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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 doi: (Published 29 July 2009) Cite this as: BMJ 2009;339:b2885
  1. Nick A Francis, medical research council health services fellow12,
  2. Christopher C Butler, professor of primary care medicine, head of department of primary care and public health1,
  3. Kerenza Hood, reader in statistics, director of south east Wales trials unit12,
  4. Sharon Simpson, senior research fellow12,
  5. Fiona Wood, lecturer1,
  6. Jacqueline Nuttall, senior trial manager12
  1. 1Department of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN
  2. 2South East Wales Trials Unit, School of Medicine, Cardiff University
  1. Correspondence to: N Francis francisna{at}
  • Accepted 4 March 2009


Objective To establish whether an interactive booklet on respiratory tract infections in children reduces reconsultation for the same illness episode, reduces antibiotic use, and affects future consulting intentions, while maintaining parental satisfaction with care.

Design Pragmatic cluster randomised controlled trial.

Setting 61 general practices in Wales and England.

Participants 558 children (6 months to 14 years) presenting to primary care with an acute respiratory tract infection (7 days or less). Children with suspected pneumonia, asthma or a serious concomitant illness, or needing immediate hospital admission were excluded. Three withdrew and 27 were lost to follow-up, leaving 528 (94.6%) with main outcome data.

Interventions Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during consultations with recruited patients (and provide it as a take home resource). Clinicians in the control group conducted their consultations as usual.

Main outcome measures The proportion of children who attended a face-to-face consultation about the same illness during the two week follow-up period. Secondary outcomes included antibiotic prescribing, antibiotic consumption, future consulting intentions, and parental satisfaction, reassurance, and enablement.

Results Reconsultation occurred in 12.9% of children in the intervention group and 16.2% in the control group (absolute risk reduction 3.3%, 95% confidence interval −2.7% to 9.3%, P=0.29). Using multilevel modelling (at the practice and individual level) to account for clustering, no significant difference in reconsulting was noted (odds ratio 0.75; 0.41 to 1.38). Antibiotics were prescribed at the index consultation to 19.5% of children in the intervention group and 40.8% of children in the control group (absolute risk reduction 21.3%, 95% confidence interval 13.7 to 28.9), P<0.001). A significant difference was still present after adjusting for clustering (odds ratio 0.29; 0.14 to 0.60). There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness (odds ratio 0.34; 0.20 to 0.57). Satisfaction, reassurance, and parental enablement scores were not significantly different between the two groups.

Conclusions Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to consult without reducing satisfaction with care.

Trial registration Current Controlled Trials ISRCTN46104365


  • We are grateful to all the patients, parents, and clinicians who participated in the development of the intervention and the trial. We gratefully acknowledge the support received from the Primary Care Research Network and from all participating research networks. We thank the administrative staff in the Department of Primary Care and Public Health and the South-East Wales Trials Unit who worked hard to ensure the success of the study. We also gratefully acknowledge the contribution made by members of the independent trial steering committee.

  • Contributors: CB conceived the study. NF, FW, CB, KH, and SS developed the intervention. CB, NF, KH, and SS wrote the protocol. All contributors sat on the study management group. NF managed the trial and NF and JN conducted the telephone interviews. NF wrote the first draft of the paper and all authors made subsequent contributions. NF is the guarantor.

  • Funding: We gratefully acknowledge funding from the Medical Research Council and the Welsh Assembly Government in the form of a joint Health Services Fellowship for NF. Funding for the development of the training website was from an educational grant from Pfizer UK. The South-East Wales Trials Unit is funded by the Welsh Office for Research and Development. All authors declare that this work was conducted independently from the study funders.

  • Sponsorship: This study was sponsored by Cardiff University.

  • Competing interests: None declared.

  • Ethical approval: This study was approved by the South East Wales Local Research Ethics Committee (Reference number 04/WSE04/109).

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