Physicians' perceptions about managed care restrictions on antibiotic prescribing

Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies

Inappropriate prescription has been associated with mounting rates of antibiotic resistance worldwide, demanding more detailed studies into physicians' decision-making process. Accordingly, this study sought to explore physicians' perceptions of factors influencing antibiotic prescribing. A systematic search was performed for qualitative studies focused on understanding physicians' perceptions of the factors, attitudes and knowledge influencing antibiotic prescription. Of the total of 35 papers selected for review purposes, 18 solely included physicians and the remaining 17 also included patients and/or other healthcare providers. Data collection was based mainly on interviews, followed by questionnaires and focus groups, and the methodologies mainly used for data analysis were grounded theory and thematic analysis. Factors cited by physicians as having an impact on antibiotic prescribing were grouped into those that were intrinsic (group 1) and those that were extrinsic (group 2) to the healthcare professional. Among the former, physicians' attitudes, such as complacency or fear, were rated as being most influential on antibiotic prescribing, whilst patient-related factors (e.g. signs and symptoms) or healthcare system-related factors (e.g. time pressure and policies/guidelines implemented) were the most commonly reported extrinsic factors. These findings revealed that: (i) antibiotic prescribing is a complex process influenced by factors affecting all the actors involved, including physicians, other healthcare providers, healthcare system, patients and the general public; and (ii) such factors are mutually dependent. Hence, by shedding new light on the process, these findings will hopefully contribute to generating new and more effective strategies for improving antibiotic prescribing and allaying global concern about antibiotic resistance.

Misprescription of antibiotics in primary care: a critical systematic review of its determinants

BACKGROUND

Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics.

METHODS

A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only.

RESULTS

A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics.

CONCLUSIONS

Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.

Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care

CONTEXT

Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents.

OBJECTIVE

To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs).

DESIGN, SETTING, AND PATIENTS

Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%).

MAIN OUTCOME MEASURE

Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin.

RESULTS

Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice.

CONCLUSIONS

Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.

Modifying provider behavior: a low-tech approach to pharmaceutical ordering

OBJECTIVE

To determine if a clinically structured, paper-based prescription form can modify pharmaceutical prescribing behavior without restricting physician freedom to select the most appropriate medication for an individual patient.

DESIGN

Uncontrolled, nonrandomized, time series design.

SETTING

The urgent care clinic of a university-affiliated, county-supported hospital that provides care for underserved, vulnerable populations.

PATIENTS

Patients (N = 2189) who had a prescription written at the intervention site during the study.

INTERVENTION

Four-phase interventions lasting 2 weeks each, with a washout period between each phase, consisting of: (1). collection of baseline data utilizing the traditional prescription blank, (2). introduction of the pre-formatted prescription form, (3). use of the pre-formatted prescription form with medication cost added, and (4). pre-formatted prescription form with target drug (ranitidine) removed.

MEASUREMENTS AND MAIN RESULTS

Physicians were less likely to prescribe ranitidine compared to cimetidine after the introduction of the cost information (P <.01) and again after the removal of ranitidine from the pre-formatted prescription form (P <.001).

CONCLUSIONS

A structured, paper-based prescription order form can shift prescribing practices without inhibiting physicians' ordering freedom.