A qualitative approach to examining antimicrobial prescribing in the outpatient dental setting

Abstract

Objective: To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting. Design: Semistructured interviews. Setting: Outpatient dental setting. Participants: Dentists from 40 Veterans’ Health Administration (VA) facilities across the United States. Methods: Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing. Results: In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist’s decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities. Conclusions: Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists’ ongoing professional development and improve evidence-based prescribing.

Barriers and facilitators to guideline concordant dental antibiotic prescribing in the United States: A qualitative study of the National DentalPBRN

“…Two studies identified that dentists were motivated to prescribe due to concerns of conflict, in which they fail to meet their patients' expectations (20,23). Additionally, research has identified conflict avoidance was a method to maintain a good clinician-patient relationship in dental practices (21). Patient satisfaction and financial stability is particularly a concern for dentists because nearly 50% of dentists work in solo practices (37).…”

“…Conversely, Thompson et al identified that though dentists were aware of risks, some viewed the risk of antibiotic‐associated adverse events as less than the risk of a spreading dental infection. Furthermore, a qualitative study of dentists recruited from high‐and‐low prescribing Veterans Health Administration (VHA) facilities found that dentists at high prescribing facilities displayed a lack of awareness of the harm of their prescribing (21). Whereas dentists in low‐prescribing sites displayed more awareness of: (1) potential antibiotic‐associated harms and (2) ongoing initiatives to improve prescribing at their VHA facility.…”

“…Since 2015, several studies have tried to understand the factors associated with appropriate and inappropriate dental antibiotic prescribing to alleviate appropriate prescribing barriers at the patient, provider, and system level. Factors identified in prior work include: patient expectation to receive antibiotics (13)(14)(15)(16)(17)(18)(19)(20)(21), provider unawareness of antibiotic resistance (20,22), provider motivation to provide the "best treatment" (16,21), fear of legal reprimand (16,20), and fear of criticism online (17). Few, if any of the existing studies have explored antibiotic prescribing by dentists using a behavior change model (22,23).…”

Ten ways to make the most of World Antimicrobial Awareness Week

“…Similarly, Manning et al 16 demonstrated how patient simulations can improve nursing-student awareness of their role in antimicrobial stewardship. Hughes et al 17 identified several opportunities for improvement in dental antimicrobial stewardship, including improved awareness of and access to evidence-based guidelines, as well as harnessing social comparison to improve prescribing behavior.…”

“…In a cross-sectional study using interviews of 90 dentists, 91.2% stated that they prescribed on a 'just in case' basis. 17 In a retrospective cohort study, 205 patients (80.7%) received empiric antibiotic therapy indicated for presumed urinary tract infection despite meeting criteria for asymptomatic bacteriuria. 18 However, given the known harms of antibiotic therapy, there is an opportunity to reframe messaging regarding "erring on the side of caution" to now mean thoroughly evaluating and monitoring the patient while considering other noninfectious causes before prescribing an antibiotic.…”