Coping with ‘the grey area’ of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing

Abstract

Background Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms. Methods Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20th percentile versus “medium” defined as 40th to 60th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved. Results Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician–patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty. Conclusions Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices.

Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN)

“…Inappropriate antibiotic prescribing behaviour is complex and driven by habit, fear, time constraints, and perceived patient expectations. Rarely, is it related to a simple knowledge gap to be affected by education alone [ 44 ]. Multifaceted approaches to antibiotic prescribing in primary care in order to facilitate a change in prescribing are essential.…”

Knowledge, Perceptions, and Perspectives of Medical Students Regarding the Use of Antibiotics and Antibiotic Resistance: A Qualitative Research in Galicia, Spain

“…Although the students are aware of the severity and consequences of the increase in antibiotic resistance, they view it as a medium-to-long-term problem. They are uncertain about the extent to which it currently affects their healthcare environment, a belief shared by medical professionals across different fields [ 25 , 26 , 27 ]. Similar findings were reported in a systematic review, which revealed that students acknowledge antibiotic resistance as a global public health concern but do not express concern about its impact in their immediate workplace or learning environment, such as their teaching hospital [ 15 ].…”

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

“…Another common theme in qualitative studies of audit and feedback is that physicians articulate that the data do not reflect their unique practice and patient characteristics. 12 13 14 15…”