Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial

Eefje G. P. M. de Bont; Geert-Jan Dinant; Gijs Elshout; Gijs van Well; Nick A. Francis; Bjorn Winkens; Jochen W. L. Cals

doi:10.1370/afm.2265

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Figure 1
Trial participant recruitment and inclusion.
FP = family physician.

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Table 1

Patient Characteristics by Group and Overall

Characteristic	Usual Care Group (n = 13,410)	Access to Booklet Group (n = 11,945)	Total (N = 25,355)
Age, mean (SD), y	3.2 (2.7)	3.3 (2.7)	3.2 (2.7)
Male, No. (%)	7,100 (52.9)	6,313 (52.9)	13,413 (52.9)
Parent socioeconomic status, No. (%)^a
Low	2,261 (16.9)	1,826 (15.4)	4,087 (16.2)
Middle	9,055 (67.8)	8,459 (71.5)	17,514 (69.5)
High	2,032 (15.2)	1,550 (13.1)	3,582 (14.2)
Top ICPC codes, No. (%)
A03.00: fever	2,471 (18.5)	2,174 (18.2)	4,645 (18.4)
R74.00: acute upper respiratory tract infection	2,653 (19.8)	2,357 (19.9)	5,010 (19.8)
H71.00: acute otitis media/myringitis	1,872 (14.0)	1,604 (13.5)	3,476 (13.8)

ICPC = International Classification of Primary Care.
↵a Socioeconomic status numbers do not add up to totals in column because of missing data.

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Table 2

Primary and Secondary Outcomes in the Total Trial Population

Outcome	Usual Care Group, No. (%) (n = 13,410)	Access to Booklet Group, No. (%) (n = 11,945)	Access to Booklet, OR (95% CI)	Use of Booklet, No. (%) (n = 3,407)	Use of Booklet, Unadjusted OR (95% CI)^a	Use of Booklet, Adjusted OR (95% CI)^b
Primary outcome
Antibiotic prescription during index consultation	3,375 (25.2)	2,809 (23.5)	0.90 (0.79-1.02)	746 (21.9)	0.83 (0.74-0.94)^c	0.85 (0.75-0.97)^c,^d
Secondary outcomes
Reconsultation of OOH within 2 wk	861 (5.5)	741 (5.4)	0.95 (0.83-1.09)	165 (4.3)	0.97 (0.80-1.16)	0.95 (0.79-1.15)
Antibiotic prescription OOH from index consultation through 2-wk follow-up	3,570 (26.6)	2,975 (24.9)	0.90 (0.79-1.02)	797 (23.4)	0.84 (0.75-0.95)^c	0.86 (0.76-0.96)^c,^d
Reconsultation of OOH during 6-mo study period	1,262 (8.1)	1,145 (8.3)	0.99 (0.84-1.18)	283 (7.3)	0.97 (0.74-1.29)	0.94 (0.71-1.25)
Referral to secondary care at index consultation^e	1,066 (7.9)	893 (7.5)	1.03 (0.87-1.21)	n/a	n/a	n/a
Prescription of any kind	5,162 (38.5)	4,245 (35.5)	0.87 (0.77-0.97)^c	1,114 (32.7)	0.77 (0.70-0.86)^c	0.79 (0.71-0.87)^c,^d

n/a = not applicable because parents of children who were referred did not receive the booklet; OOH = out-of-hours care; OR = odds ratio.
↵a Compared with control group. Corrected for center size.
↵b Compared with control group. Adjusted for age, sex, socioeconomic status.
↵c Significant difference compared with control group (P <.05).
↵d Significant difference compared with control group (P <.05). In complier-adjusted causal effect (CACE) analysis, OR (95% CI) was 0.71 (0.63-0.79) for antibiotic prescription during index consultation; 0.83 (0.75-0.93) for antibiotic prescription during index consultation and 2-wk follow-up; 0.62 (0.57-0.69) for prescription of any kind.
↵e Total of 187 (5.5%) of the children in booklet group were referred.

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Table 3

Antibiotic Prescribing Rates by Top ICPC Codes

ICPC Code	Usual Care No./n (% Within ICPC Code)	Access to Booklet No./n (% Within ICPC Code)	Use of Booklet No./n (% Within ICPC Code)
A03.00 fever	191/2,471 (7.7)	144/2,174 (6.6)	51/835 (6.1)
R74.00 acute upper respiratory tract infection	486/2,653 (18.3)	359/2,357 (15.2)	102/789 (12.9)
H71.00 acute otitis media/myringitis	1,246/1,872 (66.6)	1,034/1,604 (64.5)	289/449 (64.4)

ICPC = International Classification of Primary Care.

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Table 4

Parent-Reported Secondary Outcomes Based on Telephone Survey

Secondary Outcome	Usual Care (n = 250)	Access to Booklet (n = 303)	Use of Booklet (n = 109)
Reconsultation with own FP within 2 wk, No. (%)	73 (29.2)	104 (34.3)	37 (33.9)
Antibiotic prescription by own FP during reconsultations within 2 wk, No./n (%)	26/73 (35.6)	27/104 (26.0)	12/37 (32.4)
Hospital admission within 2 wk, No. (%)	17 (6.8)	21 (6.9)	6 (5.5)
Satisfaction with care
Satisfaction VAS score,^a median (IQR)	8.0 (7.0-8.0)	8.0 (7.0-9.0)	8.0 (7.0-9.0)
Reassurance VAS score,^a median (IQR)	8.0 (7.0-8.0)	8.0 (7.0-8.0)	8.0 (8.0-9.0)
VAS score for booklet,^a median (IQR)	–	–	8.0 (8.0-9.0)
Intention to reconsult for similar illness, No. (%)	211 (84.4)	229 (75.6)^b	78 (71.6)^b

FP = family physician; IQR = interquartile range; VAS = visual analog scale.
↵a Scores ranged from 1 (most negative answer) to 10 (most positive answer).
↵b Significant difference compared with control group (P <.05).

Supplemental Tables

Supplemental Tables

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Supplemental data: Tables 1-3 - PDF file
The Article in Brief

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial

Eefje G. P. M. de Bont , and colleagues

Background Fever is a common reason for a child to be taken to a doctor, particularly during evening hours. Since antibiotic prescribing is strongly influenced by patients' expectations, researchers developed and studied the effectiveness of an interactive booklet on managing fever for parents using after-hours care.

What This Study Found Antibiotic prescribing rates are not affected (to a statistically significant degree) when physicians have access to a parent-focused booklet on childhood fever but do decrease if the booklet is used. As part of a two-armed cluster-randomized trial at 20 out-of-hours general practice centers in The Netherlands, family physicians in the intervention group had access to a booklet on children's fever. The booklet, designed to be used in discussion with parents, provided advice on when to consult a family physician, self-management strategies, and the duration of common childhood infections. The study included 25,355 children. Antibiotic prescribing was not significantly different in the intervention and control groups, however, after adjusting for compliance (use of the booklet), there was a significant reduction in antibiotic prescribing in children managed by a family physician using the booklet (n=3407) compared to children in the control group. Children in the intervention group were also less likely to receive a prescription for any medication, including non-antibiotic medication.

Implications

Although the reduction in antibiotic prescribing in this implementation study was modest, the authors suggest that it provides evidence of the likely "real world" benefits and efficacy of the intervention and its relevance to efforts to reduce antimicrobial resistance.