Implementation of the CHIldren with acute COugh (CHICO) intervention to improve antibiotics management: a qualitative study in primary care

Background Childhood respiratory tract infections (RTIs) are common and can lead to unnecessary antibiotic use and antimicrobial resistance. The CHIldren with COugh (CHICO) intervention incorporates a clinician-focused algorithm (STARWAVe) to predict future hospitalisation risk, elicitation of carer concerns, and a carer-focused personalised leaflet recording treatment decisions and safety-netting information. Aim To examine the implementation of the CHICO intervention by primary care clinicians. Design and setting A qualitative study with primary care clinicians in England taking part in the CHICO randomised controlled trial. Method Interviews explored the CHICO intervention’s acceptability and use. Clinicians from a range of practices with high and low antibiotic dispensing rates were recruited. Normalisation process theory underpinned data collection and thematic analysis. Results Most clinicians liked the intervention because it was quick and easy to use, it helped elicit carer concerns, and reassured clinicians and carers of the appropriateness of treatment decisions. However, clinicians used it as a supportive aid for treatment decisions rather than as a tool for behaviour change. The accompanying advice leaflet helped explain treatment decisions and support self-care. The intervention did not always align with clinicians’ usual processes, which could affect use. Increased familiarisation with the algorithm led to reduced intervention use, which was further reduced during the COVID-19 pandemic as a result of changes to practice and remote consultations. Conclusion Clinicians found the CHICO intervention useful to support decision making around antibiotic prescribing and it helped discussions with carers about concerns and treatment decisions. The intervention may need to be adapted to align more with clinicians’ consultation flow and remote consultations.


Introduction
Antimicrobial resistance is recognised as one of the most pressing global public health threats of our time. 1Around 80% of all antibiotics are prescribed in primary care, 2 with approximately 50% of prescriptions in this setting being unnecessary. 3Respiratory tract infections (RTIs) in children present a major primary care challenge because they are common and costly, and ongoing uncertainty regarding diagnosis and management is a major driver of antibiotic prescribing. 4,5mproved identification of children at low risk of future hospitalisation could increase the confidence not to prescribe antibiotics.To address this, the CHIldren with COugh (CHICO) cluster randomised controlled trial (RCT) (trial registration number: ISRCTN11405239) 6,7 evaluated whether unnecessary antibiotic prescribing could be reduced by providing an intervention to support clinicians' decision making for antibiotic prescribing in children with RTIs in primary care. 8,9 the RCT, the CHICO intervention did not reduce overall antibiotic dispensing for children presenting with RTIs.Neither did it increase hospitalisation rates for RTIs in the intervention practices compared with usual practice.Sensitivity and subgroup analyses indicated decreased dispensing rates in the intervention arm for older children, for practices restricted to one site, for practices with proportionally fewer nurse practitioners, and for practices in less deprived areas.A post hoc analysis also indicated reduced antibiotic dispensing levels in the intervention arm in the pre-pandemic period.Among 121 practices with at least 1 month of intervention data, there were 11 944 observed uses.The median number of times the intervention was used for the 115 practices with 12 months of data was 70 uses at each practice, with an interquartile range of 9 to 142. Full results are reported elsewhere. 6ether an intervention is valued and what clinicians need to put it into practice can influence whether and how an intervention is used in primary care. 10,11his article describes the CHICO RCT nested qualitative study, which aimed to explore the use of the intervention The intervention had three components: eliciting explicit carer concerns during the consultation; a clinician-focused algorithm (STARWAVe) 12 to identify children at very low risk of future hospitalisation in whom antibiotics could be safely withheld; and a carer-focused personalised leaflet co-designed with carers recording decisions made at the consultation, addressing common concerns, and providing safety-netting information (see Supplementary Figure S1 for details). 9e intervention was triggered when a child of 0-9 years presented and the healthcare professional received a 'soft' (that is, a reminder) pop-up screen alert asking if the child was presenting with an RTI and providing the option to open the CHICO intervention.Clinicians could also initiate the intervention using specific EMIS (an electronic patient record management system) RTI codes.
Clinicians involved in implementing the CHICO intervention were invited to take part in semi-structured interviews to explore the use of the intervention, how it was embedded into practice, and whether it was acceptable.
Interviews were conducted in two phases (during the pilot period and after 12 months' intervention period), with findings from the pilot phase used to make changes in the main trial.
Data collection and analysis were informed by the normalisation process theory (NPT), which proposes that intervention implementation is dependent on four criteria (Box 1). 13hese four constructs were used to guide data collection and develop themes during analysis.

Sampling and recruitment
Purposive, maximum variation sampling was used to capture variation in views and experience of clinicians (GPs and practice nurses) from a range of practices.Clinicians from 56 of the 144 intervention practices in the RCT were invited to take part in an interview via email.Practices were selected based on multiple characteristics -those with large and small patient list size, with high and low antibiotic dispensing rates, and serving areas of high and low sociodemographic deprivation, with data taken from clinical commissioning groups (CCGs) -to facilitate a comprehensive understanding

How this fits in
The CHIldren with COugh (CHICO) intervention was designed as an aid to reduce unnecessary antibiotic prescribing for respiratory tract infections in children in primary care.However, the intervention did not significantly reduce overall antibiotic dispensing.GPs and nurses initially welcomed the intervention but faced difficulties integrating it into their usual consultation flow, leading to reduced use over time.The CHICO intervention may still be valuable in supporting decision making and discussions, but it needs adjustments for better integration into clinicians' workflow and remote consultations.

Data collection
Telephone interviews were conducted by an experienced social science researcher and lasted between 15 and 37 minutes, with an average time of 25 minutes.Interviews were conducted between March and September 2019 during the pilot trial phase, and between November 2019 and February 2021 (the main trial phase after practices had been using the intervention for 12 months).A flexible topic guide was used to guide interview questioning but allowed participants to present unanticipated issues (see Supplementary Box S1 for details).Similar topics were covered in both phases, with the impact of the COVID-19 pandemic added after March 2020.Audio-recorded verbal consent was gained before the interviews.

Data analysis
Interviews were audio-recorded, transcribed, anonymised, and imported into NVivo (version 10/11).The pilot data underwent rapid analysis, 16 influencing the implementation of the intervention (see Supplementary Box S2 for details).
Thematic analysis 17 was subsequently applied to all data, using iterative and deductive coding guided by NPT constructs.Initial codes were iteratively developed and then deductively organised based on NPT constructs.Three transcripts (one from the pilot phase and two from the main phase) were independently coded by experienced researchers for initial codes and groupings.These codes were then applied to remaining transcripts, with ongoing refinement.Collaboratively, three researchers developed themes within NPT constructs.Preliminary findings were discussed with the multidisciplinary trial management team for trustworthiness and enhanced understanding.

Results
Overall, 26 clinicians (20 GPs and six practice nurses) were interviewed from 24 practices (range of one to two clinicians per practice) and 13 CCGs (Table 1).Ten clinicians (eight GPs and two practice nurses) were interviewed from eight practices during the pilot phase.Findings are presented for each of the NPT constructs, illustrated with anonymised quotations (pilot interview quotations are indicated).

Coherence (understanding the purpose of CHICO)
Clinicians welcomed the CHICO intervention as it aimed to help with perceived carer concerns about not receiving antibiotics, it aligned with existing strategies and efforts to reduce unnecessary antibiotic prescribing, and clinicians believed it would fit within their usual practice:

Research
'I think that's quite straightforward … I thought it was good, it was easy to use.' (Nurse 6, pilot) However, some clinicians felt the template did not capture all the required information, meaning that they needed to make additional entries in the patient's record or 'moving between two screens' (GP 11), which could be problematic: As with the prognostic algorithm, the advice leaflet was seen to be more useful for children considered to be 'borderline' for hospitalisation or prescribing antibiotics: 'Especially when there is a borderline whether to go to the hospital or not and the score is a bit on the lesser side and parents are not keen to go to the hospital and at that time, this has particularly helped.The leaflet you're giving them the clear-cut advice of when to go and when to seek advice.'(GP 23) Challenges with CHICO in practice.Several challenges were highlighted that led to reduced use of the intervention or selective use of some of its components.Clinicians reported difficulties aligning the intervention with their usual consultation practice.The use of the algorithm to support decision making and providing carers with the letter and advice leaflet required clinicians to engage with the computer and patient record throughout the consultation.However, some would usually complete the record at the end of the consultation or after the patient had left as they liked to focus on the patient during the consultation.This led some clinicians to stop using the intervention; however, in some cases, clinicians did provide carers with pre-printed non-personalised advice leaflets:

'I do my typing up at the end of the consultation so it [intervention] doesn't alter my thought processes, "am I going to prescribe them antibiotics or not?" I have already made that decision from taking the history and doing the examination … It doesn't actually give you the scoring until you click 'save' so that pop-up comes right up right at the end.' (GP 3, pilot)
'Most of us find that it gets in the way of our consultation and so, therefore, we don't use it, but we like the leaflet, and we give that out.' (GP 11) 'Unfortunately, the leaflet thing probably got a little bit overlooked because you do the whole template, finish the consultation with the patient and then they would go and then you'd finish writing up your notes … and then up comes the "would you like to print a leaflet?" and it's "oh, I've forgotten to do that".'(Nurse 17) Some practices conducted their consultations remotely, which meant assessing the clinical symptoms required for the prognostic algorithm was challenging.This was more of an issue with telephone consultations because some symptoms could still be assessed using video where the child could still be seen and heard: 'Can assess using video, can see the child … breathlessness, wheezing.'(GP 18)

'We do a lot of video consultations as well, then you can see whether the child's running around and what they're doing, so yes it could easily be adapted I would have thought.' (Nurse 20)
It was also difficult to provide carers with personalised printed leaflets in some practices, either because of the remote consultation or because of printing issues.However, some clinicians had found ways around this, including using non-personalised pre-printed versions of the leaflet provided by the study team, saving a pdf version that could then be printed off without using the intervention, and emailing or texting the leaflets to carers: 'Often, I would just give them a nice … they were very attractive leaflets and a bit more striking than the black and white paper printout.'(GP 19) 'We've started to email the leaflet to patients … using a text messaging service … So, we have used the leaflets via telephone consultation as well, so you can do that so that bit is good.'  The increased use of remote consultations during the COVID-19 pandemic further highlighted the challenges discussed.However, having used the intervention during remote consultations during this period, clinicians did perceive some benefits to using it remotely, including less need to focus on a face-to-face consultation:

'It fits more naturally with remote working because it's easier to get whatever you need on the [computer] screen, and you're not worried about eye contact and body language.' (GP 25)
There were also fewer children presenting with respiratory illnesses, which reduced the opportunity to use the CHICO intervention during the pandemic:

Reflexive monitoring (appraisal of CHICO)
When appraising the CHICO intervention and making recommendations for future implementation, participants suggested expanding the template to encompass more information (for example, 'physical examination findings like heart rate, respiratory rate' [GP 13]).This could help overcome issues with having to record information in multiple places and switching screens: 'I think if you're filling in a template, especially when we're busy in the winter, it would be good if we could record all the information in that template and then not have to go back into the notes to record things that we think is important to record.' (GP 19)   Clinicians also recommended adapting the intervention to be more conducive to remote consultations.This could include informing carers about how to assess symptoms and having carer-reported criteria rather than having the clinician-assessed criteria.However, some clinicians worried about relying on carer-reported symptoms because these could be less accurate: 'I think the tool is little bit reliant on the clinical aspect as well, which you may not have, so it's difficult to judge on chest signs and symptoms, and respiratory distress, and that sort of thing, wheeze, based on a conversation with a parent, and even temperature.They may not have a temperature probe so you may not be able to get particular aspects of it but then some bits you will be able to get.But if it can be tweaked to amend for things that may not happen on remote working then that may obviously help.' (GP 25) Some participants valued the CHICO intervention and said they would use it in the future: 'I would have no problem with starting to use it again now because I feel you know, now we're gonna start getting back to normal and coughs will just be coughs and colds, and it would be really useful to have that back again.'(Nurse 24)

Discussion
Summary Clinicians initially welcomed the CHICO intervention in theory, but in practice it proved difficult to align the intervention flow with that of the clinician's usual use of the computer during a consultation.GPs and nurses used the intervention at the start of the trial, but use waned over time.Most clinicians liked the algorithm template and found it straightforward to use, without adding any more time to consultations.However, having to close the patient's record before the end of the consultation to complete the intervention process did not always align with their usual processes and was, therefore, problematic.The COVID-19 pandemic also impacted the use of the intervention as a result of changes to practice pathways, increased use of remote consultations, and reduced numbers of children presenting with RTIs.
While some clinicians reported that the intervention influenced their prescribing decisions and found it most useful in 'borderline cases' for hospitalisation and prescribing, others reported that they used it as a supportive aid during consultations rather than a tool to change prescribing behaviour.CHICO helped elicit carers' concerns and reassure clinicians and carers of the appropriateness of some treatment decisions.Clinicians particularly liked the safety-netting carer advice leaflet, as it helped explain treatment decisions

Research
and home care with carers, and this was seen to be the most useful intervention component.To increase the use of the intervention, the findings suggest that it may need to be adapted for use in remote consultations and to fit better with clinicians' consultation flow.

Strengths and limitations
Strengths of this study include interviewing GPs and nurses who used the intervention who worked in a diverse range of practices.The use of normalisation process theory to inform data collection and analysis enabled a focus on issues with both the intervention design and the way it was implemented in practice.
A limitation is that most clinicians were interviewed towards the end of the trial, which may have been some time after they had last used the intervention.As a result, clinicians might not have recalled important aspects of intervention use.In addition, those clinicians who had never used the tool were not interviewed, and they could have provided useful insights into the barriers to using the tool, as could clinicians from a different selection of practices.RCT recruitment at the practice level limited the ability to interview CHICO-using carers, but clinicians provided valuable carers' perspectives.
Comparison with existing literature Process evaluations of other interventions to reduce antibiotic prescribing have similarly found that clinicians value patient-facing materials and report that decision aids support rather than change their prescribing practice. 18,19linicians emphasise the need to educate parents and/or patients, and perceive their own prescribing practice to be clinically appropriate.However, the parent-oriented leaflet really acts as a tool to change clinicians' behaviour, by providing them with a substitute for giving antibiotics. 8The safety-netting information in the leaflet, which was praised by the clinicians in this study, may also help because the clear advice means they feel safer not to prescribe. 20he content of the parent/carer leaflet was co-designed with parents/carers from a range of backgrounds, and the original version is available online on the University of Bristol website. 9 The switch to online consultations during the COVID-19 pandemic might have made diagnosis and treatment decisions for children with RTIs more difficult. 21An in-person assessment of children plays a key role in clinicians' diagnostic processes for children with RTIs. 22This study showed that many clinicians reported being unable to assess some of the symptomatic predictors of hospitalisation adequately.During the COVID-19 lockdowns, rates of RTIs reduced, but continued use of remote consultations for children could contribute to higher rates of antibiotic prescribing because of increased uncertainty, which is linked to high antibiotic prescribing. 5,20

Implications for research and practice
As found in the RCT, the CHICO intervention does not appear to change overall prescribing behaviour; however, it may still be effective in some clinical groups and it was found to be a useful tool for confirming clinical decision making.Therefore, clinicians may still find the intervention helpful to support decision making around antibiotic prescribing for children with RTIs and discussions with carers about their concerns and treatment decisions.The intervention may be most useful for patients who are considered to be borderline cases for hospitalisation risk.
The intervention may need to be adapted to align more with clinicians' consultation flow and allow use during remote consultations to increase use.Patient electronic medical record providers could improve the effectiveness of the CHICO intervention if platforms could improve the timing of delivery of the intervention, such as decision aids appearing at the appropriate time in the consultation, and being aligned more with usual medical note taking.

Table 1 . Participant characteristics
It was something that we were interested in doing … We do see lots of children with coughs and colds, and some parents are generally concerned … some do also expect antibiotics if it's had a chest cough for a certain period.'(GP14)'Ithink[we were] really well prepared.The training results are really good but having a test patient was really good.' (GP 11)Collective action (using CHICO in practice)Most clinicians liked the intervention and used it as a supportive aid in consultations.It was a way of reassuring themselves and carers of the appropriateness of treatment decisions:'It's very reassuring for the professional and, of course, when you've printed out the leaflet that is the scoring we have done; it is very reassuring for parents as well.' (GP 16)Launching CHICO.During the pilot phase, clinicians were reminded to use the intervention via an electronic patient record system 'pop-up', which was triggered for all children under the age of 10 at the start of the consultation.the best way to try and get people to use it and remember it for the whole year was to keep it as automated.'(GP 13) Prognostic algorithm.Most clinicians liked the signs and symptoms template, which they found easy to use without adding any more time to consultations: (GP 22) Caring for children with coughs: Information and advice for parents.2016.https://childcough.bristol.ac.uk (accessed 22 Apr 2024).10.Horwood J, Clement C, Roberts K, et al.Increasing uptake of hepatitis C virus infection case-finding, testing, and treatment in primary care: evaluation of the HepCATT (Hepatitis C Assessment Through to Treatment) trial.Br J Gen Pract 2020; DOI: https://doi.org/10.3399/bjgp20X708785.11.Evans BA, Dale J, Davies J, et al.Implementing emergency admission risk prediction in general practice: a qualitative study.Br J Gen Pract 2022; DOI: https://doi.org/10.3399/BJGP.2021.0146.12. Hay AD, Redmond NM, Turnbull S, et al.Development and internal validation of a clinical rule to improve antibiotic use in children presenting to primary care with acute respiratory tract infection and cough: a prognostic cohort study.Lancet Respir Med 2016; 4(11): 902-910.13.May C, Finch T. Implementing, embedding, and integrating practices: an outline of Normalization Process Theory.Sociology 2009; 43(3): 535-554.14.Ministry of Housing, Communities and Local Government.English indices of deprivation 2019.2019.https://www.gov.uk/government/statistics/english-indices-ofdeprivation-2019 (accessed 22 Apr 2024).15.Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability.Field Methods 2006; 18(1): 59-82.16.Vindrola-Padros C. Doing rapid qualitative research.London: SAGE Publications, 2021.17.Braun V, Clarke V. Thematic analysis: a practical guide.London: SAGE Publications, 2022.18. Anthierens S, Tonkin-Crine S, Cals JW, et al.Clinicians' views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections.J Gen Intern Med 2015; 30(4): 408-416.19.Tonkin-Crine S, McLeod M, Borek AJ, et al.Implementing antibiotic stewardship in high-prescribing English general practices: a mixed-methods study.Br J Gen Pract 2023; DOI: https://doi.org/10.3399/BJGP.2022.0298.20.Cabral C, Lucas PJ, Ingram J, et al. "It's safer to …" parent consulting and clinician antibiotic prescribing decisions for children with respiratory tract infections: an analysis across four qualitative studies.Soc Sci Med 2015; 136-137: 156-164.21.Murphy M, Scott LJ, Salisbury C, et al.Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study.Br J Gen Pract 2021; DOI: https://doi.org/10.3399/BJGP.2020.0948.22. Horwood J, Cabral C, Hay AD, Ingram J.Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study.Br J Gen Pract 2016; DOI: https://doi.org/10.3399/bjgp16X683821.