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C-reactive protein diagnostic test uptake in primary care: a qualitative study of the UK's 2019-2024 AMR National
Rebecca E Glover1, Agata Pacho2, Nicholas Mays2
1Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK rebecca.glover@lshtm.ac.uk.
Insights
Implementing C-reactive Protein (CRP) testing for infections requires addressing policy and professional views. Successful adoption depends on integrated systems, while barriers like guideline discordance can increase antibiotic use and costs.
Area of Science:
- Healthcare policy
- Diagnostic test implementation
- Infectious disease management
Background:
- C-reactive Protein (CRP) testing aids in differentiating bacterial from viral infections.
- Primary care settings face challenges in optimizing diagnostic test implementation.
- International comparisons offer insights into successful and unsuccessful adoption strategies.
Purpose of the Study:
- To compare the implementation of C-reactive Protein (CRP) testing in primary care across Sweden, the Netherlands, the UK, and Canada.
- To identify barriers and facilitators influencing CRP test adoption and use.
- To provide actionable insights for health services considering CRP test implementation.
Main Methods:
- Qualitative interviews were conducted with 35 UK policy-makers and clinicians.
- National-level experts in Canada, Sweden, and the Netherlands were also interviewed (13 participants).
- The NASSS framework was utilized for thematic analysis of technology-supported healthcare change.
Main Results:
- The Netherlands demonstrated successful CRP implementation due to supportive infrastructure and guideline adherence.
- Sweden experienced 'CRP-itis' with widespread, guideline-discordant testing.
- UK uptake stalled due to local commissioning issues, while Canada showed limited uptake and skepticism.
- Organizational and system-level factors were key barriers and facilitators, with some limitations of the NASSS framework noted.
Conclusions:
- CRP test implementation is hindered by concerns regarding its value proposition among policymakers and professionals.
- Discordant practices between guidelines and clinicians can lead to increased antibiotic prescribing and healthcare costs.
- Local-level commissioning may lead to stagnated uptake of diagnostic tests.
- Successful implementation, if not managed properly, could negatively impact public finances.
Objectives:
This study compares the implementation of C-reactive Protein (CRP) testing to distinguish between acute bacterial and viral infections in primary care in three WHO European region countries (Sweden, the Netherlands and the UK) and one WHO Americas region country (Canada) to generate insights that health services can use to guide decision-making on CRP test implementation.
Setting:
Three settings were included: (1) national-level policy interviewees in England, (2) front-line antibiotic prescribers operating in primary care in England and (3) national-level policy interviewees in Canada, Sweden and the Netherlands.
Participants:
We conducted in-depth qualitative interviews with 35 UK antimicrobial resistance policy-makers, clinicians and allied medical professionals. We also interviewed 13 national-level diagnostic test experts in Canada, Sweden, the Netherlands and the UK. We transcribed, thematically coded and analysed the data, using the NASSS framework for analysing technology-supported healthcare change.
Results:
There were multiple barriers and facilitators to CRP test implementation. The Netherlands was seen as the country with the most successful implementation of CRP, with enabling IT, financing and quality assurance infrastructure alongside strong guideline adherence to prevent overtesting. By contrast, Swedish interviewees reported 'CRP-itis', or widespread, guideline-discordant testing. UK uptake, contingent on local-level commissioning, has stalled amid mixed professional views. Canadian professional views are sceptical, and uptake plans are nearly non-existent. The NASSS themes emerging as the strongest facilitator or barrier to diagnostic uptake were the organisation and wider systems, with some reflections emerging on the limitations of NASSS to capture interface issues emerging from the analysis.
Conclusions:
Health services considering CRP test adoption in primary care need to be mindful that, where concerns about the value proposition of the technology exist among policy-makers and professionals, CRPs are unlikely to be implemented; where there are discordant practices between policymakers/guidelines and clinicians, adoption of CRP testing may increase both antibiotic prescribing and costs to the health system. Where there is local-level commissioning of diagnostic tests, uptake may stagnate; and where implementation succeeds, it may be to the detriment of the public purse.
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