Can Private Provision of Primary Care Contribute to the Spread of Antibiotic Resistance? A Study of Antibiotic Prescription in Sweden

Abstract

Background Growing rates of antibiotic resistance, caused by increasing antibiotic use, pose a threat by making antibiotics less effective in treating infections. Objective We aimed to study whether physicians working at privately and publicly owned health centres differed in the likelihood of prescribing antibiotics and choosing broad-spectrum over narrow-spectrum antibiotics. Methods To estimate the effect of ownership on the probability of a prescribed drug being an antibiotic, we analysed all 4.5 million prescriptions issued from 2011 to 2015 at primary health centres in Västerbotten, Sweden. We controlled for patient age, sex, number of prescriptions per patient, and month of prescription, and used a maximum likelihood logit estimator. We then analysed how ownership affected the likelihood of a prescribed antibiotic being broad spectrum. We also used aggregated data to estimate the impact of the number of private health centres on the number of antibiotic prescriptions per inhabitant and the proportion of broad-spectrum antibiotics. Results Holding other factors constant, private physicians were 6% more likely to prescribe antibiotics and 9% more likely to choose broad-spectrum antibiotics. An increase by one additional private health centre was positively associated with an increase in the number of antibiotic prescriptions per inhabitant and a higher proportion, although not significant, of broadspectrum antibiotic prescriptions. Conclusion Our findings suggest that private physicians prescribe more antibiotics, especially broad-spectrum antibiotics, than public physicians. Therefore, it is crucial to provide health centres with incentives to follow guidelines for antibiotic prescription, especially when the level of private provision of primary healthcare is high.

Fifteen years with patient choice and free establishment in Swedish primary healthcare: what do we know?

“…Due to a lack of case-mix the authors could not rule out that the differences could be explained by differences in patient characteristics. However, the same pattern was found by Granlund and Zykova [ 59 ] in a register study from one region. The results showed that physicians employed at private PHC centres were 6% more likely to prescribe antibiotics and 9% more likely to prescribe broad-spectrum antibiotics compared to physicians employed at public PHC centres.…”

“…A few studies have investigated differences between private and public PHC centres, of which three studies investigated prescription patterns and/or perceived quality. The prescription of antibiotics was investigated by Maun et al [ 58 ] and Granlund and Zykova [ 59 ]. In the study by Maun et al [ 58 ], the authors found a higher prescription rate of antibiotics for private PHC centres (6.0 vs. 5.1 prescriptions per 100 individuals in a quarter) but a lower prescription rate of benzodiazepines.…”

Exploring the social ecology for appropriate antibiotic prescribing and stewardship in primary care: presenting the VALUE driven model of practice derived from qualitative analysis of public and private care settings in Singapore

“…Nevertheless, there remains a powerful need to 'connect the dots' by providing a realist [39], applied and evidence-based conceptual model that maps the social ecology and potential areas for intervention to improve appropriate antibiotic prescribing. A recent study conducted in Sweden found that doctors in private practice were 6% more likely to prescribe antibiotics as compared to doctors in public practice [40], with a similar trend observed from another cross-sectional study conducted in Malaysia [41]. Instead of dissecting and addressing the issue of inappropriate antibiotic prescribing by different primary care funding structures, the current study offers a comprehensive exploration across private and public sectors.…”

Trends in Antibiotic Use in Danish, Finnish, Norwegian and Swedish Children

“…41 This may in part explain the high antibiotic use in Finland as private providers may be more willing to prescribe antibiotics to secure patient satisfaction. 42 , 43 …”

“…41 This may in part explain the high antibiotic use in Finland as private providers may be more willing to prescribe antibiotics to secure patient satisfaction. 42,43 It has previously been found that antibiotic prescription rates and classes of antibiotics vary between different settings, which might be attributed to different guidelines and habits of prescriptions. 44 The high use of penicillins with extended spectrum in Finland is related to guidelines recommending amoxicillin (a penicillin with extended spectrum) as the first-line therapy for the treatment of otitis media.…”