Rational antibiotic prescribing in primary care: qualitative study of opportunities and obstacles

Logical knowledge

The importance of regular education and lectures on treatment guidelines for the diagnosis and treatment of infections was highlighted by many. This was true for doctors, nurses, and other staff at PHCCs, including child health care centres, nursing homes, and home care. The Centor’s criteria for pharyngotonsillitis were not known in some workplaces, even in 2016. Uncertainty about the guidelines might lead to increased antibiotic prescribing. Scepticism towards applying Strama’s mindset was expressed by a few:

'Everyone wants to do right, but sometimes you do not know what's right or wrong.'

'Involve ALL staff in education to ensure that patients at all levels get adequate expectations regarding antibiotics and their use.'

A folder on national updated treatment guidelines on common infections in primary care (published by Strama, the Public Health Agency of Sweden, and the Swedish Medical Products Agency of Sweden),¹¹ as well as other Strama information was highly appreciated. To serve as a knowledge support, the materials had to be in place when needed.

In case of urinary tract infections in the older patients, insufficient knowledge of current treatment guidelines, and too frequent a use of urine dipsticks might lead to far too many prescriptions, and the assistant nurse's knowledge seemed to need improvement.

Knowledge could be confirmed by case studies and quizzes from Strama:

'The answers [to case studies with didactic questions/Strama quiz] are now perceived as self-evident, and we are well aware of current guidelines for treatment.'

Practical and technical craftsmanship, logistics, and organisation

Good organisation for taking care of all kind of infections was important. Participants emphasised the importance of having enough time and not making assessments too quickly.

Staffing

Many experienced that having a stable team of medical staff, with good accessibility and continuity, promoted rational use of antibiotics. Insufficient staffing negatively influenced prescribing. High staff turnover made it difficult to maintain rational antibiotic use. Prescribing patterns that were not compliant with guidelines were described among locum physicians, especially those who were not specialised in general practice. Additionally, following locum physicians’ prescribing statistics was technically difficult. Some GPs considered introducing scheduled education sessions with future locum physicians, and some had already begun with this:

'For the past 1.5 years, we have had a larger proportion of temporary staff compared to earlier, often in short temporary positions, which made it harder to implement new guidelines throughout the staff.'

'A great improvement is that we only have long-term 'locum physicians' now, who attend our meetings and internal education.'

Revisits, drop-in surgery, and lack of time

Time pressure could increase antibiotic prescribing and there were difficulties in offering re-visit appointments. A free return visit within a week could reduce prescribing:

'The poor general availability in primary care is likely to increase antibiotic prescribing, as it is not always possible for the patients to get an appointment if they get worse.'

There were two sides of the coin; easily accessible drop-in surgery might result in too many prescriptions. This risk could, however, be overcome by well-developed routines and good cooperation among personnel. Also, patients could easily return, and antibiotics need not to be prescribed for safety’s sake:

'The increase [in prescriptions] can be explained by our high availability with drop-in surgery for emergency visits...'

'We have a drop-in reception at our PHCC, which allows us to easily assess the patient, decide to wait for treatment, and to offer re-visits/follow-ups liberally.'

Nurses and the team

The nurses’ triaging of patients seeing the doctors was emphasised, and checklists were considered to be a good tool for a uniform triage. Regularly talking with each other, and providing gentle reminders could help maintain a good way of working. With sufficient self-care advice, the patient usually waits before seeking care:

'The nurses assess some uncertain cases themselves before booking doctor visits, but it would be desirable that they could see more patients to assess if they are 'sick' enough. The fewer patients who see a doctor, the less risk they will get an antibiotic prescription.'

In wound care, the doctor was often involved at a late stage, which is why the need for cross-professional teams was highlighted:

'Here you probably have to resist demands for [bacterial] cultures and treatments to a greater extent, which goes well if you have seen the patient at the PHCC or the nursing home. However, this will be harder if it is the typical Friday afternoon telephone consultation with the district nurse.'

Clinical examination and laboratory tests

Several GPs estimated that C-reactive protein (CRP) was used too frequently, and should not be used when the general condition and vital parameters were unaffected:

'[Regarding] acute tonsillitis, the Centor-criteria are generally well followed. However, [we] frequently note cases where there were negative rapid antigen detection tests, and yet treatment [was provided], not rarely because CRP was taken for safety's sake, and then the CRP concentration was elevated and therefore treatment was initiated, because of the increased CRP concentration.'

Many informants considered rapid antigen detection tests (RADT) for beta-haemolytic streptococci group A (GAS) to be taken too often before clinical assessment of pharyngotonsillitis, especially when coughing was present. On the other hand, it was emphasised that RADT for GAS should be taken more frequently before actually prescribing antibiotics for pharyngotonsillitis. Some stated that well-trained nurses may decide to use a RADT for GAS in patients with three or more positive Centor criteria indicating pharyngotonsillitis:

'The group of GPs therefore decided that, hereafter, RADT for GAS cannot be performed on a patient without prior medical examination. This decision has been raised at a workplace meeting so that all healthcare professionals receive the same information.'

Many informants documented the general condition and vital signs, such as respiratory rate and pulse oximetry, before making decisions.

Some further success factors were liberally culturing for bacteria prior to antibiotic treatment, and more frequent use of computer tomography of the sinuses when suspecting sinusitis, tympanometry, and chlamydia tests, etc.

Enough time for current medical history and assessment was needed; these were often more conclusive than laboratory tests, and should precede sampling. The need for antibiotics should be questioned, and refraining from prescribing was often necessary in medically unaffected patients. Instead, symptomatic treatment was emphasised. In well-chosen cases, it might be appropriate to deviate from the treatment guidelines:

'Not to start with sampling [before medical assessment] is a rule that needs to be implemented at the PHCC, so that everyone does the same thing, simply.'

Patients

Patients' attitudes and expectations of receiving antibiotics might affect prescribing. Many described that over time, patients, to a greater extent, wanted to avoid antibiotics. It was time-consuming to inform patients about pros and cons of antibiotic treatments, and the normal time course of infections, especially if the patient was worried about complications when refraining from antibiotics. Written information summarising treatment guidelines, posters, and information leaflets in waiting rooms were effective and appreciated:

'We also put a lot of effort into explaining to the patient why they do not get antibiotics, as this sometimes might be a source of irritation.'

Frequent attenders and those accustomed to liberal antibiotic usage were risk groups for getting more antibiotics:

'Some patients have different antibiotics at home [bought from their home country], and they start using the medicine before they come to the visit.'

High morbidity among the population and nursing homes was perceived as resulting in higher prescribing. Seasonal variation in infection rate, number of patients during the vacation period, and the closure of nearby PHCCs were highlighted:

' ... the PHCC has expanded considerably and has suddenly gotten significantly more patients ... which means we might have become less strict with criteria for treatment due to increased stress. The newcomers also have different treatment-seeking patterns ... with higher expectations of getting treatment right away ... they have longer to drive ... which makes them less likely to return after deterioration, and then they rather want the doctor to make a prescription right away.'

Wisdom and reflective collegial dialogues

The GPs' reflective collegial dialogue was highlighted as they received practical tips from each other, and this was important in achieving rational antibiotic use. Continuous reconciliation helped to develop health care at the PHCC. Knowledge and skills had to be internalised by the clinician in order to bring about behavioural change:

' … but in order to achieve change, it is important to have a collegial group where you can safely discuss your mistakes and shortcomings … '

' ... each quarter we discussed and commented on prescription data [received quarterly from Strama VG], and reflected on why they look like they do ... it has also made us constantly active in the discussion and aware of our own prescriptions.'

These dialogues were particularly important for specialist trainees and locum physicians, leading to repeating the memorandums. Indications for antibiotic treatment were sharpened and adherence to guidelines increased. Several stressed the assiduous daily work that included continuous supervision of interns and specialist trainees. Improvements were noted without the number of mortalities increasing:

'Nothing special but we are very conscientious about providing regular Strama-updates, especially for the doctors.'

'We consider the decreasing curve [for antibiotic prescriptions] to be the fruit of our ongoing discussion of prescription patterns, policies, and routines within the GP team. We have followed the region's prescription rates, and we have monitored our own prescribing rates, and we have managed relatively well in our ambition.'

Consensus often was reached on the treatment of infections during the reflective collegial dialogues. By consensus, the prescribing was sometimes optimally low, sometimes evenly spread, but could be 'wrong' or high. Several noted differences between younger and older colleagues, presumably dependent on how to adapt to new guidelines and the use of new methods. Different cultures and traditions were also seen in the broadest sense. Others found significant differences in number of prescriptions and choice of antibiotics, especially in acute bronchitis:

'We need to continue to imprint on everyone the idea that doxycycline is not a cough medicine.'

The importance of a good climate where mistakes and deficiencies could be openly discussed was emphasised. Daring to challenge one another resulted in compelling discussions:

'There was a lively discussion about the reason [for the high prescribing rates]: ... it must be temporary doctors ... , not me, there must be someone else.'

Regularly consulting with the colleagues at the PHCC was a success factor, as well as regular tutorial of specialist trainees and interns in primary care. Nurses involved in telephone counselling, physicians, and all other staff members needed to have uniform strategies in all patient contacts.

Working with the yearly report to Strama was generally considered positive and the structure provided opportunities for yearly collegial learning with reflective meetings. The work could encourage the head of the PHCC to review local routines and improvement areas:

'The discussions were good; there was a learning atmosphere in the environment.'

The fictitious case studies provided by Strama, accompanied by didactic questions and tutor manuals, were considered meaningful and instructive, and gave close-to-realistic opportunities to reflect around their practice. There were no major problems in reaching consensus among colleagues when discussing the case studies. Strama’s prepared PowerPoint presentations, including lecture notes, were useful for internal training at the PHCC, and the quizzes together with joint discussions were well suited for internal team education. Scrutinising each other’s medical records regarding treatment of infections and comparing this with guidelines were an appreciated part of the reflective meetings. However, some expressed that the amount of medical records to scrutinise (three per doctor) was too many:

'The Strama project has a good foundation in reality and everyday life, and does not feel imposed at all, but natural. However, I think that the self-declarations [the yearly reports] should not be made more extensive than this.'

A few informants expressed that the yearly work was too extensive and stressful:

'I have probably mentioned earlier that I never liked the self-declaration because I feel I am being very micromanaged and imposed upon. If you do not do just as you are told, the PHCC loses a lot of money. At the same time, I understand that the money forces a discussion about Strama issues that may be useful.'