Promoting rational antibiotic prescribing for non-complicated infections: understanding social influence in primary care networks in Germany

Abstract

Background: Primary care networks in Germany are formalized regional collaborations of physicians and other healthcare providers. Common goals are optimized healthcare processes and services for patients, enhanced communication, agency for professional concerns and strengthened economic power. In the ARena study (Sustainable reduction of antibiotic-induced antimicrobial resistance), 14 primary care networks in two federal German states aimed to promote appropriate antibiotics use for acute non-complicated infections by fostering awareness and understanding. Factors related to the role of primary care networks were to be identified. Methods: For this study, audio-recorded telephone interviews were conducted with physicians, non-physician health professionals and stakeholder representatives. Pseudonymized verbatim transcripts were coded using thematic analysis. In-depth analysis was based on the inductive categories 'social support', 'social learning', 'social normative pressures' and 'social contagion' to reflect social influence processes. Data generated through a survey with physicians and non-physician health professionals were analyzed descriptively to foster understanding of the networks' potential impact on antibiotic prescribing. Results: Social influence processes proved to be relevant regarding knowledge transfer, manifestation of bestpractice care and self-reflection. Peer communication was seen as a great asset, the main reason for membership and affirmative for own perspectives. All interviewed physicians (n = 27) considered their network to be a strong support factor for daily routines, introduction of new routines, and continuity of care. They utilized network-offered training programs focusing on best practice guideline-oriented use of antibiotics and considered their networks supportive in dealing with patient expectations. A shared attitude combined with ARena intervention components facilitated reflective management of antibiotic prescribing. Non-physician health professionals (n = 11) also valued network peer exchange. They assumed their employers joined networks to offer improved and continuous care. Stakeholders (n = 7) expected networks and their members to be drivers for care optimization.

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

“…Aiming to foster appropriate antibiotic prescribing for respiratory tract infections during ambulatory visits, the authors identified a decrease of inappropriate prescription rates from 19.9% to 3.7% in 18 months attributable to peer comparison mechanisms. Such peer mechanisms and social influences have been identified in ARena as well [ 30 ].…”

Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena

“…Thus, the PCNs were expected to be an enabling factor for change of prescribing routines. This was also supported by process evaluation findings [20,25] which confirmed that it was an appropriate choice to conduct the ARena trial in the setting of PCNs. Observed antibiotic prescribing in the intervention arms at baseline [26] was both, lower than expected and lower than in matched standard care.…”

Contextual factors influencing physicians’ perception of antibiotic prescribing in primary care in Germany — a prospective observational study

“…Response rates were 75.5% (T0 n = 229), 64.0% (T1 n = 200) and 63.3% (T2 n = 184) [ 21 ]. At time of T0, 148 (55.0%) of all responders were male and the average age was 54.0 years (SD 7.6).…”

“…A qualitative study within the process evaluation of ARena pointed in the same direction [ 21 ]: Physicians described PCNs as supportive with regard to exchange (beliefs, ideas and experiences), management, and the implementation of new routines in practice, which can influence decision-making on antibiotic prescribing [ 21 , 29 ]. 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 [ 21 , 30 , 31 ]. Being part of a PCN can thus support the adoption of specific behaviors and beliefs [ 13 , 21 ].…”

“…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 [ 21 , 30 , 31 ]. Being part of a PCN can thus support the adoption of specific behaviors and beliefs [ 13 , 21 ]. With regards to the TPB, PCNs as a contextual factor might have had a strong influence on both social norms and attitudes towards the targeted behavior through social interactions and relationships.…”