General practitioner and nurse prescriber experiences of prescribing antibiotics for respiratory tract infections in UK primary care out-of-hours services (the UNITE study)

Abstract

BackgroundInterventions are needed to reduce unnecessary antibiotic prescribing for respiratory tract infections (RTIs). Although community antibiotic prescribing appears to be decreasing in the UK, figures for out-of-hours (OOH) prescribing have substantially increased. Understanding the factors influencing prescribing in OOH and any perceived differences between general practitioner (GP) and nurse prescriber (NP) prescribing habits may enable the development of tailored interventions promoting optimal prescribing in this setting.ObjectivesTo explore UK GP and NP views on and experiences of prescribing antibiotics for RTIs in primary care OOH services.MethodsThirty semi-structured interviews were conducted with GPs and NPs working in primary care OOH services. Inductive thematic analysis was used to analyse data.ResultsThe research shows that factors particular to OOH influence antibiotic prescribing, including a lack of patient follow-up, access to patient GP records, consultation time, working contracts and implementation of feedback, audit and supervision. NPs reported perceptions of greater accountability for their prescribing compared with GPs and reported they had longer consultations during which they were able to discuss decisions with patients. Participants agreed that more complex cases should be seen by GPs and highlighted the importance of consistency of decision making, illness explanations to patients as well as a perception that differences in clinical training influence communication with patients and antibiotic prescribing decisions.ConclusionsEnvironmental and social factors in OOH services and a mixed healthcare workforce provide unique influences on antibiotic prescribing for RTIs, which would need to be considered in tailoring interventions that promote prudent antibiotic prescribing in OOH services.

The prescribing needs of community practitioner nurse prescribers: A qualitative investigation using the theoretical domains framework and COM‐B

“…However, these studies have focused on antibiotic prescribing behaviour. Relationships with other prescribers and knowledge of current guidelines (Rowbotham et al, 2012;Williams et al, 2018), diagnostic uncertainty and the clinical condition of the patient (Abbo, Smith, Pereyra, Wyckoff, & Hooton, 2012;Adorka, Dikokole, Mitonga, & Allen, 2013;Rowbotham et al, 2012), in addition to patient expectations for a medicine (Adorka et al, 2013;Rowbotham et al, 2012), evidenced-based guidelines, experience and clinical complications (Philp & Winfield, 2010), peer and organizational support and patient contact (Offredy, Kendall, & Goodman, 2008) have each been reported as important influences.…”

How do general practitioners and pharmacists experience antibiotic use in out-of-hours primary care? An exploratory qualitative interview study to inform a participatory action research project

“… 5–7 The interest in antibiotic prescribing in OOH care and possible corresponding interventions is growing internationally. 8–13 The results of earlier intervention studies show us a rather limited positive effect on antibiotic prescribing in size, quality and time. These observations evoke the hypothesis that top-down intervention might have only small results.…”

“… 20–23 When working on interventions to improve antibiotic prescribing, studying and reflecting on the specifics of the context and setting are important to come up with tailored bottom-up supported solutions. 8 22 24 25 To optimise the quality of GPs’ antibiotic prescribing behaviour in OOH care, a better understanding of the present attitudes as well as interventions that build on this knowledge is needed. Prescribing behaviour is about making a diagnosis and implementing a treatment plan, and about social interactions in a specific context.…”

What Resources Do NHS Commissioning Organisations Use to Support Antimicrobial Stewardship in Primary Care in England?

“…Resources to support AMS should be promoted across the whole health economy, for example, community pharmacists, OOH staff, school nurses, care homes, as AMS leads reported mainly promoting TARGET leaflets and education to GP staff. Education across healthcare is important as OOHs and care homes are often reported as areas of greater prescribing [3,26], yet respondents in the present study reported that they were not supported as well as other groups. Monitoring uptake of initiatives could be facilitated through local engagement schemes, which over 70% of CCGs reported having [23], as practitioners have to provide evidence of how they meet the requirements of the scheme, such as attending AMS education/training.…”