A realist analysis of patient and clinician views and experiences in the randomised controlled efficacy trial of rapid respiratory microbiological point-of-care-testing in primary care (the RAPID-TEST RCT)

Problem

Antimicrobial resistance has been identified as a top 10 threat to public health. Rapid microbiological point-of-care tests (POCTRM) potentially present an opportunity to reduce unnecessary antibiotic exposure and antimicrobial resistance and modify future consulting behaviours. However, there is limited understanding of clinicians’ and patients’ attitudes towards POCTRM use in primary care and how POCTRM can be optimised to facilitate desired outcomes.

Approach

This multi-centre individually randomised controlled efficacy trial evaluates a multiplex POCTRM for suspected respiratory tract infections in primary care, with mixed-method investigation of microbial, behavioural and antibiotic mechanisms. Individual, in-depth interviews were conducted with 15 clinicians (8 General Practitioners, 4 Applied Nurse Practitioners, 1 Clinical Pharmacist, and 2 Paramedics) to explore their views on the value of the new microbial knowledge and how it may influence clinical reasoning and participant management. Further interviews were conducted with 29 patients (21 adults, 8 parents) to explore their understanding of POCTRM and the implications for treatment and future consulting. Following an inductive thematic analysis, a realist approach was applied to interpret and explain how the specific settings or circumstances in which POCTRM were implemented (context) may influence how individuals respond (mechanism) and the intended or adverse outcomes from the interaction (outcome).

Findings

Nineteen Context-Mechanism-Outcome (CMO) configurations were generated from the clinician interviews. Clinician CMOs explain how POCTRM used in different contexts (clinical knowledge and interpersonal skills, clinical identity, outcome expectancies, social pressure, environmental context) can trigger different responses (clinician knowledge and confidence, perceived patient knowledge and confidence, reduced clinician anxiety, reinforcement, stressors). The interaction between the context and mechanisms influences different outcomes on prescribing behaviours, therapeutic relationships, and perceived patient knowledge, confidence and satisfaction with care. For example, when clinicians fear adverse patient outcomes (context), viral or negative POCTRM can reduce clinicians' worry (mechanism) and reduce antibiotic prescribing (outcome). Seventeen patient CMO configurations were created from the patient interviews. Patient CMO configurations outline how contextual factors (patient knowledge, self-efficacy, anxiety, medication necessity beliefs, perceptions about clinician capability, environmental context) interact with patient mechanisms (confidence, empowerment, knowledge, action-planning, beliefs about resources, negative affect) to influence patient confidence in self-managing symptoms without antibiotics, satisfaction with care and future consulting behaviours. For example, when patients believe antibiotics are necessary (context), viral or negative POCTRM can enhance patients’ confidence in diagnosis and treatment decisions (mechanism) and reduce re-presenting for the same illness (O).

Consequences

Findings highlight how, why and in what contexts POCTRM will likely be most helpful to clinicians and facilitate positive patient outcomes. We set out a testable programme theory and recommendations to optimise POCTRM in primary care.