Primary care

Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat

Signe Flottorp, researcher, ^a Andrew D Oxman, director, ^a Kari Håvelsrud, research associate, ^a Shaun Treweek, researcher, ^a Jeph Herrin, research analyst. ^b

^a Department of Health Services Research, Norwegian Directorate for Health and Social Welfare, PO Box 8054 Dep, N-0031 Oslo, Norway, ^b Flying Buttress Associates, PO Box 2254, Charlottesville VA 22902, USA

Correspondence to: S Flottorp signe.flottorp{at}shdir.no

Objective: To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat.
Design: Unblinded, cluster randomised pretest-post-test trial.
Setting: 142 general practices in Norway.
Participants: 72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection.
Interventions: Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants.
Main outcome measures: Changes in rates of use of antibiotics, laboratory tests, and telephone consultations.
Results: Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practices in the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures.
Conclusions: Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice.

What is already known on this topic Interventions to change professional practice have small to moderate effects at best Multifaceted interventions targeted at identified barriers to change are more likely to be effective for implementing guidelines than a simple intervention selected by chance What this study adds Large variation exists in the extent of change before and after the delivery of tailored interventions to support implementing guidelines Rigorous methods are needed to evaluate interventions to change practice With passively delivered, complex interventions targeted at identified barriers there was only a 3% decrease in antibiotic prescribing for sore throat and a 5% decrease in test use for urinary tract infection in women