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Original research
Risk assessment and antibiotic prescribing decisions in children presenting to UK primary care with cough: a vignette study
  1. Martine Nurek,
  2. Brendan C Delaney,
  3. Olga Kostopoulou
  1. Surgery and Cancer, Imperial College London, London, UK
  1. Correspondence to Dr Martine Nurek; m.nurek{at}


Objectives The validated ‘STARWAVe’ (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting) clinical prediction rule (CPR) uses seven variables to guide risk assessment and antimicrobial stewardship in children presenting with cough. We aimed to compare general practitioners’ (GPs) risk assessments and prescribing decisions to those of STARWAVe and assess the influence of the CPR’s clinical variables.

Setting Primary care.

Participants 252 GPs, currently practising in the UK.

Design GPs were randomly assigned to view four (of a possible eight) clinical vignettes online. Each vignette depicted a child presenting with cough, who was described in terms of the seven STARWAVe variables. Systematically, we manipulated patient age (20 months vs 5 years), illness duration (3 vs 6 days), vomiting (present vs absent) and wheeze (present vs absent), holding the remaining STARWAVe variables constant.

Outcome measures Per vignette, GPs assessed risk of hospitalisation and indicated whether they would prescribe antibiotics or not.

Results GPs overestimated risk of hospitalisation in 9% of vignette presentations (88/1008) and underestimated it in 46% (459/1008). Despite underestimating risk, they overprescribed: 78% of prescriptions were unnecessary relative to GPs’ own risk assessments (121/156), while 83% were unnecessary relative to STARWAVe risk assessments (130/156). All four of the manipulated variables influenced risk assessments, but only three influenced prescribing decisions: a shorter illness duration reduced prescribing odds (OR 0.14, 95% CI 0.08 to 0.27, p<0.001), while vomiting and wheeze increased them (ORvomit 2.17, 95% CI 1.32 to 3.57, p=0.002; ORwheeze 8.98, 95% CI 4.99 to 16.15, p<0.001).

Conclusions Relative to STARWAVe, GPs underestimated risk of hospitalisation, overprescribed and appeared to misinterpret illness duration (prescribing for longer rather than shorter illnesses). It is important to ascertain discrepancies between CPRs and current clinical practice. This has implications for the integration of CPRs into the electronic health record and the provision of intelligible explanations to decision-makers.

  • primary care
  • respiratory infections
  • medical education & training
  • public health
  • health informatics

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors All authors contributed to the design of the study. MN performed the data collection; MN and OK performed the data analysis. MN drafted the manuscript; OK and BD provided critical revision and approved the final version.

  • Funding This research was supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. The funders had no role in the study design; in the collection, analysis and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

  • Competing interests Dr MN, Dr BD and Dr OK report grants from the NIHR Imperial Patient Safety Translational Research Centre, during the conduct of the study.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval for this study was obtained from the Health Research Authority (reference number 18/HRA/0021) and research sponsorship was provided by Imperial College London (JRO reference 17IC3882). All aspects of the study were conducted in the UK in 2018.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data are available in a public, open access repository (the Open Science Framework) under a CC-By Attribution 4.0 International Licence:

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