Risk assessment and antibiotic prescribing decisions in children presenting to UK primary care with cough: a vignette study

Objectives: The validated “STARWAVe” clinical prediction rule (CPR) uses seven variables to guide risk assessment and antimicrobial stewardship in children presenting with cough(Short illness duration, Temperature, Age, Recession, Wheeze, Asthma,Vomiting). We aimed to compare General Practitioners’ (GPs) risk assessments and prescribing decisions to those of STARWAVe, and assess the influence of the CPR’s clinical variables. Setting: Primary care. Participants: 252 GPs, currently practising in the UK. Design: GPs were randomly assigned to view four (of a possible eight) clinical vignettes online. Each vignette depicted a child presenting with cough, who was described in terms of the seven STARWAVe variables. Systematically, we manipulated patient age (20 months vs. 5 years), illness duration (3 vs. 6 days),vomiting (present vs. absent) and wheeze (present vs. absent), holding the remaining STARWAVe variables constant. Outcome measures:Per vignette, GPs assessed risk of hospitalisation and indicated whether they would prescribe antibiotics or not. Results: GPs overestimated risk of hospitalisationin 9% of vignette presentations (88/1008) and underestimated it in 46% (459/1008). Despite underestimating risk, they overprescribed: 78% of prescriptions were unnecessary relative to GPs’ own risk assessments (121/156), while 83% were unnecessary relativeto STARWAVe risk assessments (130/156). All four of the manipulated variables influenced risk assessments, but only three influenced prescribing decisions: a shorter illness duration reduced prescribing odds (OR 0.14, 95% CI 0.08-0.27, p<0.001), while vomiting and wheeze increased them (ORvomit2.17, 95% CI 1.32-3.57, p=0.002; ORwheeze8.98, 95% CI 4.99-16.15, p