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Factors Influencing Antibiotic-Prescribing Decisions Among Inpatient Physicians: A Qualitative Investigation

Published online by Cambridge University Press:  16 June 2015

Daniel Livorsi ,
Amber Comer ,
Marianne S. Matthias ,
Eli N. Perencevich  and
Matthew J. Bair
Daniel Livorsi*
Affiliation:
Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana
Amber Comer
Affiliation:
Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
Marianne S. Matthias
Affiliation:
Veterans Affairs Health Services Research and Development Service Center for Health Information and Communication, Richard Roudebush VA Medical Center, Indianapolis, Indiana Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
Eli N. Perencevich
Affiliation:
Division of General Internal Medicine and Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa Iowa City VA Health Care System, Iowa City, Iowa
Matthew J. Bair
Affiliation:
Veterans Affairs Health Services Research and Development Service Center for Health Information and Communication, Richard Roudebush VA Medical Center, Indianapolis, Indiana Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
*
Address correspondence to Daniel Livorsi, MD, MSc, Assistant Professor, Division of Infectious Diseases, Indiana University School of Medicine, 545 Barnhill Drive, EH 421 Indianapolis, IN 46202 (dlivorsi@iu.edu).
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Abstract

OBJECTIVE

To understand the professional and psychosocial factors that influence physician antibiotic prescribing habits in the inpatient setting.

DESIGN

We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participant responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis.

SETTING

Two teaching hospitals in Indianapolis, Indiana

PARTICIPANTS

A total of 30 inpatient physicians (10 physicians-in-training, 20 supervising staff) were enrolled in this study.

RESULTS

Participants recognized that antibiotics are overused, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Overprescription was largely driven by anxiety about missing an infection, whereas potential adverse effects of antibiotics did not strongly influence decision making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues’ antibiotic prescribing decisions, but they frequently avoided providing direct feedback or critique. These physicians cited obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations.

CONCLUSION

A physician-based culture of prescribing antibiotics involves overusing antibiotics and not challenging the decisions of colleagues. The potential adverse effects of antibiotics did not strongly influence decision making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic prescribing practices in the inpatient setting.

Infect. Control Hosp. Epidemiol. 2015;36(9):1065–1072

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 36 , Supplement 9 , September 2015 , pp. 1065 - 1072
Copyright
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved 

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References

1. Spellberg, B, Bartlett, JG, Gilbert, DN. The future of antibiotics and resistance. New Engl J Med 2013;368:299–302.Google Scholar
2. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States. Atlanta, GA: CDC, 2013.Google Scholar
3. Hecker, MT, Aron, DC, Patel, NP, Lehmann, MK, Donskey, CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003;163:972–978.CrossRefGoogle ScholarPubMed
4. Cosgrove, SE, Seo, SK, Bolon, MK, et al. Evaluation of postprescription review and feedback as a method of promoting rational antimicrobial use: a multicenter intervention. Infect Control Hosp Epidemiol 2012;33:374–380.Google Scholar
5. Arnold, FW, McDonald, LC, Smith, RS, Newman, D, Ramirez, JA. Improving antimicrobial use in the hospital setting by providing usage feedback to prescribing physicians. Infect Control Hosp Epidemiol 2006;27:378–382.Google Scholar
6. Camins, BC, King, MD, Wells, JB, et al. Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infect Control Hosp Epidemiol 2009;30:931–938.Google Scholar
7. Fraser, GL, Stogsdill, P, Dickens, JD Jr, Wennberg, DE, Smith, RP Jr, Prato, BS. Antibiotic optimization. An evaluation of patient safety and economic outcomes. Arch Intern Med 1997;157:1689–1694.CrossRefGoogle ScholarPubMed
8. Dellit, TH, Owens, RC, McGowan, JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.Google Scholar
9. Pope, SD, Dellit, TH, Owens, RC, Hooton, TM. Infectious Diseases Society of A, Society for Healthcare Epidemiology of A. Results of survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Infect Control Hosp Epidemiol 2009;30:97–98.Google Scholar
10. Meeker, D, Knight, TK, Friedberg, MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014;174:425–431.Google Scholar
11. Charani, E, Castro-Sanchez, E, Sevdalis, N, et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis 2013;57:188–196.Google Scholar
12. Charani, E, Edwards, R, Sevdalis, N, et al. Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis 2011;53:651–662.Google Scholar
13. Miller, WL, Crabtree, BF. The dance of interpretation. In: Miller WL, Crabtree BF, eds. Doing Qualitative Research. Thousand Oaks, CA: Sage, 1999:127–143.Google Scholar
14. Miles, MB, Huberman, AM. Qualitative Data Analysis. Thousand Oaks, CA: Sage, 1994.Google Scholar
15. Bernard, H. Research Methods in Anthropology: Qualitative and Quantitative Approaches. Walnut Creek, CA: AltaMira; 2002.Google Scholar
16. Charmaz, K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Thousand Oaks, CA: Sage, 2006.Google Scholar
17. Schouten, JA, Hulscher, ME, Natsch, S, Kullberg, BJ, van der Meer, JW, Grol, RP. Barriers to optimal antibiotic use for community-acquired pneumonia at hospitals: a qualitative study. Qual Saf Health Care 2007;16:143–149.Google Scholar
18. Cortoos, PJ, De Witte, K, Peetermans, WE, Simoens, S, Laekeman, G. Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. J Antimicrob Chemother 2008;62:189–195.Google Scholar
19. Dellit, TH, Owens, RC, McGowan, JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.Google Scholar
20. Smith, CD, Korenstein, D. Harnessing the power of peer pressure to reduce health care waste and improve clinical outcomes. Mayo Clin Proc 2015;90:311–312.Google Scholar
21. Borg, MA. National cultural dimensions as drivers of inappropriate ambulatory care consumption of antibiotics in Europe and their relevance to awareness campaigns. J Antimicrob Chemother 2012;67:763–767.CrossRefGoogle ScholarPubMed
22. Borg, MA. Prolonged perioperative surgical prophylaxis within European hospitals: an exercise in uncertainty avoidance? J Antimicrob Chemother 2014;69:1142–1144.CrossRefGoogle ScholarPubMed
23. Cortoos, PJ, De Witte, K, Peetermans, WE, Simoens, S, Laekeman, G. Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. J Antimicrob Chemother 2008;62:189–195.Google Scholar
24. De Souza, V, MacFarlane, A, Murphy, AW, Hanahoe, B, Barber, A, Cormican, M. A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. J Antimicrob Chemother 2006;58:840–843.Google Scholar
25. Bjorkman, I, Berg, J, Roing, M, Erntell, M, Lundborg, CS. Perceptions among Swedish hospital physicians on prescribing of antibiotics and antibiotic resistance. Qual Saf Health Care 2010;19:e8.Google Scholar
26. Borg, MA. National cultural dimensions as drivers of inappropriate ambulatory care consumption of antibiotics in Europe and their relevance to awareness campaigns. J Antimicrob Chemother 2012;67:763–767.Google Scholar
27. Borg, MA. Prolonged perioperative surgical prophylaxis within European hospitals: an exercise in uncertainty avoidance? J Antimicrob Chemother 2014;69:1142–1144.Google Scholar
28. Pulcini, C, Williams, F, Molinari, N, Davey, P, Nathwani, D. Junior doctors’ knowledge and perceptions of antibiotic resistance and prescribing: a survey in France and Scotland. Clin Microbiol Infect 2011;17:80–87.Google Scholar
29. Wester, CW, Durairaj, L, Evans, AT, Schwartz, DN, Husain, S, Martinez, E. Antibiotic resistance: a survey of physician perceptions. Arch Intern Med 2002;162:2210–2216.Google Scholar
30. Giblin, TB, Sinkowitz-Cochran, RL, Harris, PL, et al. Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med 2004;164:1662–1668.Google Scholar
31. De Souza, V, MacFarlane, A, Murphy, AW, Hanahoe, B, Barber, A, Cormican, M. A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. J Antimicrob Chemother 2006;58:840–843.Google Scholar
32. Davey, P, Brown, E, Charani, E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;4:CD003543.Google Scholar
33. Harbarth, S, Samore, MH. Antimicrobial resistance determinants and future control. Emerg Infect Dis 2005;11:794–801.CrossRefGoogle ScholarPubMed
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