Clinician and patient experiences with point-of-care testing for acute respiratory infections in primary care: a qualitative process evaluation of the PRUDENCE trial

Background Point-of-care testing is widely promoted for reducing unnecessary antibiotic prescribing, but how best to implement this approach in primary care is unclear. The 13-country PRUDENCE trial found that, compared with usual care alone, the addition of a point-of-care testing strategy, which could include tests for C-reactive protein, group A Streptococcus, or influenza A/B depending on the season (influenza or not) and predominant symptoms, to usual care did not reduce antibiotic prescribing among clinicians for patients with respiratory tract infections for whom the clinician was considering or had planned to prescribe antibiotics. In this embedded qualitative process evaluation of the trial, we aimed to understand how the point-of-care testing strategy was used and viewed by clinicians and patients. Methods In this qualitative process evaluation of the PRUDENCE trial, we conducted semi-structured interviews, online or in person, with patients and clinicians who participated in the trial at primary care clinics in England (UK), Ireland, Belgium, Greece, Georgia, and Germany. Patients (aged ≥18 years) were eligible if they had received point-of-care testing, with purposive sampling used to achieve variation in age, symptom presentation, type of test, and whether an antibiotic was prescribed. Clinicians were eligible if they had recruited patients and used point-of-care testing during the trial, with sampling aimed at capturing variation in professional role and clinical experience. Data collection and analysis took place concurrently until data saturation. We adopted pragmatic qualitative methodological orientation, by use of a reflexive thematic analysis with iteration within the multidisciplinary study team, to analyse the interviews and understand local contexts. Findings Between Feb 15, 2022, and July 20, 2023, 56 patients (41 [73%] women and 15 [27%] men, aged 19·0–79·0 years) participated in an interview. Between Feb 11, 2022, and Feb 22, 2024, 33 clinicians (21 [64%] women and 12 [36%] men) participated in an interview. Clinicians reported that point-of-care testing often strengthened their initial intentions to prescribe antibiotics. Point-of-care testing also influenced clinician decisions not to prescribe antibiotics when they were considering prescribing but had not yet made a firm decision to do so. Point-of-care testing often changed clinician prescribing decisions in cases of ambiguous clinical presentation, such as when patients presented with non-specific symptoms or severe discomfort, or when bacterial and viral presentations were clinically indistinguishable. Nevertheless, the prescribing implications of point-of-care testing results were frequently over-ridden, particularly when they conflicted with clinicians’ experiential knowledge; when there were doubts over test accuracy; when both patients and clinicians perceived symptoms as severe, textbook-like, or both; when timing of presentation introduced prognostic uncertainty; or when (perceived) patient expectations exerted pressure. Interpretation The availability of point-of-care testing is unlikely to be a sufficient solution alone for reducing antibiotic prescribing; multiple, related clinical and social factors need to be addressed alongside the introduction of point-of-care testing in routine primary care. Complementary interventions used together with point-of-care testing could more effectively address the multiple clinical and non-clinical drivers of antibiotic prescribing to help mitigate antimicrobial resistance. Funding Innovative Medicines Initiative 2 Joint Undertaking.