Understanding General Practitioners’ Antibiotic Prescribing Decisions in Out-of-Hours Primary Care: A Video-Elicitation Interview Study

Abstract

Infections are the most common reason why patients consult out-of-hours (OOH) primary care. Too often there is an overprescribing of antibiotics for self-limiting infections and general practitioners (GPs) do not always choose the guideline recommended antibiotics. To improve antibiotic prescribing quality, a better understanding is needed of the (non) antibiotic prescribing decisions of GPs. This study sets out to unravel GPs’ (non) antibiotic prescribing decisions in OOH primary care. We video-recorded 160 consultations on infections during OOH primary care by 21 GPs and performed video-elicitation interviews with each GP. GPs reflected on their decision-making process and communication while watching their consultation. A qualitative thematic analysis was used. GPs found that their (non) antibiotic prescribing decision-making was not only based on objective arguments, but also subconsciously influenced by their own interpretation of information. Often GPs made assumptions (about for example the patients’ reason for encounter or expectations for antibiotics) without objectifying or verifying this with the patient. From the beginning of the consultation GPs follow a dichotomous thinking process: urgent versus not urgent, viral versus bacterial, antibiotics versus no antibiotics. Safety-netting is an important but difficult tool in the OOH care context, with no long-term follow-up or relationship with the patient. GPs talk about strategies they use to talk about diagnostic uncertainty, what patients can expect or should do when things do not improve and the difficulties they encounter while doing this. This video- elicitation interview study provides actionable insights in GPs’ (non) antibiotic prescribing decisions during OOH consultations on infections.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care

“…The narrative "it's a viral infection, you don't need an antibiotic" confirms the dichotomized thinking of GPs during consultations of RTIs (bacterial vs. viral infection/antibiotics vs. no antibiotics) (31) and also ignores the fact that bacterial infection does not always benefit from antibiotics. GPs seem to assume that the reason a patient visits the GP on call with an RTI, amongst others, is receiving an antibiotic, by delivering the diagnosis directly linked to the non-antibiotic management plan, which is well-accepted by patients.…”

“…Some of the videos were used in a previous study for the purpose of elicitation interviews ( 31 ) and the complete study setup is described in a separate paper ( 49 ).…”

“…The GP, patient, and consultation characteristics were collected. Some of the videos were used in a previous study for the purpose of elicitation interviews (31) and the complete study setup is described in a separate paper (49). We used a combined deductive and inductive framework analysis with a descriptive approach (51).…”

“…The way patients present their problem has been shown to be a predictor of receiving an antibiotic, such as using a candidate diagnosis ( 13 , 15 , 28 ) or discussing or justifying the need for a consultation ( 29 , 30 ). GPs make assumptions about why the patient consults ( 31 ), and often overestimate patient expectations for antibiotics ( 28 , 32 ). Research has shown that patients with an infection consult because of unpleasant symptoms, the perceived need for action, obtaining symptomatic treatment, or concerns about illness severity.…”

Editorial: Antibiotics Special Issue on the Use of Antibiotics in Primary Care

“…For example, in this Special Issue, different qualitative studies shed light on context-specific factors that need to be taken into consideration to advance the implementation of relevant and effective interventions. Colliers et al [ 4 ] provide a rich understanding of the delivery of OOH services in Belgium; using an innovative qualitative approach (i.e., video elicitation interviews). They show that GPs make assumptions about patients’ reasons for seeking health care without objectifying or verifying such assumptions with the patient.…”