Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Abstract

Background How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Coronavirus Disease 2019 Vaccination Is Associated With Reduced Outpatient Antibiotic Prescribing in Older Adults With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2: A Population-Wide Cohort Study

“…Perhaps this is due to prescribers treating patients based on severity of illness, and concern that bacterial infection may underlie the symptoms. This theory is compatible with the multitude of contextual factors that influence antibiotic prescribing [ 32 ]. As a sensitivity analysis, shifting index date later did result in a slight decline in postdiagnosis prescribing in the community cohort, though still substantially elevated from baseline.…”

General practitioners’ role in safeguarding patients with dementia in their use of dietary supplements. A qualitative study

“…Several studies have shown that the most common reason for non-disclosure of DS use is that healthcare personnel do not ask [ 4 , 14 ]. GPs’ practice style affects patients [ 31 ] and clinical decision making varies between medical doctors even in comparable situations [ 21 , 32 ]. This includes medical tasks that are not done, such as not obtaining sufficient anamnestic information and sufficient medical examinations as shown in another study [ 33 ].…”

“…Especially when the likelihood of risk is unknown, lack of knowledge promotes pessimistic appraisals of risk as well as avoidance of decision-making [ 35 , 36 ]. Uncertainty is known to affect medical practice [ 21 ]. One problem in dealing with this uncertainty, may be the lack of communication between GPs regarding DS.…”

“…The efficiency and quality of the Nordic primary care models are documented [ 19 ]. Even so, GPs may experience and manage uncertainty and ambiguity as an integrated part of daily work, especially when working under conditions of limited time and resources, and they often experience doubts concerning their clinical decisions [ 21 ]. This is especially true when it comes to patients with dementia [ 22 ].…”

Developing a model for decision-making around antibiotic prescribing for patients with COVID-19 pneumonia in acute NHS hospitals during the first wave of the COVID-19 pandemic: qualitative results from the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients (PEACH Study)

“…Roope et al 10 concluded that revising antibiotic guidelines to be less prescriptive about duration and making duration conditional on patient factors and treatment response could help safely increase the frequency of early discontinuation of antibiotics in hospitals. Al-Azzawi et al 11 highlight the need for context to be taken into account in theories of medical decision-making, which would impact education, clinical practice and policymaking. However, there is no universally accepted definition of context in medical terms.…”