Does shared decision-making reduce antibiotic prescribing in primary care?

Esch, T.E.M. van; Brabers, A.; Hek, Karin; Dijk, Liset van; Verheij, Robert; Jong, J.D. de

doi:10.1093/jac/dky321

Cited by 39 publications

(28 citation statements)

References 24 publications

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“…This is supported by a study looking at drivers for the variability in the rate of antibiotic prescribing in UK general practices, which suggests that the influence of overall patient health in the decision to prescribe is limited, 20 and in the current study, where patients with similar risk profiles (such as Charlson scores) were also treated differently between different common infections. This variability in antibiotic prescribing after adjustment for age, gender and calendar time confirms that more consistent prescribing and optimization in decision making, such as shared decision making, could impact prescribing 40 and are essential if we are to reduce inappropriate overuse and thus avoidable resistance.…”

Section: Discussionmentioning

confidence: 72%

Antibiotic prescribing for common infections in UK general practice: variability and drivers

Palin

Mölter

Belmonte

et al. 2019

Journal of Antimicrobial Chemotherapy

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Objectives To examine variations across general practices and factors associated with antibiotic prescribing for common infections in UK primary care to identify potential targets for improvement and optimization of prescribing. Methods Oral antibiotic prescribing for common infections was analysed using anonymized UK primary care electronic health records between 2000 and 2015 using the Clinical Practice Research Datalink (CPRD). The rate of prescribing for each condition was observed over time and mean change points were compared with national guideline updates. Any correlation between the rate of prescribing for each infectious condition was estimated within a practice. Predictors of prescribing were estimated using logistic regression in a matched patient cohort (1:1 by age, sex and calendar time). Results Over 8 million patient records were examined in 587 UK general practices. Practices varied considerably in their propensity to prescribe antibiotics and this variance increased over time. Change points in prescribing did not reflect updates to national guidelines. Prescribing levels within practices were not consistent for different infectious conditions. A history of antibiotic use significantly increased the risk of receiving a subsequent antibiotic (by 22%–48% for patients with three or more antibiotic prescriptions in the past 12 months), as did higher BMI, history of smoking and flu vaccinations. Other drivers for receiving an antibiotic varied considerably for each condition. Conclusions Large variability in antibiotic prescribing between practices and within practices was observed. Prescribing guidelines alone do not positively influence a change in prescribing, suggesting more targeted interventions are required to optimize antibiotic prescribing in the UK.

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Section: Discussionmentioning

confidence: 72%

Antibiotic prescribing for common infections in UK general practice: variability and drivers

Palin

Mölter

Belmonte

et al. 2019

Journal of Antimicrobial Chemotherapy

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“…The study of practice variation helps to pinpoint practices with high antibiotic prescribing to target interventions as well as practices with low antibiotic prescribing. This allows to find out which modifiable factors are associated with low and high antibiotic prescribing, such as the level of shared decision making that GPs use [ 24 ] or the rate of diagnostic testing [ 25 ]. The outcome of such a study could be used in the design of future interventions and in antimicrobial stewardship programs.…”

Section: Discussionmentioning

confidence: 99%

Guideline Adherence in Antibiotic Prescribing to Patients with Respiratory Diseases in Primary Care: Prevalence and Practice Variation

et al. 2020

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Respiratory tract infections (RTIs) account for a large part of antibiotic prescriptions in primary care. However, guidelines advise restrictive antibiotic prescribing for RTIs. Only in certain circumstances, depending on, e.g., comorbidity, are antibiotics indicated. Most studies on guideline adherence do not account for this. We aimed to assess guideline adherence for antibiotic prescribing for RTIs as well as its variation between general practices (GPs), accounting for patient characteristics. We used data from electronic health records of GPs in the Netherlands. We selected patients who consulted their GP for acute cough, rhinitis, rhinosinusitis or sore throat in 2014. For each disease episode we assessed whether, according to the GP guideline, there was an indication for antibiotics, using the patient’s sociodemographic characteristics, comorbidity and co-medication. We assessed antibiotic prescribing for episodes with no or an unsure indication according to the guidelines. We analysed 248,896 episodes. Diagnoses with high rates of antibiotic prescribing when there was no indication include acute tonsillitis (57%), strep throat (56%), acute bronchitis (51%) and acute sinusitis (48%). Prescribing rates vary greatly between diagnoses and practices. Reduction of inappropriate antibiotic prescribing remains a key target to tackle antimicrobial resistance. Insight into reasons for guideline non-adherence may guide successful implementation of the variety of interventions already available for GPs and patients.

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“…Other studies conducted in non-US healthcare settings has found that shared decision making is effective and does not contribute to diverging from clinical guidelines. 18,22 Patient communication can be tailored to clearly delineate the role of the clinician as the prescribing decision maker with sensitivity to patient preferences that can result in a decision that is better understood by the patient. Patient education tools should increase transparency concerning the standard of care for ARI visits and support clinician decisions not to prescribe antibiotics unless truly necessary, such as those illustrated with public commitment posters.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of clinicians’ knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management

Hruza

Velasquez

Madaras‐Kelly

et al. 2020

Infect. Control Hosp. Epidemiol.

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Background:Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans’ Health Administration clinics.Methods:We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.Results:Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.Conclusion:Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians’ perceptions of antibiotic prescribing practices and should enhance their patient communication skills.

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Does shared decision-making reduce antibiotic prescribing in primary care?

Abstract: SDM can be a framework to reduce the prescribing of antibiotics and thus to control antibiotic resistance.

Cited by 39 publications

References 24 publications

Antibiotic prescribing for common infections in UK general practice: variability and drivers

Antibiotic prescribing for common infections in UK general practice: variability and drivers

Guideline Adherence in Antibiotic Prescribing to Patients with Respiratory Diseases in Primary Care: Prevalence and Practice Variation

Evaluation of clinicians’ knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management

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