Perceptions of main changes to clinical practice
Awareness and behaviour
Participation in the STAR Educational Program was presented as reinforcing already existing knowledge:
It has reinforced [my views on prescribing antibiotics] more than anything and perhaps has improved my use of a wait and see policy rather than actively prescribing. I think as a practice we were relatively low prescribers anyway but it was nice to reinforce that and to make sure what we're doing is correct really. (GP142)
In particular, locally relevant data was seen as reinforcing the salience of the issue of antibiotic resistance:
I think it is easy to get blasé about antibiotic resistance and I think having the study has focused my mind and having local knowledge and the summary of the sort of changes that might come about if you concentrate on it [is] helpful; I think it raises the profile of the whole subject a long way. (GP185)
Interviewees also reported greater self-confidence in implementing their prescribing decisions:
It has given me a lot more confidence in refusing antibiotics and in fact I have been surprised at how little resistance I've had when I say I won't give something and they say that's good. (GP271)
Inevitably, participants varied in the manner in which they expressed this change in awareness and self-confidence, the positive accounts above contrasting with the two more dismissive statements below.
In the following excerpt, the interviewer (I) probed the GP about whether participating in STAR influenced his antibiotic prescribing, and the GP seemed quick to point to minimal effect:
I: so would you say that [STAR] has changed your actual prescribing behaviour?
GP: u::hm just reminded me let's put it that way
I: mhm mhm
GP: it has just reminded me of the vigilance and how important it is you know not to prescribe when it is not necessary and things
(GP 199)
Similarly, in the following example the GP put forward that STAR was only one of the components that characterised already ongoing behaviour modifications:
I think ... STAR has come along in a general progressive movement in my prescribing which is going from prescribing obviously more to prescribing gradually less and a gradual education of my patients towards that and I see it more that- it's actually been another impetus along the direction that [I] was already travelling and so ... it has encouraged me in giving the sort of confidence and the backing to continue to move in that sort of direction; it's something we were already doing very much. (GP 229)
Whereas the interviewees in the earlier three examples ascribed a clear agency to the STAR Program: 'It has reinforced'; 'it raises the profile'; 'It has given me more confidence' and the last two excerpts relegate STAR to a more secondary position: 'it just reminded me'; 'STAR has come along in (an already) progressive movement'; 'it's been another impetus', all five data excerpts acknowledge the positive effect of heightened awareness. That there should be individual differences was only to be expected as, after all, the degree to which antibiotic prescribing behaviour needed to be modified varied as well.
Enhanced communication versus consultation length
Generally, participants felt that applying the communication skills presented in STAR provided greater insight into patients' wishes and demands, which was then seen to impact directly on future consultation rates and, ultimately, on patients self-managing future episodes:
I think [my patients] probably get a better deal out of me actually ... because they get more time which is most of all what they're after and actually I mean I never used to leap on the idea of antibiotics as a way of terminating the consultation quickly before anyway but I think I'm just a little bit more prepared to listen to the patient's experience ... more so than I was ever used to doing. (GP 150)
Most clinicians perceived consultations to be lengthened by an average of two to three minutes as a result of implementing the new communication skills. However, again this was generally seen as a positive trade-off to reduce or prevent future consultations:
I think it probably does make the consultations a bit longer but not drastically so you know and I would think I feel reasonably confident that we will you know recoup that extra time in the future by people hopefully not re-presenting for antibiotics quite as often. (GP 216)
I suppose in the long term they won't come back will they so in a way it's saved you time ... next time perhaps they'll not come in because you get people coming in saying 'I've had a cough for two days' and you think 'well, so what, bugger off', whereas if you'd spend more time on the first consultation explaining to them why you think they don't need them they may not come back, but it's certainly in the short term that it takes more time. (GP 256)
Impact on (the) practice
Although the type of antibiotics prescribed was not an explicit interview question (see Appendix A), the topic did arise tangentially, as in the following two data extracts:
... my perception is that I am using [antibiotics] less often, and I've changed the range of antibiotics that I commonly use. (GP 275)
... occasionally I have had a patient who has had severe reactions, for example, when a patient had really bad jaundice after some amoxicillin so it is just a perception from my viewpoint but I seem to see the incidence as far as side effects or bad reactions is less than it was and whether that is related to prescribing more appropriately or less, I don't know. (GP 207)
However, as GPs reported increased self-confidence regarding prescribing decisions, to a large extent based on the research evidence provided in the online learning program, the general references to 'more appropriate' prescribing behaviour in the data may well indicate a shift towards narrow spectrum antibiotics prescription in addition to prescribing fewer antibiotics overall.
There was little perceived change in the frequency with which specimens were sent to the lab, nor was there a noticeable increase in re-consultation rates, although in this respect, the need to present a united front across the practice was repeatedly mentioned:
... colleagues have a few patients who according to criteria were not prescribed at the time but they re-present a week later and their condition is worse therefore I have prescribed. But if they come and there is no change I don't prescribe. I mean you have to reinforce what they were told last time. I think we tried to do that more since the program, not just give in to have a quiet life. (GP207)
... we have one mum who brought a child for 3 days on the trot; really struggled with the concept of having no antibiotics and we all, the thing was we could see her coming in the end, ... and we were communicating amongst ourselves to make sure we didn't actually break or crack under the pressure. (GP 161)
Finally, two GPs stated that neither their thinking nor their prescribing behaviour was in any way influenced by STAR, although both of them indicated this was because they were already implementing the skills promoted in the STAR Program. As one of them summarised:
... it was a revision exercise, I think, ... if you do a study and you say 'oh, I'm already doing that', at least you know that what you are doing is right ... the reason that [participating in STAR] did not change my practice is not because I ignore what was being said, it was because I had already agreed with what was being said. (GP 171)
Evaluating the STAR Educational Program
Communication skills examples
In evaluating the contents of the program, rather than its reported effects, views were sometimes polarised. The presentation of key communication skills was described either in terms of new, useful and exciting, or as old and familiar, though perhaps in need of 'brushing up'. In either instance, however, implementing these skills was acknowledged as leading to better patient care and, ultimately, greater personal satisfaction:
I think the communication skills aspect was good, being able to ask patients what they feel about antibiotics and to have a more adult conversation about it ... it sort of encourages you not just to be defensive and [say] 'we don't want to prescribe' but be proactive ... asking the patients what they felt was the benefit of taking antibiotics and what did they think they were going to get out of it .... and sort of telling people it is a self-limiting illness, some of those skills I thought was very good and make it much easier to prescribe the way I'd like to. (GP 229)
The seminar
Respondents viewed the seminar as providing a much-needed 'human touch', although a small number of interviewees, especially those working in single-handed or very small practices, considered it a waste of time and money. Participation in the program seminar was also presented as a unique chance to focus on a particular issue and to increase communication within the practice team:
... the trouble is in general practice you don't have time to sit and talk and [it's] usually sort of a business practice meeting we don't often have clinical sort of where we actually discuss and necessarily change or discuss the pros and cons of various things on a regular basis. I'm not saying we don't ever talk about things at all, we communicate quite well, but it's finding the time to do it. (GP 161)
Seminar trainer feedback indicated that it proved difficult at times to gather all the trial participants from a particular practice at a particular time, with the absence of practice nurses, who are often in charge of minor illness (telephone) triage, especially commented upon. Overall, however, trainers described the seminar discussions as lively, with participants most eagerly engaged in discussing local resistance rates as correlated with own practice data.
The online training
The online aspect of the training was generally evaluated positively, with a particular emphasis on its promotion of independent learning and flexibility in accessing the program. However, six out of thirty-three practices experienced (initial) technical difficulties and especially in practices with older computer systems, or for clinicians less comfortable with IT, delays in video streaming and inability to access the program depending on certain computer settings could lead to frustration:
... there was a kind of pointlessness about the use of the technology, having video streaming that just made it irritatingly slow to download and it didn't contribute anything, and you'd actually watch a videotape of somebody talking, I would just as soon have read the text to be honest. (GP 171)
Finally, some participants found the video material lacking in authenticity:
... there was some amusement during the video consultation with the various patients and doctor scenarios because it all seemed to go so beautifully according to plan and the patients never argued and there was lots of time and I thought - we all discussed that and we thought it was rather amusing, we didn't think it was totally realistic. (GP 207)
Research evidence and guidelines
The presentation of up-to-date evidence was generally seen as one of the most useful aspects of the STAR Program. Participants described how they discussed the modified Centor clinical scoring tool for managing sore throat, as well as the prescribing guidelines and evidence summaries with patients during consultations:
... you gave us guidelines on- primary care guidelines that have been very useful actually. Again, we've given our nurses copies of those to have a look at when they are seeing patients with minor illnesses. You know, I think no one has given them training in good antibiotic prescribing so I do think they over-prescribe, even though they're very good. I think those guidelines have been quite helpful, in fact we keep them pinned up by the uh, when they're doing nurse triage we keep them pinned up by the phone, so they can refer to those. (GP 248)
... the Centor guidelines, the other guidelines, can't remember what they were called now, the ones for the sinusitis and things you know, those I actually have them on my desktop. So what I do is I just put them on if I get someone stroppy ... just put them on and turn the screen and say 'read that, that's the guidelines we've got', because if you've given them an examination and you know they haven't got a temperature and they haven't many chest signs ... On the whole they tend to sort of 'oh okay' then, it's on the screen so it must be true and they see that's it's, you know, it's an official document. (GP 256)
As evident from seminar trainer feedback as well as interview data, and in line with the 'computer-says-no' scenario presented in the above data excerpt, STAR participants repeatedly requested antibiotic resistance information leaflets or posters that can be displayed in surgery waiting rooms. Interviewees noted that presentation of the research evidence and guidelines in this more generally accessible format could have provided them with an added tool, and they expected it to be part of the overall program.
Case studies and self-reflection
About a fifth of interviewees reported that they did not see the merits of the reflective exercises or recording their own consultations online:
I: ... and what did you think was the least useful
GP: I think finding my own cases to put in. I don't know there's plenty of cases you could have found. It was hard to find an interesting one. But in terms of looking at that it didn't really affect what I was doing in any way, it was just a bit time consuming. That was a bit of a chore. (GP152)
However, one of these participants, unprompted, addressed his own reservations on this issue, thereby aligning himself with the majority standpoint:
... the tasks of recording some of one's own consultations ... I don't know whether recording them had any benefit over simply thinking about them. Obviously recording them takes up a bit more time, but having said that I don't know if I didn't have to record them whether I'd really spend time ((laughs)) thinking about (those cases). It felt frustrating at some level but I'm well aware that that sort of thing does actually improve one's processing of it. (GP216)
Overall evaluation of key STAR components
The core aspects of the STAR Program considered 'most useful' and reported by these sampled participants as responsible for influencing their prescribing most were the research evidence and guidelines provided in the program, and the online communication skills examples, both of which were explicitly mentioned by 12 of the 31 interviewees. Ten interviewees reported that their prescribing behaviour had changed because of the increased overall awareness of the antibiotic resistance issue that results from working through the program as a whole, with four of those singling out the impact of discussing local resistance rates during the STAR seminar.
In contrast, there were also respondents who considered the research evidence not directly relevant to their own clinical practice, or found it too difficult to process online. Moreover, the web forum, originally envisaged to become an ongoing learning resource, was dismissed by many as irrelevant, a format participants could not or would not engage with, even if their busy working lives would allow them time to do so.
However, it was clear that all interviewed study participants subscribed to the view summarised by GP 207 as follows:
... overall I think it's just the being better educated and having therefore more clinical expertise and [the] communication tools to prescribe appropriately, treat appropriately, and therefore give better patient care, which is the bottom line. (GP207)