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Sievert EDC, Korn L, Gross M, Santana AP, Böhm R, Betsch C. Communicating diagnostic uncertainty reduces expectations of receiving antibiotics: Two online experiments with hypothetical patients. Appl Psychol Health Well Being 2024; 16:1459-1478. [PMID: 38500005 DOI: 10.1111/aphw.12536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/13/2024] [Indexed: 03/20/2024]
Abstract
The overprescription of antibiotics due to diagnostic uncertainty and inappropriate patient expectations influence antimicrobial resistance. This research assesses (i) whether communicating diagnostic uncertainty reduces expectations of receiving antibiotics and (ii) which communication strategies minimise unintended consequences of such communication. In two experimental online studies conducted in January and April 2023, participants read a vignette describing a doctor consultation for an ear infection and expressed their expectations of receiving antibiotics, trust in their doctor, rated the doctor's reputation and provided their intention to get a second doctor's opinion. Study 1 (N = 2213) investigated whether communicating diagnostic uncertainty and social externalities of antibiotic use (the negative social impacts of developing antibiotic resistance) decreases expectations for antibiotics and explores potential unintended consequences on the doctor-patient relationship. In Study 2 (N = 527), we aimed to replicate and extend the findings by adding specific treatment recommendations. Disclosing diagnostic uncertainty (vs. certainty) and communicating (vs. not communicating) the social externalities of antibiotic overuse reduced patients' expectations of receiving antibiotics. Yet, communicating uncertainty impaired trust in the doctor and the doctor's reputation. Combining the communication of uncertainty with specific treatment recommendations-particularly delayed antibiotic prescriptions-showed important to prevent these unintended consequences.
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Affiliation(s)
- Elisabeth D C Sievert
- Health Communication, Institute for Planetary Health Behaviour, University of Erfurt, Erfurt, Germany
- Health Communication, Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Lars Korn
- Health Communication, Institute for Planetary Health Behaviour, University of Erfurt, Erfurt, Germany
- Health Communication, Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Marina Gross
- Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Ana Paula Santana
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Robert Böhm
- Faculty of Psychology, University of Vienna, Vienna, Austria
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Social Data Science (SODAS), University of Copenhagen, Copenhagen, Denmark
| | - Cornelia Betsch
- Health Communication, Institute for Planetary Health Behaviour, University of Erfurt, Erfurt, Germany
- Health Communication, Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
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Tigges P, Greser A, Gágyor I, Kraft J, Maun A, Schmiemann G, Schwienhorst-Stich EM, Heintze C, Schuster A. Addressing AMR and planetary health in primary care: the potential of general practitioners as change agents. Front Public Health 2024; 12:1383423. [PMID: 39145182 PMCID: PMC11322125 DOI: 10.3389/fpubh.2024.1383423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 07/11/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Antimicrobial resistance is closely linked with the health and stability of environmental systems and therefore a challenge for the health of the planet. General Practitioners, owing to their trusted positions and close patient relationships, can play a crucial role in addressing antimicrobial resistance within the framework of Planetary Health. The goal of our study was to examine General Practitioners' knowledge, attitude, and practice regarding the linkage of antimicrobial resistance with Planetary Health to understand their potential as agents of change in this domain. Materials and methods We conducted 19 guided interviews with General Practitioners from four different German federal states (August-September 2022). Participants were selected from the intervention group of the RedAres randomized controlled trial, a study designed to optimize therapy and prescribing practices for uncomplicated urinary tract infections in general practice. Data were analyzed using Mayring's structured qualitative content analysis and the typology approach by Kelle and Kluge. Results General Practitioners generally demonstrated the ability to identify the interlinkages between antimicrobial resistance and Planetary Health. However, they exhibited varying levels of knowledge, problem awareness, and accountability for the associated challenges and partially outsourced the responsibility for Planetary Health. Some General Practitioners were capable of integrating Planetary Health arguments into patient counseling. They recognized rational prescribing practice, self-reflection on antimicrobial resistance and Planetary Health, interprofessional exchange, and raising awareness among patients as potential avenues for engagement in promoting Planetary Health. Discussion As antimicrobial resistance is increasingly recognized as a Planetary Health challenge, empowering General Practitioners as change agents requires tailored measures based on their level of previous knowledge and their attitude toward Planetary Health. General Practitioners express a need for concrete advice on how to integrate antimicrobial resistance as a Planetary Health topic into their daily activities. Developing and evaluating adaptable training materials is essential. Additionally, the integration of Planetary Health outcomes into clinical guidelines could accelerate the adoption of this dimension in antibiotic prescribing practices within primary care settings.
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Affiliation(s)
- Paula Tigges
- Charité – Universitätsmedizin Berlin, Institute of General Practice, Berlin, Germany
| | - Alexandra Greser
- Department of General Practice, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ildikó Gágyor
- Department of General Practice, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Judith Kraft
- Charité – Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Guido Schmiemann
- Department of Health Service Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Eva-Maria Schwienhorst-Stich
- Department of General Practice, University Hospital Wuerzburg, Wuerzburg, Germany
- Faculty of Medicine, Working Group Climate and Planetary Health, University of Würzburg, Wuerzburg, Germany
| | - Christoph Heintze
- Charité – Universitätsmedizin Berlin, Institute of General Practice, Berlin, Germany
| | - Angela Schuster
- Charité – Universitätsmedizin Berlin, Institute of General Practice, Berlin, Germany
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Lansink C, Sinha B, Meessen N, Dekkers T, Beerlage-de Jong N. Why Do Physicians Prescribe Antibiotics? A Systematic Review of the Psycho-Socio-Organisational Factors Related to Potentially Inappropriate Prescribing of Antimicrobials in Europe. Infect Dis Rep 2024; 16:664-683. [PMID: 39195002 DOI: 10.3390/idr16040051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/29/2024] Open
Abstract
Purpose: Effective antimicrobial use enhances care quality and combats antibiotic resistance. Yet, non-guideline factors influence potentially inappropriate prescribing. This study explores psycho-socio-organisational factors in antimicrobial prescribing as perceived by physicians across primary, secondary, and tertiary care. Methods: Adhering to PRISMA guidelines, a systematic review was conducted using PubMed and Scopus databases from 1 January 2000, to 8 March 2023, with an update search until 30 January 2024. Inclusion criteria focused on studies in Europe exploring psycho-socio-organisational factors for antibiotic prescribing from physicians' perspectives in hospital, inpatient, or primary care settings. Exclusion criteria targeted out-of-office prescriptions or low-quality studies. To evaluate the latter, several quality and risk-of-bias checklists were used. Data were extracted on study characteristics, study design, and methods and identified determinants of antibiotic prescribing. Data was analysed using a narrative synthesis method. Results: Among 8370 articles, 58 met inclusion criteria, yielding 35 articles from 23 countries. Three main themes emerged: personal, psychological, and organisational factors, encompassing seven determinants including work experience, knowledge, guideline adherence, uncertainty management, perceived pressure, time constraints, and diagnostic resource availability. Uncertainty management was key, with work experience and knowledge mitigating it. No additional factors emerged in the updated search. Conclusion: Enhanced uncertainty management decreases perceived patient and/or parental pressure to prescribe antibiotics, contributing to reducing potentially inappropriate prescribing (PIP). Therefore, it is imperative to educate physicians on effectively managing uncertainty. Interventions to improve antibiotic prescribing should be tailored to the specific needs and preferences of the different prescribing physicians.
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Affiliation(s)
- Chiara Lansink
- Section of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
| | - Bhanu Sinha
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Nico Meessen
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Tessa Dekkers
- Section of Psychology, Health and Technology, Centre for eHealth and Wellbeing Research, University of Twente, 7500 AE Enschede, The Netherlands
| | - Nienke Beerlage-de Jong
- Section of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Howard A, Reza N, Aston S, Woods B, Gerada A, Buchan I, Hope W, Märtson AG. Antimicrobial treatment imprecision: an outcome-based model to close the data-to-action loop. THE LANCET. INFECTIOUS DISEASES 2024; 24:e47-e58. [PMID: 37660712 DOI: 10.1016/s1473-3099(23)00367-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 09/05/2023]
Abstract
Health-care systems, food supply chains, and society in general are threatened by the inexorable rise of antimicrobial resistance. This threat is driven by many factors, one of which is inappropriate antimicrobial treatment. The ability of policy makers and leaders in health care, public health, regulatory agencies, and research and development to deliver frameworks for appropriate, sustainable antimicrobial treatment is hampered by a scarcity of tangible outcome-based measures of the damage it causes. In this Personal View, a mathematically grounded, outcome-based measure of antimicrobial treatment appropriateness, called imprecision, is proposed. We outline a framework for policy makers and health-care leaders to use this metric to deliver more effective antimicrobial stewardship interventions to future patient pathways. This will be achieved using learning antimicrobial systems built on public and practitioner engagement; solid implementation science; advances in artificial intelligence; and changes to regulation, research, and development. The outcomes of this framework would be more ecologically and organisationally sustainable patterns of antimicrobial development, regulation, and prescribing. We discuss practical, ethical, and regulatory considerations involved in the delivery of novel antimicrobial drug development, and policy and patient pathways built on artificial intelligence-augmented measures of antimicrobial treatment imprecision.
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Affiliation(s)
- Alex Howard
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK.
| | - Nada Reza
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Stephen Aston
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Beth Woods
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Alessandro Gerada
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK
| | - Iain Buchan
- Department of Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - William Hope
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK
| | - Anne-Grete Märtson
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Marshall T, Taverner T, Freidoony L. Medicalising diagnoses and treatment preferences: a retrospective cohort study of throat-related consultations in electronic primary care records. BJGP Open 2023; 7:BJGPO.2023.0056. [PMID: 37429635 PMCID: PMC11176689 DOI: 10.3399/bjgpo.2023.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/21/2023] [Accepted: 07/06/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Rather than first diagnosing and then deciding on treatment, GPs may intuitively decide on treatment and justify this through choice of diagnosis. AIM To investigate the relationship between choice of a medicalising diagnosis and antibiotic treatment for throat-related consultations. DESIGN & SETTING A retrospective cohort study in a large database of UK electronic primary care records between 1 January 2010 and 1 January 2020. METHOD All first throat-related consultations were included, categorised as either pharyngitis/tonsillitis or sore throat. The outcome was any antibiotic prescription on the consultation date. GP-level random effects on prescribing and on diagnosis were estimated in a series of mixed-effects regression models, including age, sex, weekday, month, and clinician characteristics as fixed effects. GPs were grouped into quintiles by antibiotic prescribing propensity, and described the proportion of patients they diagnosed with pharyngitis/tonsillitis or sore throat in each quintile. RESULTS The analysis dataset included 393 590 throat-related consultations with 6881 staff. Diagnosis of pharyngitis/tonsillitis was strongly associated with antibiotic prescribing (adjusted odds ratio = 13.41, 95% confidence interval = 12.8 to 14.04). GP random effect accounted for 18% of variation in prescribing and for 26% of variation in diagnosis. GPs in the lowest quintile of antibiotic prescribing propensity diagnosed pharyngitis/tonsillitis on 31% of occasions, compared with 55% in the highest quintile. CONCLUSION There is substantial variation among GPs in diagnosis and treatment of throat-related problems. Preference for a medicalising diagnosis is associated with a preference for antibiotics, suggesting a common propensity to both diagnose and treat.
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Affiliation(s)
- Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tom Taverner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Leila Freidoony
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Wushouer H, Du K, Chen S, Li H, Zhang W, Yang Y, Hu L, Zhou Y, Sun H, Zheng B, Guan X, Shi L. Evaluation of prescription review and feedback policy on rational antibiotic use in primary healthcare settings in Beijing, China: a qualitative study using the Theoretical Domains Framework and the behaviour change wheel. JAC Antimicrob Resist 2023; 5:dlad128. [PMID: 38046566 PMCID: PMC10691747 DOI: 10.1093/jacamr/dlad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/14/2023] [Indexed: 12/05/2023] Open
Abstract
Objectives To decelerate antibiotic resistance driven by inappropriate antibiotic prescribing, a prescription review and feedback (PRF) policy is implemented in primary healthcare institutions (PHIs) in Beijing, China. However, evaluation of PRF implementation in PHIs is scarce. This study aims to systematically identify the barriers and facilitators of PRF policy implementation to provide evidence for antimicrobial stewardship. Methods We conducted key informant interviews with 40 stakeholders engaged in the implementation of PRF in Beijing, including physicians, pharmacists and administrators. Interviews were audio recorded and transcribed verbatim. We coded the interview transcripts and mapped informant views to domains of the Theoretical Domains Framework. We then used a behaviour change wheel to suggest possible behavioural interventions. Results Procedural knowledge (Knowledge) and skills (Skill) of PRF were possessed by stakeholders. They felt responsible to promote the appropriate use of antibiotics (Social/professional role and identity) and believed that PRF could help to change inappropriate provider behaviours (Behavioural regulation) in prescribing antibiotics (Beliefs about consequences) under increased intention on antibiotic use (Stages of change). Moreover, informants called for a more unified review standard to enhance PRF implementation (Goals). Frequently identified barriers to PRF included inadequate capacity (Skill), using punishment mechanism (Behaviour regulation), reaching consistently lower antibiotic prescription rates (Goals), lack of resources (Environmental context and resources) and perceived pressure coming from patients (Social influences). Conclusions Stakeholders believed that PRF implementation promoted the rational use of antibiotics at PHIs in Beijing. Still, PRF was hampered by inconsistencies in review process and resources needed for PRF implementation.
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Affiliation(s)
- Haishaerjiang Wushouer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
| | - Kexin Du
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Shicai Chen
- Department of Clinical Pharmacology, National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - Huangqianyu Li
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
| | - Wanmeng Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Yaoyao Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Lin Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Yue Zhou
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- Department of Pharmacy, Peking University People’s Hospital, Beijing 100044, China
| | - Hui Sun
- United Nations Children’s Fund, China Office, Beijing 100600, China
| | - Bo Zheng
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing 100034, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
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Xue T, Liu C, Li Z, Liu J, Tang Y. Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China. Front Public Health 2022; 10:1008217. [PMID: 36605239 PMCID: PMC9807867 DOI: 10.3389/fpubh.2022.1008217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs). Methods A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute. Results In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (β = 0.69 for request for antibiotics, p < 0.01; β = -1.2 for easiness of follow-up, p < 0.001). Conclusion Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.
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Affiliation(s)
- Tianqin Xue
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Wuhan, Hubei, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Zhuoxian Li
- Medical Record Management Department, Yueyang Maternal and Child Health-Care Hospital, Yueyang, Hunan, China
| | - Junjie Liu
- School of Statistics and Mathematics, Central University of Finance and Economics, Beijing, China
| | - Yuqing Tang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Wuhan, Hubei, China
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Kühn L, Kronsteiner D, Kaufmann-Kolle P, Andres E, Szecsenyi J, Wensing M, Poss-Doering R. Implementation fidelity in a multifaceted program to foster rational antibiotics use in primary care: an observational study. BMC Med Res Methodol 2022; 22:243. [PMID: 36123597 PMCID: PMC9487096 DOI: 10.1186/s12874-022-01725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ARena study (Sustainable Reduction of Antimicrobial Resistance in German Ambulatory Care) is a three-arm, cluster randomized trial to evaluate a multifaceted implementation program in a German primary care setting. In the context of a prospective process evaluation conducted alongside ARena, this study aimed to document and explore fidelity of the implementation program. METHODS This observational study is based on data generated in a three-wave survey of 312 participating physicians in the ARena program and attendance documentation. Measures concerned persistence of participation in the ARena program and adherence to intervention components (thematic quality circles, e-learning, basic expenditure reimbursements, additional bonus payments and a computerized decision support system). Participants' views on five domains of the implementation were also measured. Binary logistic and multiple linear regression analyses were used to explore which views on the implementation were associated with participants' adherence to quality circles and use of additional bonus compensation. RESULTS The analysis of fidelity showed overall high persistence of participation in the intervention components across the three intervention arms (90,1%; 97,9%; 92,9%). 96.4% of planned quality circles were delivered to study participants and, across waves, 30.4% to 93% of practices participated; 56.1% of physicians attended the maximum of four quality circles. 84% of the practices (n = 158) with a minimum of one index patient received a performance-based additional bonus payment at least once. In total, bonus compensation was triggered for 51.8% of affected patients. Participation rate for e-learning (a prerequisite for reimbursement of project-related expenditure) covered 90.8% of practices across all intervention arms, with the highest rate in arm II (96.5%). Uptake of expenditure reimbursement was heterogeneous across study arms, with a mean rate of 86.5% (89.1% in arm I, 96.4% in arm II and 74.1% in arm III). Participants' views regarding participant responsiveness (OR = 2.298) 95% CI [1.598, 3.305] and Context (OR = 2.146) 95% CI [1.135, 4.055] affected additional bonus payment. Participants' views on participant responsiveness (Beta = 0.718) 95% CI [0.479, 0.957], Context (Beta = 0.323) 95% CI [0.055, 0.590] and Culture of shared decision-making (Beta = -0.334) 95% CI [-0.614, -0.053] affected quality circle attendance. CONCLUSION This study showed an overall high fidelity to the implementation program. Participants' views on the implementation were associated with degree of intervention fidelity. TRIAL REGISTRATION ISRCTN, ISRCTN58150046.
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Affiliation(s)
- Lukas Kühn
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | | | - Edith Andres
- aQua Institut, Maschmuehlenweg 8-10, 37073, Goettingen, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,aQua Institut, Maschmuehlenweg 8-10, 37073, Goettingen, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Regina Poss-Doering
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
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Prescribing antibiotics: Factors driving decision-making in general practice. A discrete choice experiment. Soc Sci Med 2022; 305:115033. [PMID: 35617765 DOI: 10.1016/j.socscimed.2022.115033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Antimicrobial resistance is a threat to human health. We need to strive for a rational use of antibiotics to reduce the selection of resistant bacteria. Most antibiotics are prescribed in general practice, but little is known about factors influencing general practitioners' (GPs) decision-making when prescribing antibiotics. AIM To 1) assess the importance of factors that influence decisions by GPs to prescribe antibiotics for acute respiratory tract infections (RTIs) and 2) identify segments of GPs influenced differently when deciding to prescribe antibiotics. METHODS A questionnaire survey including a discrete choice experiment was conducted. Danish GPs were asked to indicate whether they would prescribe antibiotics in six hypothetical choice sets with six variables: whether the GP is behind schedule, patient's temperature, patient's general condition, lung auscultation findings, C-reactive protein (CRP) level, and whether the patient expects antibiotics. Error component and latent class models were estimated and the probabilities of prescribing in different scenarios were calculated. RESULTS The questionnaire was distributed to every Danish GP (n = 3,336); 1,152 (35%) responded. Results showed that GPs were influenced by (in prioritised order): CRP level (Relative importance (RI) 0.54), patient's general condition (RI 0.20), crackles at auscultation (RI 0.15), and fever (RI 0.10). Being behind schedule and patient expectations had no significant impact on antibiotic prescription at the aggregate level. The latent class analysis identified five classes of GPs: generalists, CRP-guided, general condition-guided, reluctant prescribers, and stethoscopy-guided. For all classes, CRP was the most important driver, while GPs were heterogeneously affected by other drivers. CONCLUSION The most important factor affecting Danish GPs' decision to prescribe antibiotics at the aggregate level, in subgroups of GPs, and across latent classes was the CRP value. Hence, the use of CRP testing is an important factor to consider in order to promote rational antibiotic use in the battle against antimicrobial resistance.
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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. Antibiotics (Basel) 2021; 10:antibiotics10101151. [PMID: 34680732 PMCID: PMC8532997 DOI: 10.3390/antibiotics10101151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 01/22/2023] Open
Abstract
The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.
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Poss-Doering R, Kronsteiner D, Kamradt M, Andres E, Kaufmann-Kolle P, Wensing M, Szecsenyi J. Antibiotic prescribing for acute, non-complicated infections in primary care in Germany: baseline assessment in the cluster randomized trial ARena. BMC Infect Dis 2021; 21:877. [PMID: 34445964 PMCID: PMC8394572 DOI: 10.1186/s12879-021-06571-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is fueled by inappropriate use of antibiotics. Global and national strategies support rational use of antibiotics to retain treatment options and reduce resistance. In Germany, the ARena project (Sustainable reduction of antibiotic-induced antimicrobial resistance) intended to promote rational use of antibiotics for acute non-complicated infections by addressing network-affiliated physicians, primary care teams and patients through multiple interacting interventions. The present study documented patterns of antibiotic prescribing for patients with acute non-complicated infections who consulted a physician in these networks at the start of the ARena project. It explored variation across subgroups of patients and draws comparisons to prescribing patterns of non-targeted physicians. METHODS This retrospective cross-sectional analysis used mixed logistic regression models to explore factors associated with the primary outcome, which was the percentage of patient cases with acute non-complicated respiratory tract infections consulting primary care practices who were treated with antibiotics. Secondary outcomes concerned the prescribing of different types of antibiotics. Descriptive methods were used to summarize the data referring to targeted physicians in primary care networks, non-targeted physicians (reference group), and patient subgroups. RESULTS Overall, antibiotic prescribing rates were 32.0% in primary care networks and 31.7% in the reference group. General practitioners prescribed antibiotics more frequently than other medical specialist groups (otolaryngologists vs. General practitioners OR = 0.465 CI = [0.302; 0.719], p < 0.001, pediatricians vs. General practitioners: OR = 0.369 CI = [0.135; 1.011], p = 0.053). Quinolone prescribing rates were 9.9% in primary care networks and 8.1% in reference group. Patients with comorbidities had a higher likelihood of receiving an antibiotic and quinolone prescription and were less likely to receive a guideline-recommended substance. Younger patients were less likely to receive antibiotics (OR = 0.771 CI = [0.636; 0.933], p = 0.008). Female gender was more likely to receive an antibiotic prescription (OR = 1.293 CI = [1.201, 1.392], p < 0.001). CONCLUSION This study provided an overview of observed antibiotic prescribing for acute non-complicated respiratory tract infections in German primary care at the start of the ARena project. Findings indicate potential for improvement and will serve as comparator for the post-interventional outcome evaluation to facilitate describing of potential changes.
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Affiliation(s)
- Regina Poss-Doering
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Dorothea Kronsteiner
- IMBI Institute for Medical Biometry, University Hospital Heidelberg, Heidelberg, Germany
| | - Martina Kamradt
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | | | | | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
- aQua Institut, Goettingen, Germany
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Poss-Doering R, Kühn L, Kamradt M, Stürmlinger A, Glassen K, Andres E, Kaufmann-Kolle P, Wambach V, Bader L, Szecsenyi J, Wensing M. Fostering Appropriate Antibiotic Use in a Complex Intervention: Mixed-Methods Process Evaluation Alongside the Cluster-Randomized Trial ARena. Antibiotics (Basel) 2020; 9:E878. [PMID: 33302559 PMCID: PMC7764260 DOI: 10.3390/antibiotics9120878] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/04/2023] Open
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.
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Affiliation(s)
- Regina Poss-Doering
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
| | - Lukas Kühn
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
| | - Martina Kamradt
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
| | - Anna Stürmlinger
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
| | - Katharina Glassen
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
| | - Edith Andres
- aQua Institut, Maschmuehlenweg 8-10, 37073 Goettingen, Germany; (E.A.); (P.K.-K.)
| | - Petra Kaufmann-Kolle
- aQua Institut, Maschmuehlenweg 8-10, 37073 Goettingen, Germany; (E.A.); (P.K.-K.)
| | - Veit Wambach
- Agentur deutscher Arztnetze e.V., Friedrichstraße 171, 10117 Berlin, Germany;
| | - Lutz Bader
- Kassenärztliche Vereinigung Bayerns (KVB), 80684 München, Germany;
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
- aQua Institut, Maschmuehlenweg 8-10, 37073 Goettingen, Germany; (E.A.); (P.K.-K.)
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; (L.K.); (M.K.); (A.S.); (K.G.); (J.S.); (M.W.)
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Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary care physicians' attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ Open 2020; 10:e034983. [PMID: 32665343 PMCID: PMC7365421 DOI: 10.1136/bmjopen-2019-034983] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship is needed to improve prescribing and address the threat of antibiotic resistance. A better understanding of primary care physicians (PCPs) attitudes towards antibiotic prescribing and outpatient antibiotic stewardship is needed to identify barriers to stewardship implementation and help tailor stewardship strategies. The aim of this study was to assess PCPs current attitudes towards antibiotic resistance, inappropriate antibiotic prescribing and the feasibility of outpatient stewardship efforts. DESIGN Eight focus groups with PCPs were conducted by an independent moderator using a moderator guide. Focus groups were audio recorded, transcribed and coded for major themes using deductive and inductive content analysis methods. SETTING Focus groups were conducted in four US cities: Philadelphia, Birmingham, Chicago and Los Angeles. PARTICIPANTS Two focus groups were conducted in each city-one with family medicine and internal medicine physicians and one with paediatricians. A total of 26 family medicine/internal medicine physicians and 26 paediatricians participated. RESULTS Participants acknowledged that resistance is an important public health issue, but not as important as other pressing problems (eg, obesity, opioids). Many considered resistance to be more of a hospital issue. While participants recognised inappropriate prescribing as a problem in outpatient settings, many felt that the key drivers were non-primary care settings (eg, urgent care clinics, retail clinics) and patient demand. Participants reacted positively to stewardship efforts aimed at educating patients and clinicians. They questioned the validity of antibiotic prescribing metrics. This scepticism was due to a number of factors, including the feasibility of capturing prescribing quality, a belief that physicians will 'game the system' to improve their measures, and dissatisfaction and distrust of quality measurement in general. CONCLUSIONS Stakeholders will need to consider physician attitudes and beliefs about antibiotic stewardship when implementing interventions aimed at improving prescribing.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea M Garcia
- Health & Science, American Medical Association, Chicago, Illinois, USA
| | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
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