Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing

Abstract

Background Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate ‘in the moment’: dual process theories, which propose two systems of thought (‘automatic’ and ‘analytical’), may inform this. Objective(s) Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing. Methods We conducted a mixed methods study. Primary care physicians in Scotland (n = 158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorized as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics and decision difficulty, time and appropriateness. A subgroup (n = 5) verbalized their thoughts (think aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively. Results Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing. Conclusion Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings and facilitating appropriate use of both modes of thinking.

Point-of-care testing, antibiotic prescribing, and prescribing confidence for respiratory tract infections in primary care: a prospective audit in 18 European countries

“…14,15 Challenges facing prescribers include uncertainty about aetiology, unavailability of point-of-care (POC) diagnostic testing to aid prescribing decisions, unfamiliarity with current guidelines, risk-adverse prescribing behaviour and non-evidence based patients' expectations about effectiveness of antibiotics. [16][17][18][19][20] Additional influences include health care system and cultural factors. 3,21,22 POC testing for RTI management has been introduced in primary care thus far mainly to identify a Streptococcal A throat infection, 23 and to use the biomarker C-reactive protein (CRP) to inform antibiotic prescribing for acute cough.…”

Health care professionals' knowledge and attitudes towards antibiotic prescribing for the treatment of urinary tract infections: A systematic review

“…In an open-ended item type of question, participants are asked to articulate their responses in their own words. Depending on the nature of the assessment the responses could be brief account (Bala et al, 2022) or a more comprehensive narrative account (McCleary et al, 2021). Because the participants can express responses in many ways, openended responses are often more difficult to evaluate and may require intense coding and marking (Sam et al, 2022;Veloski et al, 1999).…”