Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice

Factors influencing antibiotic prescribing for respiratory tract infections in primary care - a comparison of physicians with different antibiotic prescribing rates

BACKGROUND

There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years.

OBJECTIVE

To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors.

DESIGN AND SETTING

A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006-2014. The data were divided into three 3-year periods.

SUBJECTS

The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group.

MAIN OUTCOME MEASURES

For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics.

RESULTS

The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days.

CONCLUSION

Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.

Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review

BACKGROUND

Antibiotic resistance is growing globally. The practice of health professionals when prescribing antibiotics in primary health care settings significantly impacts antibiotic resistance. Antibiotic prescription is a complex process influenced by various internal and external factors. This systematic review aims to summarize the available evidence regarding factors contributing to the variation in antibiotic prescribing among physicians in primary healthcare settings.

METHODS

This systematic review was conducted based on PRISMA guidelines. We included qualitative, quantitative and mixed methods studies that examined factors influencing prescription practice and variability among primary healthcare physicians. We excluded editorials, opinions, systematic reviews and studies published in languages other than English. We searched studies from electronic databases: PubMed, ProQuest Health and Medicine, Web Science, and Scopus. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (Version 2018). Narrative synthesis was employed to synthesize the result and incorporate quantitative studies.

RESULTS

Of the 1816 identified studies, 49 studies spanning 2000-2023 were eligible for review. The factors influencing antibiotic prescription practice and variability were grouped into physician-related, patient-related, and healthcare system-related factors. Clinical guidelines, previous patient experience, physician experience, colleagues' prescribing practice, pharmaceutical pressure, time pressure, and financial considerations were found to be influencing factors of antibiotic prescribing practice. In addition, individual practice patterns, practice volume, and relationship with patients were also other factors for the variability of antibiotic prescription, especially for intra-physician prescription variability.

CONCLUSION

Antibiotic prescription practice in primary health care is a complex practice, influenced by a combination of different factors and this may account for the variation. To address the factors that influence the variability of antibiotic prescription (intra- and inter-physician), interventions should aim to reduce diagnostic uncertainty and provide continuous medical education and training to promote patient-centred care.

Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds

BACKGROUND

Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions.

METHODS

PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer.

RESULTS

PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited.

CONCLUSIONS

We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.

Throat infections and use of streptococcal antigen test and antibiotic treatment in general practice; a web-based survey

OBJECTIVE

The aim of this study was to investigate the use of streptococcal antigen tests and antibiotic prescription in general practice in Norway in relation to the national guidelines for sore throat.

DESIGN

This study was based on a web-based survey.

SETTING

Norwegian general practice.

SUBJECTS

4700 members of the Norwegian College of General Practice received the survey by E-mail.

MAIN OUTCOME MEASURES

General practitioner (GP) adherence to national guidelines.

RESULTS

In total, 807 GPs responded and were included in the study. According to the guidelines, 20% and 30% of the GPs would perform unnecessary streptococcal antigen testing when presented with mild and severe infections respectively, while 52% would not perform the test at moderate infection. Phenoxymethylpenicillin was recommended by 95% of the GPs.

CONCLUSION

In this survey of self-selected GPs, we identified some non-adherence to National guidelines for streptococcal antigen testing and antibiotic prescribing. However, when antibiotic treatment was offered, the correct antibiotics were prescribed.Key pointsNorwegian guidelines for diagnosis and treatment of throat infections include the use of Centor criteria as a clinical tool to limit the unnecessary use of antibiotics. In this web-based survey, we investigated the use of streptococcal antigen tests and antibiotic prescription in general practice in relation to the national guidelines.•Streptococcal antigen tests were not always performed according to Norwegian guidelines, causing inappropriate antibiotic prescribing.•National guidelines were followed in the choice of antibiotics for sore throat.

Biomarkers as point-of-care tests to guide prescription of antibiotics in people with acute respiratory infections in primary care

BACKGROUND

Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. It follows that in many cases antibiotic use will not be beneficial to a patient's recovery but may expose them to potential side effects. Furthermore, limiting unnecessary antibiotic use is a key factor in controlling antibiotic resistance. One strategy to reduce antibiotic use in primary care is point-of-care biomarkers. A point-of-care biomarker (test) of inflammation identifies part of the acute phase response to tissue injury regardless of the aetiology (infection, trauma, or inflammation) and may be used as a surrogate marker of infection, potentially assisting the physician in the clinical decision whether to use an antibiotic to treat ARIs. Biomarkers may guide antibiotic prescription by ruling out a serious bacterial infection and help identify patients in whom no benefit from antibiotic treatment can be anticipated. This is an update of a Cochrane Review first published in 2014.

OBJECTIVES

To assess the benefits and harms of point-of-care biomarker tests of inflammation to guide antibiotic treatment in people presenting with symptoms of acute respiratory infections in primary care settings regardless of patient age.

SEARCH METHODS

We searched CENTRAL (2022, Issue 6), MEDLINE (1946 to 14 June 2022), Embase (1974 to 14 June 2022), CINAHL (1981 to 14 June 2022), Web of Science (1955 to 14 June 2022), and LILACS (1982 to 14 June 2022). We also searched three trial registries (10 December 2021) for completed and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared the use of point-of-care biomarkers with standard care. We included trials that randomised individual participants, as well as trials that randomised clusters of patients (cluster-RCTs).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on the following primary outcomes: number of participants given an antibiotic prescription at index consultation and within 28 days follow-up; participant recovery within seven days follow-up; and total mortality within 28 days follow-up. We assessed risk of bias using the Cochrane risk of bias tool and the certainty of the evidence using GRADE. We used random-effects meta-analyses when feasible. We further analysed results with considerable heterogeneity in prespecified subgroups of individual and cluster-RCTs.

MAIN RESULTS

We included seven new trials in this update, for a total of 13 included trials. Twelve trials (10,218 participants in total, 2335 of which were children) evaluated a C-reactive protein point-of-care test, and one trial (317 adult participants) evaluated a procalcitonin point-of-care test. The studies were conducted in Europe, Russia, and Asia. Overall, the included trials had a low or unclear risk of bias. However all studies were open-labelled, thereby introducing high risk of bias due to lack of blinding. The use of C-reactive protein point-of-care tests to guide antibiotic prescription likely reduces the number of participants given an antibiotic prescription, from 516 prescriptions of antibiotics per 1000 participants in the control group to 397 prescriptions of antibiotics per 1000 participants in the intervention group (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69 to 0.86; 12 trials, 10,218 participants; I² = 79%; moderate-certainty evidence).  Overall, use of C-reactive protein tests also reduce the number of participants given an antibiotic prescription within 28 days follow-up (664 prescriptions of antibiotics per 1000 participants in the control group versus 538 prescriptions of antibiotics per 1000 participants in the intervention group) (RR 0.81, 95% CI 0.76 to 0.86; 7 trials, 5091 participants; I² = 29; high-certainty evidence). The prescription of antibiotics as guided by C-reactive protein tests likely does not reduce the number of participants recovered, within seven or 28 days follow-up (567 participants recovered within seven days follow-up per 1000 participants in the control group versus 584 participants recovered within seven days follow-up per 1000 participants in the intervention group) (recovery within seven days follow-up: RR 1.03, 95% CI 0.96 to 1.12; I² = 0%; moderate-certainty evidence) (recovery within 28 days follow-up: RR 1.02, 95% CI 0.79 to 1.32; I² = 0%; moderate-certainty evidence). The use of C-reactive protein tests may not increase total mortality within 28 days follow-up, from 1 death per 1000 participants in the control group to 0 deaths per 1000 participants in the intervention group (RR 0.53, 95% CI 0.10 to 2.92; I² = 0%; low-certainty evidence). We are uncertain as to whether procalcitonin affects any of the primary or secondary outcomes because there were few participants, thereby limiting the certainty of evidence. We assessed the certainty of the evidence as moderate to high according to GRADE for the primary outcomes for C-reactive protein test, except for mortality, as there were very few deaths, thereby limiting the certainty of the evidence.

AUTHORS' CONCLUSIONS

The use of C-reactive protein point-of-care tests as an adjunct to standard care likely reduces the number of participants given an antibiotic prescription in primary care patients who present with symptoms of acute respiratory infection. The use of C-reactive protein point-of-care tests likely does not affect recovery rates. It is unlikely that further research will substantially change our conclusion regarding the reduction in number of participants given an antibiotic prescription, although the size of the estimated effect may change.  The use of C-reactive protein point-of-care tests may not increase mortality within 28 days follow-up, but there were very few events. Studies that recorded deaths and hospital admissions were performed in children from low- and middle-income countries and older adults with comorbidities.  Future studies should focus on children, immunocompromised individuals, and people aged 80 years and above with comorbidities. More studies evaluating procalcitonin and potential new biomarkers as point-of-care tests used in primary care to guide antibiotic prescription are needed.  Furthermore, studies are needed to validate C-reactive protein decision algorithms, with a specific focus on potential age group differences.

Promoting rational antibiotic therapy among high antibiotic prescribers in German primary care-study protocol of the ElektRA 4-arm cluster-randomized controlled trial

Background

The rational use of antibiotics is of great importance in health care. In primary care, acute respiratory infections are the most common cause of inappropriate antibiotic prescribing. Since existing studies aiming to optimize antibiotic use are usually based on the voluntary participation of physicians, general practitioners (GPs) with inappropriate prescribing behavior are underrepresented. For the first time in Germany, the ElektRA study will assess and compare the effects of three interventions on antibiotic prescribing rates for respiratory and urinary tract infections among high prescribers in primary care.

Method

ElektRA is a 4-arm cluster-randomized controlled trial among German GPs in nine regional Associations of Statutory Health Insurance Physicians. On their behalf, the Central Research Institute of Ambulatory Health Care in Germany (Zi) analyses all outpatient claims and prescription data. Based on this database, high antibiotic prescribing GPs are identified and randomized into four groups: a control group (N=2000) and three intervention arms. We test social norm feedback on antibiotic prescribing (N=2000), social norm feedback plus online training on rational prescribing practice and communication strategies (N=2000), and social norm feedback plus online peer-moderated training on rational antibiotic prescribing, communication strategies, and sustainable behavior change (N=1250). The primary outcome is the overall rate of antibiotic prescriptions. Outcomes are measured before intervention (T0, October 2020–September 2022) and over a period of 15 months (T1, October 2022 to December 2023) after randomization.

Discussion

The aim of the study is to implement individualized, low-threshold interventions to reduce antibiotic prescribing among high prescribers in primary care. If successful, a change in behavior among otherwise difficult-to-reach high prescribers will directly improve patient care. The increase in quality of care will ideally be achieved both in terms of the quantity of antibiotics used as well as the kind of substances prescribed. Also, if effective strategies for high prescribers are identified through this study, they can be applied not only to the antibiotics addressed in this study, but also to other areas of prescription management.

Trial registration

Current Controlled Trials ISRCTN95468513.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01241-4.

Antibiotic Prescribing Practices for Upper Respiratory Tract Infections Among Primary Care Providers: A Descriptive Study

Background

Most antibiotics are prescribed in the ambulatory setting with estimates that up to 50% of use is inappropriate. Understanding factors associated with antibiotic misuse is essential to advancing better stewardship in this setting. We sought to assess the frequency of unnecessary antibiotic use for upper respiratory infections (URIs) among primary care providers and identify patient and provider characteristics associated with misuse.

Methods

Unnecessary antibiotic prescribing was assessed in a descriptive study by using adults ≥18 years seen for common URIs in a large, Upper Midwest, integrated health system, electronic medical records from June 2017 through May 2018. Individual provider rates of unnecessary prescribing were compared for primary care providers practicing in the departments of internal medicine, family medicine, or urgent care. Patient and provider characteristics associated with unnecessary prescribing were identified with a logistic regression model.

Results

A total of 49 463 patient encounters were included. Overall, antibiotics were prescribed unnecessarily for 42.2% (95% confidence interval [CI], 41.7–42.6) of the encounters. Patients with acute bronchitis received unnecessary antibiotics most frequently (74.2%; 95% CI, 73.4–75.0). Males and older patients were more likely to have an unnecessary antibiotic prescription. Provider characteristics associated with higher rates of unnecessary prescribing included being in a rural practice, having more years in practice, and being in higher volume practices such as an urgent care setting. Fifteen percent of providers accounted for half of all unnecessary antibiotic prescriptions.

Conclusions

Although higher-volume practices, a rural setting, or longer time in practice were predictors, unnecessary prescribing was common among all providers.

Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study

OBJECTIVE

To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates.

DESIGN

Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data.

SETTING

OOH primary care of the Central Denmark Region.

SUBJECTS

All patient contacts in 2014-2017.

MAIN OUTCOME MEASURES

GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance).

RESULTS

We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r²: 0.008-0.025).

CONCLUSION

Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England

BACKGROUND

Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians' decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients.

SETTING

We test our prediction on general practitioners' antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population.

METHODS

We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs' prescribing.

RESULTS

We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure.

CONCLUSIONS

Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians' work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45.

HIGHLIGHTS

Many physicians are working under increasing pressure.We test the importance of pressure on physicians' prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.[Formula: see text].

Guideline Adherence of Asymptomatic Bacteriuria Could Be Improved among General Practitioners in The Netherlands: A Survey Study

Asymptomatic bacteriuria (ASB) is a common finding in certain populations. This study assessed general practitioners’ (GPs’) knowledge about ASB and their current clinical practice regarding urine testing. Methods: An online survey was used for GPs in the Netherlands from October to December 2020. Results: In total, 99 surveys were included in the analyses. All GPs strongly agreed with the statements about their knowledge and self-confidence regarding urine diagnostics and treatment of ASB. The median knowledge score was 4 out of 6 (IQR 2 to 6). Most GPs (64 of 92; 70%) followed the guideline for the choice of urine diagnostics and reported appropriate indications for urine testing. However, 71/94 (75.5%) GPs would treat patients for ASB if they have diabetes mellitus. Further, 34 (37%) of 92 participants would inappropriately repeat a urine test after a patient was treated for a urinary tract infection (UTI). One-third of the GPs responded that ASB was insufficiently addressed within the guidelines for UTI. Conclusion: These results indicate that knowledge about ASB could be improved in primary care in the Netherlands, mainly in diabetic patients that have ASB, as well as for follow-up tests after treatment for UTI.

Prescribing antibiotics: the use of diagnostic tests in general practice. A register-based study

OBJECTIVE

To assess (i) the pattern of antibiotic prescribing in Danish general practice, (ii) the use of diagnostic tests [point-of-care (POC) and tests analysed at the hospital laboratory (laboratory tests)], and (iii) the frequency of diagnostic testing in relation to antibiotic prescriptions.

DESIGN

Retrospective cross-sectional register-based study.

SETTING

General practice in a geographical area of Denmark covering 455,956 inhabitants.

SUBJECTS

We studied redeemed antibiotic prescriptions and performed diagnostic tests in general practice from 2013 to 2017 among inhabitants in nine selected municipalities.

MAIN OUTCOME MEASURES

Frequency of antibiotic courses. Frequency and type of diagnostic testing performed in relation to types of antibiotics.

RESULTS

A total of 783,252 antibiotic courses were redeemed from general practice with an overall decrease of 19% during 2013-2017. Diagnostic testing increased by 6% during this period. POC tests comprised the majority of performed diagnostic tests (83%) with C-reactive protein (CRP) as the most frequently used test. A 27% increase in the use of laboratory tests was observed. Tests were performed in relation to 43% of all antibiotic courses; most in relation to prescriptions for sulphonamide and trimethoprim (57%) and rarely when prescribing tetracyclines (10%). Conflicting with national guidelines, Danish GPs prescribed fluoroquinolones without performing any kind of diagnostic testing in 48% of the cases.

CONCLUSIONS

This study provides an overview of the use of diagnostic tests in relation to antibiotics and creates basis for further research into the variability between types of antibiotics. The study indicates that there is room for improvement to use diagnostic tests as an aid to promote prudent antibiotic use.KEY POINTSDiagnostic tests (point-of-care or tests analysed at the hospital laboratory), can increase diagnostic certainty and lead to a reduction in antibiotic use in general practice.A decrease in antibiotic courses in general practice in Denmark was observed during 2013-2017, while the use of diagnostic tests increased.A diagnostic test was performed in relation to 43% of antibiotic courses.Only 52% of prescribed fluoroquinolones was related to a diagnostic test, conflicting with national guidelines.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Background

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

Method

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

Results

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades.

Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

Conclusion

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01574-x.

Antibiotic treatment of community-acquired pneumonia: A questionnaire survey in Danish general practice

BACKGROUND

Discrepancies exist in Danish guidelines for the treatment of bacterial community-acquired pneumonia (CAP). This study aimed to investigate how general practitioners (GPs) treat adults with CAP and explore associations between GP characteristics and treatment duration.

METHODS

In autumn 2020, GPs in the North Denmark Region were asked to complete an electronic questionnaire on antibiotic prescribing for CAP. Information about GP gender, age, experience and type of practice was obtained. Multivariable logistic regression was used to analyse the association between GP characteristics and treatment duration.

RESULTS

A total of 298 GPs were invited to participate of whom 108 completed the survey. Penicillin V was used as first line treatment for CAP by all participants. Treatment duration varied from 5 (54.6%) to 10 days (8.3%). A 5-day course of penicillin was less likely to be prescribed by male GPs (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13-0.94) and more likely to be prescribed by GPs with 5-9 years of experience in general practice (OR 5.03, 95% CI 1.09-23.21) compared to those with 10-19 years of experience.

CONCLUSION

Variation in antibiotic treatment of CAP emphasises the importance of generating solid evidence about the optimal duration regarding both effectiveness and safety.

Exploring antibiotic prescribing in public and private primary care settings in Singapore: a qualitative analysis informing theory and evidence-based planning for value-driven intervention design

BACKGROUND

Singapore's healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems.

AIM

To explore processes underpinning decision-making for antibiotic prescribing, by considering doctors' experiences in different primary care settings.

METHODS

Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing.

RESULTS

Given Singapore's lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices. These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change.

CONCLUSIONS

These VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly.

Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases

OBJECTIVES

Identifying characteristics associated with the appropriateness of antibiotic prescriptions is useful to guide antibiotic stewardship interventions. Proxy indicators estimating the appropriateness of antibiotic prescriptions at the general practitioner (GP) level have recently been validated. Our objectives were to identify (a) clusters of GPs according to their appropriateness score based on these proxy indicator results, and (b) GPs', patients' and practices' characteristics associated with inappropriate prescriptions.

METHODS

We conducted a cross-sectional observational study analysing antibiotics prescribed by GPs in one large French region in 2019, using the Health Insurance databases. We identified clusters of GPs according to their appropriateness score calculated from ten proxy indicators' results. We then analysed the association between the clusters with more inappropriate practices compared with the one with less inappropriate practices, and GPs', patients', and practices' characteristics. We performed bivariate and multivariable analyses using logistic polytomous regressions.

RESULTS

We included 4819 GPs who were grouped into three clusters. GPs who belong to the clusters with more inappropriate practices were more likely to practice in certain geographical area, to be male, not to have a particular medical practice, to be practicing for longer, to have more patients and consultations, to have a higher proportion of elderly patients, and to prescribe more drugs, more antibiotics and a higher proportion of broad-spectrum antibiotics.

CONCLUSION

We identified clusters of practice as well as factors associated with the appropriateness of antibiotic prescriptions, using routinely collected data. This might help to guide antibiotic stewardship interventions.

Time to retire? A register-based study of GPs' practice style prior to retirement

In many healthcare systems a large share of general practitioners (GPs) is retiring. The literature has shown a negative correlation between physicians' age and their quality of care. However, little is known about whether GPs exhibit different practice styles in the years prior to retirement. This study investigates whether GPs who are closer to retirement make different professional choices than GPs who are not as close to retirement. Using detailed administrative data on 555 Danish GPs and their patients from 2005 to 2017, we study GPs' practice styles across a ten-year period prior to retirement and compare these with GPs who retire at a later date ('non-retiring GPs'), while controlling for age differences as well as exogenous factors affecting healthcare provision. We focus on the GPs' number of enlisted patients, revenue, provision of consultations, and treatment behaviour in consultations. We find no differences between retiring and non-retiring GPs for key outcomes such as 'revenue per patient' and 'consultations per patient'. However, we find that retiring GPs have fewer enlisted patients in their final years of practicing. This finding is driven by more patients leaving rather than fewer patients joining their lists. We also find that retirement is associated with other dimensions of GPs' practice style, e.g. their provision of home visits, prescribing, and referral rates. Overall, we find a modest association between GPs' retirement and their practice style.

The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records

BACKGROUND

Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing.

METHODS

This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing.

RESULTS

There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate.

CONCLUSIONS

We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.

Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians

Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO "Watch and Reserve" list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO "Watch and Reserve" list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

Structural Antibiotic Surveillance and Stewardship via Indication-Linked Quality Indicators: Pilot in Dutch Primary Care

Insight into antibiotic prescribing quality is key to general practitioners (GPs) to improve their prescribing behavior and to national antibiotic surveillance and stewardship programs. Additionally to numbers of prescribed antibiotics, quality indicators (QIs) linked to the clinical indication for prescribing are urgently needed. The aim of this proof of concept study was to define indication-linked QIs which can be easily implemented in Dutch primary care by collaborating with data-extraction/processing companies that routinely process patient data for GP practices. An expert group of academic and practicing GPs defined indication-linked QIs for which outcomes can be derived from routine care data. QI outcomes were calculated and fed back to GPs from 44 practices, associations between QI outcomes were determined, and GPs’ opinions and suggestions with respect to the new set were captured using an online questionnaire. The new set comprises: (1) total number of prescribed antibiotics per 1000 registered patients and percentages of generally non-1st choice antibiotics; (2) prescribing percentages for episodes of upper and lower respiratory tract infection; (3) 1st choice prescribing for episodes of tonsillitis, pneumonia and cystitis in women. Large inter-practice variation in QI outcomes was found. The validity of the QI outcomes was confirmed by associations that were expected. The new set was highly appreciated by GPs and additional QIs were suggested. We conclude that it proved feasible to provide GPs with informative, indication-linked feedback of their antibiotic prescribing quality by collaborating with established data extraction/processing companies. Based on GPs’ suggestions the set will be refined and extended and used in the near future as yearly feedback with benchmarking for GPs and for national surveillance and stewardship purposes.

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

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.

Predictors and variability of antibiotic prescribing amongst family physicians

BACKGROUND

Rising rates of antimicrobial resistance are driven by overuse of antibiotics. Characterizing physician antibiotic prescribing variability can inform interventions to optimize antibiotic use.

OBJECTIVES

To describe predictors of overall antibiotic prescribing as well as the inter-physician variability in antibiotic prescribing amongst family physicians.

METHODS

We conducted a 5 year cohort study of antibiotic prescribing rates by family physicians in Ontario, Canada using a repository of electronic medical records. Using multilevel logistic regression models fitted with random intercepts for physicians, we evaluated the association of patient-, physician- and clinic-level characteristics with antibiotic prescribing rates.

RESULTS

We included 3956921 physician-patient encounters, 322129 unique patients and 313 physicians from 41 family medicine clinics. Physicians prescribed a median of 54 (interdecile range 28-95) antibiotics per 1000 encounters. Female children aged 3-5 years were most likely to receive antibiotics compared with men ≥65 years (OR 4.01, 95% CI 3.89-4.13). The only significant physician-level predictor was median daily patient visits of ≥20 compared with <10 (OR 1.28, 95% CI 1.06-1.55). The median ORs without and with patient characteristics were 1.68 and 1.69, respectively. Thus, the odds of receiving an antibiotic varied by 1.7-fold for the same patient simply by virtue of encountering two different physicians.

CONCLUSIONS

We observed substantial inter-physician variability in antibiotic prescribing that could not be explained by sociodemographic and clinical patient differences, suggesting that risk adjustment of antibiotic prescribing practices may not be required for audit and feedback of family physicians working in similar practice settings.

Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study

BACKGROUND

In 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%-23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015-2016.

AIM

To investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.

DESIGN & SETTING

Longitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.

METHOD

Linear generalised estimating equations models were fitted, examining the effect of the 2015-2016 QP on the number of antibiotic items per specific therapeutic group age-sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.

RESULTS

Antibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015-2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015-2016 QP compared with other practices (interaction p<0.001).

CONCLUSION

In high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

Practice-Level Association between Antibiotic Prescribing and Resistance: An Observational Study in Primary Care

A direct relation between antibiotic use and resistance has been shown at country level. We aim to investigate the association between antibiotic prescribing for patients from individual Dutch primary care practices and antibiotic resistance of bacterial isolates from routinely submitted urine samples from their patient populations. Practices' antibiotic prescribing data were obtained from the Julius Network and related to numbers of registered patients. Practices were classified as low-, middle- or high-prescribers and from each group size-matching practices were chosen. Culture and susceptibility data from submitted urine samples were obtained from the microbiology laboratory. Percentages of resistant isolates, and resistant isolates per 1000 registered patients per year (population resistance) were calculated and compared between the groups. The percentages of resistant Escherichia coli varied considerably between individual practices, but the three prescribing groups' means were very similar. However, as the higher-prescribing practices requested more urine cultures per 1000 registered patients, population resistance was markedly higher in the higher-prescribing groups. This study showed that the highly variable resistance percentages for individual practices were unrelated to antibiotic prescribing levels. However, population resistance (resistant strains per practice population) was related to antibiotic prescribing levels, which was shown to coincide with numbers of urine culture requests. Whether more urine culture requests in the higher-prescribing groups were related to treatment failures, more complex patient populations, or to general practitioners' testing behaviour needs further investigation.

Analysis of a high-prescribing state's 2016 outpatient antibiotic prescriptions: Implications for outpatient antimicrobial stewardship interventions

OBJECTIVE

To identify prescriber characteristics that predict antibiotic high-prescribing behavior to inform statewide antimicrobial stewardship interventions.

DESIGN

Retrospective analysis of 2016 IQVIA Xponent, formerly QuintilesIMS, outpatient retail pharmacy oral antibiotic prescriptions in Tennessee.

SETTING

Statewide retail pharmacies filling outpatient antibiotic prescriptions.

PARTICIPANTS

Prescribers who wrote at least 1 antibiotic prescription filled at a retail pharmacy in Tennessee in 2016.

METHODS

Multivariable logistic regression, including prescriber gender, birth decade, specialty, and practice location, and patient gender and age group, to determine the association with high prescribing.

RESULTS

In 2016, 7,949,816 outpatient oral antibiotic prescriptions were filled in Tennessee: 1,195 prescriptions per 1,000 total population. Moreover, 50% of Tennessee's outpatient oral antibiotic prescriptions were written by 9.3% of prescribers. Specific specialties and prescriber types were associated with high prescribing: urology (odds ratio [OR], 3.249; 95% confidence interval [CI], 3.208-3.289), nurse practitioners (OR, 2.675; 95% CI, 2.658-2.692), dermatologists (OR, 2.396; 95% CI, 2.365-2.428), physician assistants (OR, 2.382; 95% CI, 2.364-2.400), and pediatric physicians (OR, 2.340; 95% CI, 2.320-2.361). Prescribers born in the 1960s were most likely to be high prescribers (OR, 2.574; 95% CI, 2.532-2.618). Prescribers in rural areas were more likely than prescribers in all other practice locations to be high prescribers. High prescribers were more likely to prescribe broader-spectrum antibiotics (P < .001).

CONCLUSIONS

Targeting high prescribers, independent of specialty, degree, practice location, age, or gender, may be the best strategy for implementing cost-conscious, effective outpatient antimicrobial stewardship interventions. More information about high prescribers, such as patient volumes, clinical scope, and specific barriers to intervention, is needed.

Comparison of antibiotic prescribing and antimicrobial resistance in urinary tract infections at the municipal level among women in two Nordic regions

Objectives

To describe and compare the prescribing of antibiotics used for urinary tract infections and its correlation with resistance in Escherichia coli in urinary samples across two adjacent regions-the Capital Region and the Skaane Region-and their municipalities in Denmark and Sweden.

Methods

The Capital Region consists of 29 municipalities and 725 960 female inhabitants aged ≥18 years and the Skaane Region consists of 33 municipalities and 515 668 female inhabitants aged ≥18 years. Aggregated data from outpatient care on the prescribing of pivmecillinam, trimethoprim and nitrofurantoin from both regions were analysed. The Department of Clinical Microbiology in both regions provided data on E. coli resistance in urinary samples from women aged ≥18 years. Data were measured as the number of prescriptions/1000 women/year, number of DDDs/1000 women/year and DDDs/prescription. Correlation analyses between antibiotic prescribing and antibiotic resistance rates were performed.

Results

Antibiotic prescribing and resistance rates were significantly higher in the Capital Region compared with the Skaane Region. Large variations in prescription and resistance rates were found at the municipal level, but there were no correlations between the antibiotic prescription and resistance rates when each region was analysed separately.

Conclusions

Although closely related, there are large differences in antibiotic prescribing and antibiotic resistance. It is suggested that the regional guidelines are an important driver and explanatory factor for the variations; however, further research is needed in this new field and factors such as the influence of cultural aspects should be the target of further research.

Validity of microscopy for diagnosing urinary tract infection in general practice - a systematic review

Objective: To investigate the validity of microscopy as a diagnostic tool for urinary tract infection in general practice. Methods: (Design/setting) A systematic review was conducted by searching Medline for clinical studies made in general practice, outpatient clinics or similar settings in which the accuracy/validity of microscopy was evaluated with urine culture as the reference standard. Results: Our search resulted in 108 titles. 28 potentially eligible studies were retrieved for full-text reading. We included eight studies involving 4582 patients in this review. The quality of the studies was moderate to high. Specificity ranged from 27% to 100%, sensitivity from 47% to 97%. The variation between studies did not allow for meta-analysis. Conclusion: We did not find substantial evidence to determine the clinical validity of microscopy performed in general practice on urine samples from patients with symptoms of UTI. Key points Urinary tract infection is common in general practice. Methods for precise diagnosis are needed in order to avoid inappropriate treatment. Currently no evidence-based consensus exists regarding the use of urinary microscopy in general practice. We did not find substantial evidence to determine the overall clinical validity of microscopy performed in general practice on urine samples from patients with symptoms of UTI. Light microscopy with oil immersion had high sensitivity and specificity but is time-consuming. Phase-contrast microscopy is quick and had high specificity but lower sensitivity.

Danish GPs' and practice nurses' management of acute sore throat and adherence to guidelines

BACKGROUND

Sore throat is a frequent presentation of acute respiratory tract infections in general practice. Though these infections are often harmless and self-limiting, antibiotics are frequently prescribed. In Denmark, practice nurses manage an increasing part of patients with acute minor illnesses.

OBJECTIVES

We aimed (i) to investigate Danish practice nurses' and GPs' management of patients presenting with a sore throat and (ii) to explore to what extent management is according to current Danish guidelines.

METHODS

A cross-sectional study was conducted during winter 2017, involving GPs and practice nurses in Danish general practices. Patients with a sore throat were registered according to the Audit Project Odense method.

RESULTS

A total of 44 practices participated with the registration of 1503 patients presenting with a sore throat. Most patients had a strep A test performed, especially when managed by a practice nurse (84.6% versus 61.8%, χ2 = 90.1, P < 0.05). In total, 40.6% of performed strep A tests were not according to guideline recommendations. Antibiotics were prescribed for about one-third of patients, regardless whether managed by a practice nurse or a GP (χ2 = 0.33, P = 0.57). However, 32.4% of these prescriptions were not in line with Danish guidelines.

CONCLUSION

Patients with acute sore throat were managed similarly by GPs and practice nurses, apart from a higher use of strep A tests in patients seen by practice nurses. Importantly, this study demonstrated that there is still room for improvement of the management of these patients in Danish general practice.

Relationship between prescribing of antibiotics and other medicines in primary care: a cross-sectional study

BACKGROUND

High levels of antibiotic prescribing are a major concern as they drive antimicrobial resistance. It is currently unknown whether practices that prescribe higher levels of antibiotics also prescribe more medicines in general.

AIM

To evaluate the relationship between antibiotic and general prescribing levels in primary care.

DESIGN AND SETTING

Cross-sectional study in 2014-2015 of 6517 general practices in England using NHS digital practice prescribing data (NHS-DPPD) for the main study, and of 587 general practices in the UK using the Clinical Practice Research Datalink for a replication study.

METHOD

Linear regression to assess determinants of antibiotic prescribing.

RESULTS

NHS-DPPD practices prescribed an average of 576.1 antibiotics per 1000 patients per year (329.9 at the 5th percentile and 808.7 at the 95th percentile). The levels of prescribing of antibiotics and other medicines were strongly correlated. Practices with high levels of prescribing of other medicines (a rate of 27 159.8 at the 95th percentile) prescribed 80% more antibiotics than low-prescribing practices (rate of 8815.9 at the 5th percentile). After adjustment, NHS-DPPD practices with high prescribing of other medicines gave 60% more antibiotic prescriptions than low-prescribing practices (corresponding to higher prescribing of 276.3 antibiotics per 1000 patients per year). Prescribing of non-opioid painkillers and benzodiazepines were also strong indicators of the level of antibiotic prescribing. General prescribing levels were a much stronger driver for antibiotic prescribing than other risk factors, such as deprivation.

CONCLUSION

The propensity of GPs to prescribe medications generally is an important driver for antibiotic prescribing. Interventions that aim to optimise antibiotic prescribing will need to target general prescribing behaviours, in addition to specifically targeting antibiotics.