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Objective: To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection. Design: Pragmatic, 2x2 factorial, cluster randomised controlled trial. Setting: 20 general practices in the Netherlands. Participants: 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection. Main outcome measures: The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days' follow-up, reconsultation, clinical recovery, and patients' satisfaction and enablement. Interventions: General practitioners' use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care. Results: General practitioners in the C reactive protein test group prescribed antibiotics to31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days' follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was nonsignificant). Patients' recovery and satisfaction were similar in all study groups. Conclusion: Both general practitioners' use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients' recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care. Trial registration: Current Controlled Trials ISRCTN85154857.

Original publication




Journal article


BMJ (Online)

Publication Date





1112 - 1115