“If it’s less than twenty, you can turn around and say “computer says no””; Clinician perspectives on access to CRP testing in primary care out of hours bases.

Problem

Point of care CRP testing has been advised by NICE to support antibiotics prescribing decisions in LRTI. However, implementation has been limited. Antibiotic prescribing in OOH primary care shows an increasing trend with time. CRP may be a useful tool to guide prescribing decisions in a clinical context where doctors are dealing with uncertainty, are unfamiliar with the patients and under pressure to see patients quickly

Approach

This paper reports on the qualitative component of an on-going mixed-methods evaluation of a study in which point of care CRP testing was made available to clinicians working in Care UK OOH bases. We undertook semi-structured interviews with clinicians working in the out of hours bases with access to the CRP testing, with the use of a topic guide. Interviews were transcribed verbatim and analysed thematically. Ten interviews have been conducted to date, with further interviews planned. To date, we have spoken to 8 GPs and 2 ANPs, including those who use CRP testing never, sporadically and often.

Findings

Clinicians reflected on the role of CRP in supporting clinical assessment, with perspectives ranging from CRP test results supporting confidence in decision making, to uncertainty about how CRP test results sit within the hierarchy of components comprising clinical assessment. Clinicians who used the tests explained how the results supported communication with patients, in the context of antibiotic stewardship. CRP results offered a neutral way for the clinician to decline to prescribe antibiotics, especially when the patient wanted or expected antibiotics (“it’s difficult to fight with concrete science”) . We heard accounts about how the guidance about what to do in the CRP middle range supported the greater use of delayed prescriptions. Challenges to using CRP testing included the difficulty of maintaining training and awareness amongst a varied and variable staff team, who work irregular shifts across different bases, the pressures of time and workload in OOH settings, and concerns about leaving patients in clinical rooms to use a central machine. Having an HCA to do the test, or desktop POC equipment in each room were identified as changes that could mitigate against this.

Consequences

Uncertainty about the value (and potential risks)of CRP testing in a holistic clinical assessment limited uptake for some clinicians we spoke to. Training, resource and time-pressure issues reduced usage for some, which could be potentially mitigated against, including HCA support to do the test, desk-top equipment, and strategies for on-going training. The clinicians we spoke to valued having CRP results as a tool support their decisions to not prescribe antibiotics, in the face of what they perceived as patient expectations: “it has taken the no-antibiotics sting out of a lot of consultations”. This could be a powerful motivator for supporting uptake.