The complex phenomenon of dysrational antibiotics prescribing decisions in German primary healthcare: a qualitative interview study using dual process theory

Abstract

Background Antibiotic prescription rates in primary care in Germany are moderate, but still considered too high. The ARena study (Sustainable reduction of antibiotic-induced antimicrobial resistance) was initiated to foster awareness and understanding of the growing challenge and promotes rational antibiotics use for acute, non-complicated and self-limiting infections. Methods The present study was performed as part of the process evaluation of the ARena study. Interviews were conducted with a purposive sample of physicians participating in the ARena study to identify factors relevant to primary care physicians’ decision-making when prescribing antibiotics for acute non-complicated infections. Generated data were audio-recorded. Pseudonymized verbatim transcripts were coded using a pre-defined framework. The Dual Process Theory was applied to provide understanding of individual health professional factors that induce dysrational prescribing decisions. Results Based on medical as well as non-medical considerations, physicians developed habits in decision making on antibiotics prescribing. They acknowledged inadequate antibiotics prescribing for acute, non-complicated infections in situations involving uncertainty regarding diagnosis, prognosis, continuity of care, patient expectations and when not knowing the patient. Educative efforts empowered physicians to override habitual prescribing. A theory-driven model provides transparency as to how dysrational prescribing decisions occur and suggests remedy by providing new experiences and new recognizable patterns through educative efforts. Conclusions Educational interventions may only change prescribing behaviours if they result in active rational rather than routine-based decision-making on antibiotics prescribing. Trial registration ISRCTN, ISRCTN58150046.

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

“…Interviewed physicians pointed to a potential discrimination against elderly patients by confronting them with digital educational solutions, rated health literacy competencies of the younger population to be higher and saw employed patients at a higher risk of demanding antibiotics due to work-related stressors. These perceptions are supported by prior research [ 33 ]. A connection between age and antibiotic-related health literacy has not been identified.…”

Baseline assessment of antibiotics prescribing for acute, non-complicated infections in primary care in Germany in the cluster randomized trial ARena

“…The prescription rates for quinolones were generally moderate to low in PCNs (9.9%) and RGs (8.1%) and thus match recent ndings of a study that examined antibiotic prescribing in the US outpatient setting where 9.4% of investigated visits for acute respiratory infections received a broad-spectrum antibiotic [22]. Prescribing quinolones seemed to be associated with a higher number of comorbidities and higher patient age as well which complements ndings 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 prescriptions [23]. To some extend this con rms ndings from a 2010 study that investigated uoroquinolone prescriptions for acute cough in German primary care to nd predictors for unjusti ed prescriptions.…”

“…However, our data showed that the percentage of observed cases of Eastern European patients was higher than the one of Southern Europeans in PCNs as well as in RGs. This is contrasted by ndings of the process evalaution in ARena where physicians indicated their subjective perception of many Southern Europeans asking for antibiotics prescriptions [23].…”

Baseline assessment of antibiotics prescribing for acute, non-complicated infections in primary care in Germany in the cluster randomized trial ARena

“…The prescription rates for quinolones were generally moderate to low in PCNs (9.9%) and RGs (8.1%) and thus match recent ndings of a study that examined antibiotic prescribing in the US outpatient setting where 9.4% of investigated visits for acute respiratory infections received a broad-spectrum antibiotic [19]. Prescribing quinolones seemed to be associated with a higher number of comorbidities and higher patient age as well which complements ndings 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 prescriptions [20]. To some extend this con rms ndings from a 2010 study that investigated uoroquinolone prescriptions for acute cough in German primary care to nd predictors for unjusti ed prescriptions.…”

“…However, our data showed that the percentage of observed cases of Eastern European patients was higher than the one of Southern Europeans in PCNs as well as in RGs. This is contrasted by ndings of the process evalaution in ARena where physicians indicated their subjective perception of many Southern Europeans asking for antibiotics prescriptions [20].…”