Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices

Abstract

Background Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. Methods This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. Results Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience – participants viewed the strategies as having limited value as ‘clinical tools’, perceiving them as useful only in ‘rare’ instances of clinical uncertainty and/or for those less experienced. Strategies as ‘social tools’ – participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities – participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context – various other situational and practical issues were raised with implementing the strategies. Conclusions High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful ‘clinical tools’ in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as ‘social tools’ to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.

Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice

“…Given that much existing qualitative research with healthcare professionals about AMS strategies was within trials and unspecific to implementation or high-prescribing practices, we conducted our own qualitative research. The methods of this focus group study are reported in detail elsewhere [ 26 ]. In brief, we held nine focus groups with 50 professionals (3–11 per practice) in high-prescribing practices (i.e.…”

“…Influences on antibiotic prescribing: We fully report the identified influences on antibiotic prescribing and optimisation in our review of qualitative studies in the UK [ 34 , 35 ], our focus group study in high-prescribing practices [ 26 ] and in Supplementary File 1 . From these, we selected influences considered important, modifiable by an intervention and most feasible to address.…”

“…Views on & use of strategies 21. Access to resources to use strategies 3 AMS strategies 3 AMS strategies, resources Additional influences identified in the focus groups in relation to POC-CRPT and DP [ 26 ] 22. Perceived fit of strategies with clinical roles and experience 23.…”

“…We also decided not to offer the 10-min POC-CRPT as it was deemed too time-consuming by clinicians. In our focus groups [ 26 ], we found that an important barrier to using POC-CRPT and DPs was ambiguity about evidence and when, and how, to use the strategies; and professionals in our workshops and think-aloud interviews asked for evidence and clear guidelines on using these strategies. Consequently, we needed to strike a balance between making the intervention short and not losing important content, and between providing evidence and guidance while allowing flexibility and autonomy.…”

Social and Contextual Influences on Antibiotic Prescribing and Antimicrobial Stewardship: A Qualitative Study with Clinical Commissioning Group and General Practice Professionals

“…We found that deprived and ethnic minority populations were perceived as needing more antibiotics, as clinicians consider the wider context of patients' lives, such as their (perceived) ability to self-care, reconsult if needed, risk of complications, and the impact of not working. This illustrates the role of perceptions of general practice clinicians in considering and treating patients holistically [25]. Participants also suggested that higher prescribing might be more likely in situations when explaining non-prescribing decisions to patients is difficult, for example, due to cultural understandings and spoken languages.…”