Ridder D, Lensvelt‐Mulders G. Patient‐oriented interventions to improve antibiotic prescribing practices in respiratory tract infections: a meta‐analysis. Health Psychology Review 2012;6 Special Issue(1):92‐112.
van der Velden 2012
    1. Velden AW, Pijpers EJ, Kuyvenhoven MM, Tonkin‐Crine SK, Little P, Verheij TJ. Effectiveness of physician‐targeted interventions to improve antibiotic use for respiratory tract infections. British Journal of General Practice 2012;62(605):e801‐7. [PUBMED: 23211259] - PMC - PubMed
Venekamp 2015
    1. Venekamp RP, Sanders S, Glasziou PP, Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2015, Issue 6. [DOI: 10.1002/14651858.CD000219.pub4] - DOI - PMC - PubMed
Vodicka 2013
    1. Vodicka TA, Thompson M, Lucas P, Heneghan C, Blair PS, Buckley DI, et al. Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review. British Journal of General Practice 2013;63(612):e445‐54. [PUBMED: 23834881] - PMC - PubMed
WHO 2001
    1. World Health Organization. WHO Global Strategy for Containment of Antimicrobial Resistance. http://www.who.int/csr/resources/publications/drugresist/en/EGlobal_Stra.... Geneva, 2001 (accessed 15 July 2013).
WHO 2012
    1. World Health Organization. The evolving threat of antimicrobial resistance: options for action. http://whqlibdoc.who.int/publications/2012/9789241503181_eng.pdf 2012 (accessed 15 July 2013).
Wood 2013
    1. Wood F, Phillips C, Brookes‐Howell L, Hood K, Verheij T, Coenen S, et al. Primary care clinicians' perceptions of antibiotic resistance: a multi‐country qualitative interview study. Journal of Antimicrobial Chemotherapy 2013;68:237‐43. - PubMed

References to other published versions of this review

Coxeter 2014
    1. Coxeter P, Hoffmann T, Mar Chris B. Shared decision making for acute respiratory infections in primary care. Cochrane Database of Systematic Reviews 2014, Issue 1. [DOI: 10.1002/14651858.CD010907] - DOI - PMC - PubMed

Publication types

Substances