Fostering Appropriate Antibiotic Use in a Complex Intervention: Mixed-Methods Process Evaluation Alongside the Cluster-Randomized Trial ARena

Abstract

The cluster randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance, 2017–2020) promoted appropriate use of antibiotics for acute non-complicated infections in primary care networks (PCNs) in Germany. A process evaluation assessed determinants of practice and explored factors associated with antibiotic prescribing patterns. This work describes its findings on uptake and impacts of the complex intervention program and indicates potential implementation into routine care. In a nested mixed-methods approach, a three-wave study-specific survey for participating physicians and medical assistants assessed potential impacts and uptake of the complex intervention program. Stakeholders received a one-time online questionnaire to reflect on network-related aspects. Semi-structured, open-ended interviews, with a purposive sample of physicians, medical assistants and stakeholders, explored program component acceptance for daily practice and perceived sustainability of intervention component effects. Intervention components were perceived to be smoothly integrable into practice routines. The highest uptake was reported for educational components: feedback reports, background information, e-learning modules and disease-specific quality circles (QCs). Participation in PCNs was seen as the motivational factor for guideline-oriented patient care and adoption of new routines. Future approaches to fostering appropriate antibiotics use by targeting health literacy competencies and clinician’s therapy decisions should combine evidence-based information sources, audit and feedback reports and QCs.

Antibiotic prescribing for acute, non-complicated infections in primary care in Germany: baseline assessment in the cluster randomized trial ARena

“…Prescribing rates for quinolones were generally moderate to low in PCNs (9.9%) and RG (8.1%) and thus also match findings of the study from USA where in 9.4% of investigated visits for acute respiratory infections a broad-spectrum antibiotic was received [ 24 ]. Prescribing quinolones seemed to be associated with a higher number of comorbidities and higher patient age as well which complements findings of the process evaluation conducted alongside ARena where uncertainty about diagnoses, prognosis, continuity of care and perceptions about patient preferences were found to be among the reasons for non-indicated prescribing [ 25 , 26 ]. To some extend this confirms findings from a 2010 study that investigated fluoroquinolone prescribing for acute cough in German primary care to find predictors for unjustified prescribing.…”

Implementation Fidelity In A Multifaceted Program To Foster Rational Antibiotics Use In Primary Care: An Observational Study

“…This present study was based on survey data collected during the PE and the additional documentation (attendance data). Findings of qualitative analyses have been reported elsewhere [37][38][39]. Figure 2 summarizes the study design and sample size of the PE.…”

“…Findings in the PE conducted alongside ARena indicate that interviewed physicians did interpret additional compensation as one key to generate behavior change. However, additional compensation might only be an incentive to participate in a study, but of lesser importance after this decision is taken [39]. Jan et al [44] also identi ed increased administrative workloads and inadequate understandings of performance-based payment contents as principal reasons for aversions of family practitioners to engage.…”

Contextual Factors Influencing Physicians’ Perception of Antibiotic Prescribing in Primary Care in Germany - A Prospective Observational Study

“…Research further showed that PCNs can act as effective drivers of innovation and quality improvement, especially when communication and support functioned well within the networks [19,28,29]. Being part of a PCN can thus support the adoption of speci c behaviors and beliefs [13,19].…”

“…When interpreting results, it should be considered that PCN member physicians might show stronger tendencies to innovation and development than physicians who are not part of a PCN [13,19]. The data analyzed in this study were generated in the process evaluation carried out alongside ARena.…”