Comparing GPs’ antibiotic prescribing decisions to a clinical prediction rule: an online vignette study

Martine Nurek, Alastair D Hay, Olga Kostopoulou

Research output: Contribution to journalArticle (Academic Journal)peer-review

2 Citations (Scopus)
32 Downloads (Pure)


Background: The ‘STARWAVe’ clinical prediction rule (CPR) uses seven factors to guide risk assessment and antibiotic prescribing in children with cough (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting).

Aim: To assess the influence of STARWAVe factors on GPs’ unaided risk assessments and prescribing decisions.

Design and setting: Clinical vignettes administered to 188 UK GPs online.

Method: GPs were randomly assigned to view 32 (out of a possible 64) vignettes online depicting children with cough. The vignettes comprised the seven STARWAVe factors, which were varied systematically. For each vignette, GPs assessed risk of deterioration in one of two ways (sliding-scale versus risk-category selection) and indicated whether they would prescribe antibiotics. Finally, GPs saw an additional vignette, suggesting that the parent was concerned. Mixed-effects regressions were used to measure the influence of STARWAVe factors, risk-elicitation method, and parental concern on GPs’ assessments and decisions.

Results: Six STARWAVe risk factors correctly increased GPs’ risk assessments (bssliding-scale≥0.66, odds ratios [ORs]category-selection≥1.75, Ps≤0.001), whereas one incorrectly reduced them (short illness duration: bsliding-scale −0.30, ORcategory-selection 0.80, P≤0.039). Conversely, one STARWAVe factor increased prescribing odds (temperature: OR 5.22, P
Conclusion: GPs use some, but not all, STARWAVe factors when making unaided risk assessments and prescribing decisions. Such discrepancies must be considered when introducing CPRs to clinical practice.
Original languageEnglish
Pages (from-to)e176-e185
JournalBritish Journal of General Practice
Issue number728
Early online date20 Feb 2023
Publication statusPublished - 1 Mar 2023

Bibliographical note

Funding Information:
This study was funded by the National Institute for Health and Care Research (NIHR) Imperial Patient Safety Translational Research Centre (http://www.imperial. views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Funding Information:
Patient and public involvement: The Imperial College London Research Partners Group (comprising patients, carers, and members of the public) gave feedback on the study design. The authors gratefully acknowledge infrastructure support from the NIHR Imperial Patient Safety Translational Research Centre, the NIHR Imperial Biomedical Research Centre, and the NIHR Clinical Research Network.

Publisher Copyright:
©The Authors.


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