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BMC Health Services Research
Published in: BMC Health Services Research 1/2024

Open Access 01-12-2024 | Antibiotic | Research

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

Authors: Benjamin Schüz, Oliver Scholle, Ulrike Haug, Roland Tillmann, Christopher Jones

Published in: BMC Health Services Research | Issue 1/2024

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Abstract

Background

Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

Methods

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30–61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

Results

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

Conclusions

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.
Appendix
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Literature
1.
2.
Baede VO, David MZ, Andrasevic AT, Blanc DS, Borg M, Brennan G, et al. MRSA surveillance programmes worldwide: moving towards a harmonised international approach. Int J Antimicrob Agents. 2022;59:106538.CrossRefPubMed
3.
European Antimicrobial Resistance Collaborators. The burden of bacterial antimicrobial resistance in the WHO European region in 2019: a cross-country systematic analysis. Lancet Public Health. 2022;7:e897–913.CrossRef
4.
Chatterjee A, Modarai M, Naylor NR, Boyd SE, Atun R, Barlow J, et al. Quantifying drivers of antibiotic resistance in humans: a systematic review. Lancet Infect Dis. 2018;18:e368–78.CrossRefPubMed
5.
Kern WV. Rationale Antibiotikaverordnung in Der Humanmedizin. Bundesgesundheitsbl. 2018;61:580–8.CrossRef
6.
7.
Goossens H, Ferech M, Stichele RV, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579–87.CrossRefPubMed
8.
Zweigner J, Meyer E, Gastmeier P, Schwab F. Rate of antibiotic prescriptions in German outpatient care - are the guidelines followed or are they still exceeded? GMS Hyg Infect Control. 2018;13:Doc04.PubMedPubMedCentral
9.
Poss-Doering R, Kronsteiner D, Kamradt M, Andres E, Kaufmann-Kolle P, Wensing M, et al. Antibiotic prescribing for acute, non-complicated infections in primary care in Germany: baseline assessment in the cluster randomized trial ARena. BMC Infect Dis. 2021;21:877.CrossRefPubMedPubMedCentral
10.
European Centre for Disease Prevention and Control. Antimicrobial consumption in the EU/EEA (ESAC-Net) - Annual Epidemiological Report for 2021. Stockholm: European Centre for Disease Prevention and Control; 2022.
11.
Scholle O, Asendorf M, Buck C, Grill S, Jones C, Kollhorst B et al. Regional variations in Outpatient Antibiotic Prescribing in Germany: a small area analysis based on Claims Data. Antibiotics. 2022;11.
12.
13.
Filippini M, Masiero G, Moschetti K. Socioeconomic determinants of regional differences in outpatient antibiotic consumption: evidence from Switzerland. Health Policy. 2006;78:77–92.CrossRefPubMed
14.
Devine P, O’Kane M, Bucholc M. Trends, Variation, and factors influencing antibiotic prescribing: a longitudinal study in primary care using a Multilevel Modelling Approach. Antibiot (Basel). 2021;11:17.CrossRef
15.
van der Roof I, Oude Boerrigter L, Wielders CCH, Smit LAM. Use of antibiotics among residents living close to Poultry or Goat farms: a nationwide analysis in the Netherlands. Antibiot (Basel). 2021;10:1346.CrossRef
16.
Huibers L, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB. Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study. Scand J Prim Health Care. 2022;40:227–36.CrossRefPubMedPubMedCentral
17.
Bizune D, Tsay S, Palms D, King L, Bartoces M, Link-Gelles R, et al. Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract infections in a commercially insured Population, United States, 2017. Open Forum Infect Dis. 2023;10:ofac584.CrossRefPubMedPubMedCentral
18.
Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open. 2023;13:e065006.CrossRefPubMedPubMedCentral
19.
Lescure DLA, van Oorschot W, van der Brouwer R, Tjon-A-Tsien AML, Bonnema IV, et al. Providing antibiotics to immigrants: a qualitative study of general practitioners’ and pharmacists’ experiences. BMC Prim Care. 2022;23:100.CrossRefPubMedPubMedCentral
20.
21.
Schüz B, Jones C, Scholle O, Haug U. Regional variations in antibiotic prescribing in Germany: understanding differences through an adapted theoretical domains Framework. Health psychology for all: Equity, Inclusiveness and Transformation. Bremen, Germany: European Health Psychology Society; 2023. p. 280.
22.
Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.CrossRefPubMedPubMedCentral
23.
Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the theoretical domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.CrossRefPubMedPubMedCentral
24.
Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26–33.CrossRefPubMedPubMedCentral
25.
Courtenay M, Rowbotham S, Lim R, Peters S, Yates K, Chater A. Examining influences on antibiotic prescribing by nurse and pharmacist prescribers: a qualitative study using the theoretical domains Framework and COM-B. BMJ Open. 2019;9:e029177.CrossRefPubMedPubMedCentral
26.
Bursey K, Hall A, Pike A, Etchegary H, Aubrey-Bassler K, Patey AM, et al. Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the theoretical domains Framework. BMJ Open. 2022;12:e066681.CrossRefPubMedPubMedCentral
27.
Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf PV, Al-Hail M, et al. Investigating clinicians’ determinants of antimicrobial prescribing behaviour using the theoretical domains Framework. J Hosp Infect. 2022;122:72–83.CrossRefPubMed
28.
Sargent L, McCullough A, Del Mar C, Lowe J. Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the theoretical domains Framework and the Behaviour Change Wheel. BMC Fam Pract. 2017;18:20.CrossRefPubMedPubMedCentral
29.
Commission Regulation (EU). 2016/2066 of 21 November 2016 amending the annexes to Regulation (EC) No 1059/2003 of the European Parliament and of the Council on the establishment of a common classification of territorial units for statistics (NUTS). 2016.
30.
31.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3:77–101.CrossRef
32.
Kuckartz U, Rädiker S. Analyzing qualitative data with MAXQDA: text, Audio, and video. Cham: Springer International Publishing; 2019.CrossRef
33.
Leyland AH, Groenewegen PP, Context. Composition and how their influences vary. In: Leyland AH, Groenewegen PP, editors. Multilevel Modelling for Public Health and Health Services Research: Health in Context. Cham: Springer International Publishing; 2020. pp. 107–22.CrossRef
34.
Bornemann R, Tillmann R. [Antibiotic therapy in Bielefeld (AnTiB)-a local project for the promotion of rational antibiotic prescribing in the outpatient paediatric sector]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2019;62:952–9.CrossRefPubMed
35.
Stedman M, Lunt M, Davies M, Fulton-McAlister E, Hussain A, van Staa T, et al. Controlling antibiotic usage—A national analysis of General Practitioner/Family Doctor practices links overall antibiotic levels to demography, geography, comorbidity factors with local discretionary prescribing choices. Int J Clin Pract. 2020;74:e13515.CrossRefPubMed
36.
Simon M, Thilly N, Pereira O, Pulcini C. Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases. Clinical Microbiology and Infection. 2022;28:609.e1-609.e6.
37.
Poss-Doering R, Kamradt M, Glassen K, Andres E, Kaufmann-Kolle P, Wensing M. Promoting rational antibiotic prescribing for non-complicated infections: understanding social influence in primary care networks in Germany. BMC Fam Pract. 2020;21:51.CrossRefPubMedPubMedCentral
38.
Neugebauer M, Ebert M, Vogelmann R. [Lack of information and provision of information at the workplace as potential reasons for inappropriate antibiotic therapy in Germany]. Z Evid Fortbild Qual Gesundhwes. 2019;144–145:35–41.CrossRefPubMed
39.
Petruschke I, Stichling K, Greser A, Gagyor I, Bleidorn J. [The general practitioner perspective of a multimodal intervention for the adequate use of antibiotics in urinary tract infection - a qualitative interview study]. Z Evid Fortbild Qual Gesundhwes. 2022;170:1–6.CrossRefPubMed
40.
McKay R, Law M, McGrail K, Balshaw R, Reyes R, Patrick DM. What can we learn by examining variations in the use of urine culture in the management of acute cystitis? A retrospective cohort study with linked administrative data in British Columbia, Canada, 2005–2011. PLoS One. 2019;14:e0213534.
41.
42.
Kim NN, Marikar D. Antibiotic prescribing for upper respiratory tract infections: NICE guidelines. Archives Disease Child - Educ Pract. 2020;105:104–6.CrossRef
43.
de Bont EGPM, Alink M, Falkenberg FCJ, Dinant G-J, Cals JWL. Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review. BMJ Open. 2015;5:e007612.CrossRefPubMedPubMedCentral
44.
O’Sullivan JW, Harvey RT, Glasziou PP, McCullough A. Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care. Cochrane Database Syst Rev. 2016;11:CD011360.PubMed
45.
Biezen R, Ciavarella S, Manski-Nankervis J-A, Monaghan T, Buising K. Addressing Antimicrobial stewardship in primary care-developing patient information sheets using Co-design Methodology. Antibiot (Basel). 2023;12:458.CrossRef
Metadata
Title
Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers
Authors
Benjamin Schüz
Oliver Scholle
Ulrike Haug
Roland Tillmann
Christopher Jones
Publication date
01-12-2024
Publisher
BioMed Central
Keyword
Antibiotic
Published in
BMC Health Services Research / Issue 1/2024
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-024-11059-z

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