Coping With Diagnostic Uncertainty in Antibiotic Prescribing: A Latent Class Study of Primary Care Physicians in Hubei China

Abstract

Background: Misuse of antibiotics is prevalent worldwide and primary care is a major contributor. Although a clear diagnosis is fundamental for rational antibiotic use, primary care physicians often struggle with diagnostic uncertainty. However, we know little about how physicians cope with this situation and its association with antibiotic prescribing.Methods: A total of 583 primary care physicians were surveyed using the Dealing with Uncertainty Questionnaire. Their prescriptions (n = 949,181) over the year 2018 were retrieved retrospectively. Two categories of behavioral patterns of participants were identified based on latent class analyses (high vs. low openness and collaborativeness) in responding to diagnostic uncertainty. Multi-level logistic regression models were established to determine the associations between these behavioral patterns and antibiotic prescribing (overall and broad-spectrum antibiotics) for illness without an indication for antibiotics and those with a conditional indication for antibiotics, respectively, after adjustment for variations of patient (level one) and physician (level two) characteristics.Results: Most physicians reported open communications with their patients (80.96%), collected further information (85.08%), and referred patients to specialists (68.95%) in dealing with diagnostic uncertainly. More than half (56.95%) sought help from colleagues. Less than 20% acted on intuition or adopted a “wait and see” strategy. About 40% participants (n = 238) were classified into the group of low openness and collaborativeness in coping with diagnostic uncertainty. They were more likely to prescribe antibiotics for the recorded illness without an indication for antibiotics (AOR = 1.013 for all antibiotics, p = 0.024; AOR = 1.047 for broad-spectrum antibiotics, p < 0.001), as well as for the recorded illness with a conditional indication for antibiotics (AOR = 1.226 for all antibiotic, p < 0.001; AOR = 1.257 for broad-spectrum antibiotics, p < 0.001).Conclusion: Low tolerance with diagnostic uncertainty is evident in primary care. Inappropriate and over antibiotic prescribing is shaped by physicians' coping methods of diagnostic uncertainty. Physicians' openness and collaborativeness in responding to diagnostic uncertainty is associated with lower antibiotic prescribing in primary care. Interventions targeting on better management of diagnostic uncertainty may offer a promising approach in reducing antibiotic use in primary care.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

“…The empiric use of antibiotics was also more likely among GPs when there was diagnostic uncertainty, similar to the findings from recent studies from a number of other countries [ 106 , 107 , 108 , 109 ]. Prescribing antibiotics when there is uncertainty between possible viral or bacterial infections is exacerbated when laboratory tests are expensive, there is a lack of access to them as well as a lack of sensitive and cost-effective point-of-care testing equipment within LMIC settings [ 16 , 17 , 110 , 111 ].…”

Appropriate use of antibiotics for acute respiratory infections at primary healthcare facilities in China: a nationwide cross-sectional study from 2017 to 2019

“…Moreover, surveillance of antibiotic use should also distinguish conditions for which antibiotic treatment is always justified to avoid underuse of antibiotics in certain cases. 16 , 57 Finally, our finding indicates the need for a long-term, nationwide, government intervened, cross-sectoral antimicrobial stewardship program to promote evidence-based antibiotic use and enhance the consistency in the quality of healthcare services throughout China. 36 …”

Clinical Uncertainty Influences Antibiotic Prescribing for Upper Respiratory Tract Infections: A Qualitative Study of Township Hospital Physicians and Village Doctors in Rural Shandong Province, China

“…Respondents reported that URTIs were the most common reason for patients visiting township hospitals and village clinics, which is in line with previous studies in rural China [ 38 , 39 ], and that URTIs are the major diagnosis for which antibiotics are prescribed. Although the vast majority of URTIs are self-limiting, meaning it is usually possible to ‘wait and see’, few respondents reported adopting the strategy [ 25 ]. Respondents reported that, due to diagnostic and prognostic uncertainty, they prescribe antibiotics just in case, aiming to mitigate the perceived risk of complications (such as hospital admission).…”

“…Significant research on clinical uncertainty in other settings worldwide has been conducted, strongly indicating that clinical uncertainty is associated with higher levels of antibiotic prescribing [ 1 , 21 , 25 ]. The specific reasons for clinical uncertainty are often context- and culture-specific, and understanding how clinical uncertainty influences clinician practices concerning antibiotic use in rural China is currently limited.…”