Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care – a mixed methods study in Sweden

Abstract

BackgroundPrescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.MethodsOur mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners’ audit registrations. Qualitative data were collected through observations and semi-structured interviews.ResultsFrom the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner’s diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.ConclusionsLow prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses’ triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

Rational antibiotic prescribing in primary care: qualitative study of opportunities and obstacles

“…Moreover, in low prescribing PHCCs, new knowledge was not only internalised in the PHCC as a whole, but also in all personnel through an ongoing professional discussion. 13 This is in line with the results from the present study.…”

“…The results in this study are consistent with a previous study showing that several factors are important for rational antibiotic prescribing in primary care: the GP’s diagnostic process, internalised guidelines, nurse triage, patient expectation, and promoting management leadership. 13 The authors’ previous knowledge of the area might be both a strength and a weakness. The fact that they have similar experiences from their practical work has enabled them to understand the written text in a richer way.…”

Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review

“…Doctors may overestimate the pressure to prescribe antibiotics for acute cough [ 68 – 70 ] or other acute respiratory illnesses [ 50 ], often prescribing antibiotics for patients who did not request them [ 71 ]. There is mounting evidence that patients’ expectations for antibiotics for ARTI have lessened in recent years, especially where the consultation is more patient centred [ 41 , 67 , 72 – 76 ]. This illustrates the importance of a patient-centred consultation with good communication skills employed by the PCP.…”

Registered Nurses´ Views on Telephone Nursing for Patients with Respiratory Tract Infections in Primary Health Care – A qualitative interview study

“…RNs reported that they preferred their main duties, and viewed answering telephone calls as imposed work, which is in line with organizational and individual perspective. These circumstances could perhaps be overcome by education and facilitating PHCC adaption and transformation of guidelines among all staff through inter-professional discussions (7,37). A previous study (7) revealed that low-prescribing PHCCs regarding antibiotics had reserved time for regular meetings concerning medical issues, and prioritized training within and between professions.…”

“…These circumstances could perhaps be overcome by education and facilitating PHCC adaption and transformation of guidelines among all staff through inter-professional discussions (7,37). A previous study (7) revealed that low-prescribing PHCCs regarding antibiotics had reserved time for regular meetings concerning medical issues, and prioritized training within and between professions. Somehow, RNs' knowledge and competence on telephone nursing issues in PHCCs, where RN self-advice is crucial, is taken for granted by organisations.…”