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

https://doi.org/10.1016/j.ijantimicag.2012.09.003Get rights and content

Abstract

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.

Introduction

Concerns raised about antibiotic resistance have highlighted this field as an important public health problem calling for prompt countermeasures. According to the World Health Organization (WHO), infections caused by microorganisms often fail to respond to conventional therapy, increasing health costs, morbidity and mortality, and threatening a return to the pre-antibiotic era [1]. In Europe, wide variations in resistance status are found depending on the pathogen type, antimicrobial substance and geographical region, with unimpeded growth rates being observed for some resistant strains [2], [3], [4].

Currently, there are few doubts about the association between the use of antibiotics and the spread of antibiotic resistance, with misprescription of antibiotics being one of the major favouring factors [5], [6], [7]. As key stakeholders in the field, physicians have been the target of numerous interventions aimed at addressing the factors underlying the misprescription of antibiotics and, ultimately, improving the quality of such prescribing [8], [9]. Exploring and understanding the factors specific to each setting is the first and most important step towards designing effective interventions [10].

Insofar as published reviews seek to evaluate the influence on antibiotic prescribing of the aspects identified, they have nevertheless not attempted to explore and identify the subjective opinions held by physicians or the type of prescriber-related attitudes and knowledge that could not be identified by researchers a priori [11]. This is the main objective of qualitative studies and could prove extremely useful in terms of improving knowledge in this field.

Qualitative methods are becoming increasingly prevalent in medical and related research [12], and several qualitative studies have investigated the factors involved in antibiotic prescribing. A review of such qualitative literature is fundamental to gaining insight into the culture of antibiotic prescribing, and this review therefore set out to explore and identify physicians’ perceptions of factors, attitudes and knowledge influencing antibiotic prescribing.

Section snippets

Search strategy/search methods for identification of studies

For the purpose of this systematic bibliographic review, MEDLINE PubMed scientific database was searched from January 1987 to December 2011 using the following broad-based search term strategy: (attitud* OR knowle* OR percept*) AND (physician* OR doctor* OR practitioner*) AND (antibiotic OR antimicrobial*). The selection criteria required papers to be published in English, Portuguese or Spanish, with those in other languages being excluded from the review.

Study content inclusion

Studies were deemed eligible for review

Search results

The search strategy identified a total of 1032 studies in the MEDLINE PubMed scientific database. Following screening, 223 papers were retrieved and assessed as eligible for perusal of the full text, resulting in a final total of 35 studies included in the review (Fig. 1) [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49]. Of these, 26

Discussion

This was a systematic review of qualitative studies focused on examining the subjective opinions of physicians about all the factors that influence the antibiotic prescribing process, providing a new, specific overview of each factor involved and its influence on the outcomes of antibiotic use. In the results, attitudes emerge as being the most important factor affecting antibiotic prescription, a finding that could be of great importance when it comes to designing interventions to improve

Implications for practice and research

Qualitative methodology is becoming routine in medical studies, assuming the main role of exploring complex topics and defining new approaches to the field targeted [74], [75]. With regard to antibiotic prescribing, this methodology has shown itself to be very useful for understanding the subjective perceptions of all the players involved, essentially physicians and policy-makers. This paper presents a fundamental understanding of the factors that physicians see as influencing antibiotic

Conclusions

In conclusion, we believe that these findings will promote a better understanding of physicians’ perceptions of the factors that influence the antibiotic prescribing process, clarify how such factors influence the decision-making process, and highlight their importance in the design of strategies aimed at tackling this concern effectively.

Funding: This work was supported by the Fundação para a Ciência e a Tecnologia (FCT) [grant PTDC/SAU-ESA/105530/2008] from the Portuguese Ministry of Science

References (75)

  • K. Brinsley et al.

    An assessment of issues surrounding implementation of the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

    Am J Infect Control

    (2005)
  • World Health Organization

    Antibiotic resistance

    (2012)
  • O. Heuer et al.

    Antimicrobial resistance surveillance in Europe: annual report of the European Antimicrobial Resistance Surveillance Network (EARS-Net)

    (2010)
  • Lepape A, Monnet DL. Experience of European intensive care physicians with infections due to antibiotic-resistant...
  • C. Costelloe et al.

    Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis

    BMJ

    (2010)
  • N. van de Sande-Bruinsma et al.

    Antimicrobial drug use and resistance in Europe

    Emerg Infect Dis

    (2008)
  • S. Tonkin-Crine et al.

    Antibiotic prescribing for acute respiratory tract infections in primary care: a systematic review and meta-ethnography

    J Antimicrob Chemother

    (2011)
  • P. Lopez-Vazquez et al.

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

    J Eval Clin Pract

    (2012)
  • N. Britten

    Making sense of qualitative research: a new series

    Med Educ

    (2005)
  • A. Kuper et al.

    An introduction to reading and appraising qualitative research

    BMJ

    (2008)
  • Public Health Resource Unit (PHRU)

    Critical Appraisal Skills Programme (CASP). Collaboration for Qualitative Methodologies

    (2006)
  • J.A. Schouten et al.

    Barriers to optimal antibiotic use for community-acquired pneumonia at hospitals: a qualitative study

    Qual Saf Health Care

    (2007)
  • D.A. Palmer et al.

    Parents’ and physicians’ views on antibiotics

    Pediatrics

    (1997)
  • L.S. Barden et al.

    Current attitudes regarding use of antimicrobial agents: results from physician's and parents’ focus group discussions

    Clin Pediatr (Phila)

    (1998)
  • C.C. Butler et al.

    Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats

    BMJ

    (1998)
  • M. Hasty et al.

    Physicians’ perceptions about managed care restrictions on antibiotic prescribing

    J Gen Intern Med

    (1999)
  • S. Coenen et al.

    Antibiotics for coughing in general practice: a qualitative decision analysis

    Fam Pract

    (2000)
  • S. Walker et al.

    Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions

    CMAJ

    (2000)
  • I. Björnsdóttir et al.

    Telephone prescribing of antibiotics. General practitioners’ views and reflections

    Eur J Public Health

    (2001)
  • E. Paluck et al.

    Prescribing practices and attitudes toward giving children antibiotics

    Can Fam Physician

    (2001)
  • T. Liabsuetrakul et al.

    Current status of prophylactic use of antimicrobial agents for Cesarean section in Thailand

    J Obstet Gynaecol Res

    (2002)
  • S. Kumar et al.

    Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study

    BMJ

    (2003)
  • A. Altiner et al.

    Acute cough: a qualitative analysis of how GPs manage the consultation when patients explicitly or implicitly expect antibiotic prescriptions

    Fam Pract

    (2004)
  • P.G. Mol et al.

    Adherence barriers to antimicrobial treatment guidelines in teaching hospital, the Netherlands

    Emerg Infect Dis

    (2004)
  • G. Sivagnanam et al.

    A survey on current attitude of practicing physicians upon usage of antimicrobial agents in southern part of India

    MedGenMed

    (2004)
  • M.C. Weiss et al.

    Perceptions of patient expectation for an antibiotic: a comparison of walk-in centre nurses and GPs

    Fam Pract

    (2004)
  • S. Zaffani et al.

    An analysis of the factors influencing the paediatrician–parents relationship: the importance of the socio-demographic characteristics of the mothers

    Child Care Health Dev

    (2005)
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