Implications for research and practice
If STARWAVe is to be provided as a decision aid to GPs, then several issues need to be addressed. First, risk of admission to hospital guides prescribing in the STARWAVe model; the current findings suggest that this may not be true for GPs. Consequently, a STARWAVe-based decision aid may fail to bring about meaningful change. As mentioned in the Introduction, a multicomponent intervention that includes STARWAVe decision support is currently at clinical trial,Second, decision aid developers will need to consider how best to present risk estimates to GPs. The present findings suggest that the risk-elicitation format can influence explicit risk assessments. Risk assessments cast on a sliding scale were inflated relative to those cast via category selection, but they were also better aligned with GPs’ own management decisions (suggesting a certain ‘fidelity’ or ‘construct validity’) and STARWAVe’s recommended management pathways (suggesting potential normative value). Presenting risk scores as point-estimates on a continuous scale may thus be more effective — and more likely to influence decisions — than presenting them as categories (for example, ‘very low’ and ‘high’).Third, the authors have found consistent evidence to suggest that GPs’ interpretation of illness duration runs counter to STARWAVe. Qualitative work investigating why GPs prescribe antibiotics for longer (versus shorter) illnesses could return valuable insights. GPs may be adopting a ‘wait-and-see’ approach to prescribing in an attempt to reduce prescriptions.The present study highlights the importance of examining how practitioners appraise information and assess risk when designing decision support tools. When discrepancies are observed, such tools should be introduced carefully and explained to practitioners so that they do not result in loss of trust and limited use.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.