Ethical dilemmas in antibiotic prescribing: analysis of everyday practice

Uncovering influential factors in human antibiotic prescribing: a meta-synthesis study informed by the Theoretical Domains Framework

This study aimed to identify modifiable determinants (facilitators and barriers) related to the choice of prescribing antibiotics in human medicine across clinical settings. Enhanced management of antibiotics can help slow the spread of resistant bacteria. A qualitative meta-synthesis approach was used, according to Sandelowski and Barroso's method. Included studies were evaluated using the Critical Appraisal Skills Programme. Findings were extracted and organized to form a qualitative meta-summary. The Theoretical Domains Framework, the Capabilities-Opportunities-Motivation (COM-B) model and the Behaviour Change Wheel were used as a coding matrix for data interpretation. The analysis of 63 included studies revealed barriers and facilitators in 12 of 14 domains specified by the Theoretical Domains Framework. Prescribers' capabilities, motivation and opportunities were found to be the main drivers of antibiotic prescribing behaviour. Knowledge, skills, beliefs, expectations, the influence of patients and colleagues, organizational culture and infrastructure characteristics have a significant impact on prescribing behaviours. A comprehensive inventory of factors related to antibiotic prescribing has been compiled. Interventions to promote appropriate antibiotic prescribing should take a systemic approach rather than focusing solely on individual-level variables. Furthermore, the adoption of co-design approaches for such interventions is desirable to ensure greater applicability and sustainability in the real-world context of organizations.

OUP accepted manuscript

In order to design appropriate antimicrobial stewardship (AMS) programmes, it is crucial to understand challenges to tackling antibiotic resistance (AMR) specific to each healthcare setting. Antibiotic prescribing in primary care accounts for most prescriptions with a significant proportion considered clinically inappropriate. Qualitative research has a long history in social sciences, but its value and contribution are still contested in medical journals including in the AMR/AMS field. However, through its focus on understanding, meaning making and explaining, qualitative research can offer insights in how to improve AMS efforts in primary care. This paper provides an overview of unique considerations, contributions and challenges related to using qualitative research in AMS to help the AMS community new to qualitative research to utilize its potential most fully. First, we discuss specific considerations for AMS in relation to the stages of conducting a qualitative study, including identifying a research question and choosing a suitable methodology; sampling appropriate participants; planning a recruitment strategy; choosing a method of data collection; and conducting data analysis. These are illustrated with examples of qualitative AMS studies in primary care. Second, we highlight the importance of patient and public involvement throughout all stages of the project and ensuring quality in qualitative AMS research. Finally, drawing on these considerations, we make a further case for the value and contribution of qualitative methodologies in AMS/AMR research while outlining future directions for both AMS and qualitative research, including the need for studies with diverse actors; interdisciplinary collaborations; and complex decisions on methodologies and timelines.

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.

Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues?

BACKGROUND

Diagnostic uncertainty (DU) in primary care is ubiquitous, yet no review has specifically examined its communication, or the associated ethical issues.

OBJECTIVES

To identify what is known about the communication of DU in primary care and the associated ethical issues.

METHODS

Systematic review, critical interpretive synthesis and ethical analysis of primary research published worldwide. Medline, Embase, Web of Science and SCOPUS were searched for papers from 1988 to 2020 relating to primary care AND diagnostic uncertainty AND [ethics OR behaviours OR communication]. Critical interpretive synthesis and ethical analysis were applied to data extracted.

RESULTS

Sixteen papers met inclusion criteria. Although DU is inherent in primary care, its communication is often limited. Evidence on the effects of communicating DU to patients is mixed; research on patient perspectives of DU is lacking. The empirical literature is significantly limited by inconsistencies in how DU is defined and measured. No primary ethical analysis was identified; secondary analysis of the included papers identified ethical issues relating to maintaining patient autonomy in the face of clinical uncertainty, a gap in considering the direct effects of (not) communicating DU on patients, and considerations regarding over-investigation and justice.

CONCLUSIONS

This review highlights significant gaps in the literature: there is a need for explicit ethical and patient-centred empirical analyses on the effects of communicating DU, and research directly examining patient preferences for this communication. Consensus on how DU should be defined, and greater research into tools for its measurement, would help to strengthen the empirical evidence base.

The predictive values of a deliberative and a paternalistic attitude towards two situations of moral conflict: A study among Dutch nurse practitioners and physician assistants

Background

In this study, we examined the predictive values of a moral deliberate and paternalistic attitude on the propensity of yielding to pressure. In these hypothesised positive and negative relationships, we further sought to ascertain whether moral disengagement plays a pivotal role when individuals deviate from ethical standards, rules and regulations when yielding to pressure.

Aim(s)

This study's primary aim was to assess the predictive value of a moral deliberative and paternalistic attitude for yielding to pressure when physician assistants (PAs) and nurse practitioners (NPs) face moral conflicts.

Method

This validation study was cross‐sectional and based on a convenience sample of Dutch PAs and NPs. The MSQ‐DELIB and MSQ‐PATER scales indicate a moral deliberate or paternalistic attitude. These scales were assumed to have a predictive value towards the degree of yielding to pressure by PAs and NPs. Yielding to pressure was measured by two vignettes in which respondents faced a moral conflict (vignette 1: prescribing unindicated antibiotics and vignette 2: discharging a difficult patient from the hospital).

Results

Only moral deliberation was a significant predictor of yielding to pressure. That is, we found a positive effect in vignette 1 (in which the pressure came from the patient). In contrast, we found a negative relationship in vignette 2 (in which pressure went from the working environment). Paternalism did not affect yielding to pressure in either vignette.

Conclusion

This study suggests that PAs and NPs having a moral deliberative attitude makes them receptive to pressure exerted by patients to break moral standards. On the other hand, they are more resilient against doing so when this pressure comes from different sources than the patient. Further research is needed to find more conclusive evidence for this differential effect.

Communication training and the prescribing pattern of antibiotic prescription in primary health care

BACKGROUND

The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians.

METHODS

In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs.

RESULTS

Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger.

CONCLUSIONS

Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.

Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography

BACKGROUND

Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections.

AIM

The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists).

DESIGN AND SETTING

Systematic review and meta-ethnography of qualitative studies.

METHOD

A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed.

RESULTS

In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary).

CONCLUSION

Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities.

Factors influencing antibiotic prescribing in long-term care facilities: a qualitative in-depth study

Background

Insight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors.

Methods

Semi-structured qualitative interviews were conducted with physicians (n = 13) and nursing staff (n = 13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff.

Results

The analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians’ perceived risks, influence of others, and influence of the environment. Each category comprises several factors that may influence the decision to prescribe or not prescribe antibiotics directly (e.g. pressure of patients’ family leading to antibiotic prescribing) or indirectly via influence on other factors (e.g. unfamiliarity with patients resulting in a higher physician perceived risk of non-treatment, in turn resulting in a higher tendency to prescribe antibiotics).

Conclusions

Our interview study shows that several non-rational factors may affect antibiotic prescribing decision making in long-term care facilities, suggesting opportunities to reduce inappropriate antibiotic use. We developed a conceptual model that integrates the identified categories of influencing factors and shows the relationships between those categories. This model may be used as a practical tool in long-term care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriate antibiotic prescribing.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2318-14-136) contains supplementary material, which is available to authorized users.

Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice

BACKGROUND

Antibiotic resistance is a public health concern worldwide. A high proportion of antibiotics are prescribed in primary care, often for conditions where there is no evidence of benefit. Without a change in these prescribing patterns, resistance will persist as a significant problem in the future. Little is known about how trainees in general practice perceive and develop their prescribing.

AIM

To explore the attitudes of trainees in general practice towards antibiotic use and resistance, and the perceived influences on their prescribing.

DESIGN AND SETTING

A qualitative study of 17 vocational trainees in general practice (GP registrars) in both rural and urban areas in Australia employing semi-structured interviews and a focus group.

METHOD

Maximum variation purposive sampling of GP registrars from diverse backgrounds and training stages continued until thematic saturation was achieved. Topics of discussion included awareness of antibiotic resistance, use of evidence-based guidelines, and perceived influences on prescribing. Transcribed interviews were coded independently by two researchers. Data collection and analysis were concurrent and cumulative, using a process of iterative thematic analysis.

RESULTS

Registrars were aware of the importance of evidence-based antibiotic prescribing and the impact of their decisions on resistance. Many expressed a sense of dissonance between their knowledge and behaviours. Contextual influences on their decisions included patient and system factors, diagnostic uncertainty, transitioning from hospital medicine, and the habits of, and relationship with, their supervisor.

CONCLUSION

Understanding how trainees in general practice perceive and develop antibiotic prescribing habits will enable targeted educational interventions to be designed and implemented at a crucial stage in training, working towards ensuring appropriate antibiotic prescribing in the future.

Understanding variation in primary medical care: a nine-country qualitative study of clinicians' accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection

OBJECTIVES

There is a wide variation between European countries in antibiotic prescribing for patients in primary care with lower respiratory tract infection (LRTI) that is not explained by case mix and clinical factors alone. Variation in antibiotic prescribing that is not warranted by differences in illness and clinical presentation may increase selection of resistant organisms, contributing to the problem of antibiotic resistance. This study aimed to investigate clinicians' accounts of non-clinical factors that influence their antibiotic prescribing decision for patients with LRTI, to understand variation and identify opportunities for addressing possible unhelpful variation.

DESIGN

Multicountry qualitative semistructured interview study, with data subjected to a five-stage analytic framework approach (familiarisation, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation), and with interviewers commenting on preliminary analytic themes.

SETTING

Primary care.

PARTICIPANTS

Eighty primary care clinicians randomly selected from primary care research networks based in nine European cities.

RESULTS

Clinicians' accounts identified non-clinical factors imposed by the healthcare system operating within specific regional primary care research networks, including patient access to antibiotics before consulting a doctor (Barcelona and Milan), systems to reduce patient expectations for antibiotics (Southampton and Antwerp) and lack of consistent treatment guidelines (Balatonfüred and Łódź). Secondly, accounts revealed factors related to specific characteristics of clinicians regardless of network (professional ethos, self-belief in decision-making and commitment to shared decision-making).

CONCLUSIONS

Addressing healthcare system factors (eg, limiting patients' self-management with antibiotics before consulting in primary care, increased public awareness and provision of more consistent guidelines) may assist in reducing unhelpful variation in antibiotic prescribing. Promoting clinicians' receptivity to change, confidence in decision-making and readiness to invest in explaining prescribing decisions may also be beneficial. As factors were emphasised differently between networks, local flexibility in interventions is likely to maximise effectiveness.

Uncomfortable prescribing decisions in hospitals: the impact of teamwork

OBJECTIVES

Prescribing is not always driven by therapeutic motives alone; social and intrinsic factors also play a part in the decision. However, most research into prescribing influences has been conducted in general practice, with very little conducted within hospitals. One potential influence is the hospital multidisciplinary team, yet little attention has been paid to how interactions between teams and team members may influence prescribing. This study investigated the effect that team interaction and structure had upon UK hospital doctors' prescribing decisions, particularly their discomfort felt prescribing.

DESIGN AND SETTING

The study used the critical incident technique and in-depth interviews. Prior to an in-depth interview, 48 doctors of varying grades from four hospitals were asked to remember any uncomfortable prescribing decisions that they had recently made. These 'incidents' were discussed in depth. All interviews were tape-recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

RESULTS

There were 193 critical incidents described in the interviews. Over one-third were related to the difficulties of prescribing within a team environment. Discomfort frequently arose because of factors relating to the hierarchical structure; in particular, junior doctors described their discomfort when they were uncertain of seniors' prescribing decisions. Prescribers also adhered to rules of prescribing etiquette, including the maintenance of other doctors'/teams' prescribing decisions and adherence to prescribing norms. Discomfort also arose from a perceived pressure to prescribe from the nursing team. Doctors admitted to prescribing to maintain overall team relationships, sometimes ignoring hospital regulations and best practice to do so.

CONCLUSION

Overall, this study demonstrated that hospital doctors' prescribing decisions were strongly influenced by relationships with other team members, particularly nurses and senior doctors. Ways of reducing this discomfort should be explored and further research is advocated in this area.

What are the non-biomedical reasons which make family doctors over-prescribe antibiotics for upper respiratory tract infection in a mixed private/public Asian setting?

OBJECTIVES

To examine the non-biomedical reasons which make family doctors over-prescribe antibiotics for upper respiratory tract infection (URTI) in a mixed private/public Asian setting.

METHODS

The questionnaire was sent to the members of the Hong Kong College of Family Physicians between August and December 2001.

RESULTS

A total of 801 family doctors completed a postal questionnaire with an overall response rate of 65.0. A significant number of respondents (21.8) felt they might be prescribing antibiotics too often for URTI but the majority of them felt they were using antibiotics just a bit too often. Doctors who were older, more senior or in private practice were more likely to feel that they might be prescribing antibiotics too often. More than 50 of respondents thought that to satisfy the patient or his/her carer and fear of medicolegal problem if the patient deteriorates would make them very likely or likely to over-prescribe antibiotics for patients with URTIs. Public doctors might over-prescribe in order to save time, whereas private doctors might do so in order to keep patients in their practice.

CONCLUSION

The results showed that doctors with certain characteristics are more likely to over-prescribe antibiotics. Factors, other than biomedical ones, may play important roles in doctor's prescription of antibiotics for URTI.