Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Primary Care
Published in: BMC Primary Care 1/2021

Open Access 01-12-2021 | Antibiotic | Research article

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Authors: Resha Al-Azzawi, Peder A. Halvorsen, Torsten Risør

Published in: BMC Primary Care | Issue 1/2021

Login to get access

Abstract

Background

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

Method

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

Results

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades.
Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

Conclusion

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.
Appendix
Available only for authorised users
Literature
1.
Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39(4):418–27.PubMed
2.
Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: theory and implication [published correction appears in Acad Med 1992 Apr;67(4):287]. Acad Med. 1990;65(10):611–21.PubMed
3.
Elstein AS, Schulman LS, Sprafka SA. Medical problem solving: an analysis of clinical reasoning. Cambridge: Harvard University Press; 1978.
4.
Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic reasoning strategies and diagnostic success. Med Educ. 2003;37(8):695–703.PubMed
5.
Cook DA, Sherbino J, Durning SJ. Management reasoning: beyond the diagnosis. JAMA. 2018;319(22):2267–8.PubMed
6.
Cook DA, Durning SJ, Sherbino J, Gruppen LD. Management reasoning: implications for health professions educators and a research agenda. Acad Med. 2019;94(9):1310–6.PubMed
7.
Foot C, Naylor C, Imison C. The quality of GP diagnosis and referral: The King’s Fund Publication; 2010.
8.
O’Donnell CA. Variation in GP referral rates: what can we learn from the literature? Fam Pract. 2000;17:462–71.PubMed
9.
Baker R, Lecouturier J, Bond S. Explaining variation in GP referral rates for x-rays for back pain. Implementation Sci. 2006;1:15.
10.
Morrison J, Anderson MJ, Sutton M, et al. Factors influencing variation in prescribing of antidepressants by general practices in Scotland. Br J Gen Pract. 2009;59(559):e25–31.PubMedPubMedCentral
11.
Sleath B, Shih YC. Sociological influences on antidepressant prescribing. Soc Sci Med. 2003;56(6):1335–44.PubMed
12.
Durning S, Artino AR Jr, Pangaro L, et al. Context and clinical reasoning: understanding the perspective of the expert’s voice. Med Educ. 2011;45(9):927–38.PubMed
13.
Weiner SJ, Schwartz A. Contextual errors in medical decision making: overlooked and understudied. Acad Med. 2016;91(5):657–62.PubMed
14.
Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at chicago area veterans health administration sites. Acad Med. 2017;92:1287–93.PubMed
15.
Weiner SJ, Schwartz A, Sharma G, et al. Patient-centred decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573–9.PubMed
16.
Schwartz A, Weiner SJ, Weaver F, et al. Uncharted territory: measuring the costs of diagnostic errors outside the medical record. BMJ Qual Saf. 2012;21:918–24.PubMed
17.
Ulrich RS, Giplin L. Healing arts: nutrition for the soul. In: Frampton SB, Giplin L, Charmel P, editors. Putting patients first: designing and practicing patient centered care 2003. San Francisco: Jossey-Bass; 2003. p. 117e46.
18.
Choi J-H, Beltran LO, Kim H-S. Impacts of indoor daylight environments on patient average length of stay (ALOS) in a healthcare facility. Build Environ. 2012;50:65e75.
19.
Beauchemin KM, Hays P. Dying in the dark: sunshine, gender and outcomes in myocardial infarction. J R Soc Med. 1998;91(7):352e4.
20.
Strumiło, Chlabicz S, Pytel-Krolczuk B, et al. Combined assessment of clinical and patient factors on doctors’ decisions to prescribe antibiotics. BMC Family Practice. 2016;17:63.PubMedPubMedCentral
21.
Turnbull S, Lucas PJ, Redmond NM, et al. What gives rise to clinician gut feeling, its influence on management decisions and its prognostic value for children with RTI in primary care: a prospective cohort study. BMC Fam Pract. 2018;19:25.PubMedPubMedCentral
22.
Public Health England. English Surveillance Programme for Antimicrobial Utilisation & Resistance (ESPAUR) Report 2019-2020. UK: DOH; 2020.
23.
CDC. Antibiotic resistance threats in the United States. Atlanta: U.S. Department of Health & Human Services; 2019.
24.
25.
Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–73.PubMed
26.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
27.
Petursson P. GPs’ reasons for “non-pharmacological” prescribing of antibiotics. A phenomenological study. Scand J Prim Health Care. 2005;23(2):120–5.PubMed
28.
Tsiantou V, Shea S, Martinez L, et al. Eliciting general practitioners’ salient beliefs towards prescribing: a qualitative study based on the theory of planned behaviour in Greece. J Clin Pharm Ther. 2013;38(2):109–14.PubMed
29.
Cordoba G, Siersma V, Lopez-Valcarcel B, et al. Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries. BMC Fam Pract. 2015;16:7.PubMedPubMedCentral
30.
Strandberg EL, Brorsson A, Hagstam C, et al. “I’m Dr Jekyll and Mr Hyde”: are GPs’ antibiotic prescribing patterns contextually dependent? A qualitative focus group study. Scand J Prim Health Care. 2013;31(3):158–65.PubMedPubMedCentral
31.
Aabenhus R, Siersam V, Sandholt H, et al. Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice. J Antimicrob Chemother. 2017;72(8):2385–91.PubMed
32.
Jaruseviciene L, Radzeviciene-Jurgute R, Lazarus JV, et al. A study of antibiotic prescribing: the experience of Lithuanian and Russian GPs. Cent Eur J Med. 2012;7:790–9.
33.
Mazzaglia G, Caputi AP, Rossi A, et al. Exploring patient- and doctor-related variables associated with antibiotic prescribing for respiratory infections in primary care. Eur J Clin Pharmacol. 2003;59:651–7.PubMed
34.
Loikas D, Karlsson L, von Euler M, et al. Does patient’s sex influence treatment in primary care? Experiences and expressed knowledge among physicians--a qualitative study. BMC Fam Pract. 2015;16:137.PubMedPubMedCentral
35.
Schattner A. Are physicians’ decisions affected by multiple nonclinical factors? Intern Med. 2014;4(3):1–11.
36.
Kumar S, Little P, Britten N. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ. 2003;326(7381):138.PubMedPubMedCentral
37.
Mousquès J, Renaud T, Scemama O. Is the “practice style” hypothesis relevant for general practitioners? An analysis of antibiotics prescription for acute rhinopharyngitis. Soc Sci Med. 2010;70(8):1176–84.PubMed
38.
Eggermont D, Smit MAM, Kwestroo GA, Verheij RA, et al. The influence of gender concordance between general practitioner and patient on antibiotic prescribing for sore throat symptoms: a retrospective study. BMC Fam Pract. 2018;19:175.PubMedPubMedCentral
39.
Björnsdóttir I, Holme Hansen E. Intentions, strategies and uncertainty inherent in antibiotic prescribing. Eur J Gen Pract. 2009;8(1):18–24.
40.
Di Caccavo A, Reid F. Decisional conflict in general practice: Strategies of patient management. Soc. Sci. Med. 1995;41(3):347–53.PubMed
41.
Drewniak D, Krones T, Sauer C, et al. The influence of patients’ immigration background and residence permit status on treatment decisions in health care. Results of a factorial survey among general practitioners in Switzerland. Soc Sci Med. 2016;161:64–73.PubMed
42.
Scott A, Shiell A, King M. Is general practitioner decision making associated with patient socio-economic status? Soc Sci Med. 1996;42(1):35–46.PubMed
43.
Portnoy DB, Han PK, Ferrer RA, et al. Physicians’ attitudes about communicating and managing scientific uncertainty differ by perceived ambiguity aversion of their patients. Health Expect. 2013;16(4):362–72.PubMed
44.
Geneau R, Lehoux P, Pineault R, et al. Understanding the work of general practitioners: a social science perspective on the context of medical decision making in primary care. BMC Fam Pract. 2008;9:12.PubMedPubMedCentral
45.
Horwood J, Cabral C, Hay AD, et al. Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study. Br J Gen Pract. 2016;66(644):e207–13.PubMedPubMedCentral
46.
Björnsdóttir I, Hansen EH. Ethical dilemmas in antibiotic prescribing: analysis of everyday practice. J Clin Pharm Ther. 2002;27(6):431–40.PubMed
47.
Coenen S, Michiels B, Van Royen P, et al. Antibiotics for coughing in general practice: a questionnaire study to quantify and condense the reasons for prescribing. BMC Fam Pract. 2002;3:16.PubMedPubMedCentral
48.
Chauhan BF, Jeyaraman MM, Mann AS, et al. Behavior change interventions and policies influencing primary healthcare professionals’ practice-an overview of reviews. Implement Sci. 2017;12(1):3.PubMedPubMedCentral
49.
Weiss MC, Fitzpatrick R, Scott DK, et al. Pressures on the general practitioner and decisions to prescribe. Fam Pract. 1996;13(5):432–8.PubMed
50.
Williams SJ, Halls AV, Tonkin-Crine S, Moore MV, et al. General practitioner and nurse prescriber experiences of prescribing antibiotics for respiratory tract infections in UK primary care out-of-hours services (the UNITE study). J Antimicrob Chemother. 2018;73(3):795–803.PubMed
51.
Bradley CP. Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners. Br J Gen Pract. 1992;42(364):454–8.PubMedPubMedCentral
52.
Ashdown HF, Räisänen U, Wang K, et al. Prescribing antibiotics to ‘at-risk’ children with influenza-like illness in primary care: qualitative study. BMJ Open. 2016;6:e011497.PubMedPubMedCentral
53.
McIsaac WJ, Goel V. Sore throat management practices of Canadian family physicians. Fam Pract. 1997;14(1):34–9.PubMed
54.
Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ. 1998;317(7159):637–42.PubMedPubMedCentral
55.
Nazareth I, King M. Decision making by general practitioners in diagnosis and management of lower urinary tract symptoms in women. BMJ. 1993;306:1103.PubMedPubMedCentral
56.
Stocks NP, Fahey T. The treatment of acute bronchitis by general practitioners in the UK. Results of a cross sectional postal survey. Aust Fam Physician. 2002;31(7):676–9.PubMed
57.
Macfarlane J, Holmes W, Macfarlane R, et al. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315(7117):1211–4.PubMedPubMedCentral
58.
McIsaac WJ, To T. Antibiotics for lower respiratory tract infections. Still too frequently prescribed? Can Fam Physician. 2004;50:569–75.PubMedPubMedCentral
59.
Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotic prescribing for acute cough: the effect of perceived patient demand. Br J Gen Pract. 2006;56(524):183–90.PubMedPubMedCentral
60.
Hajjaj FM, Salek MS, Basra MK, et al. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice. J R Soc Med. 2010;103(5):178–87.PubMedPubMedCentral
61.
Sirota M, Round T, Samaranayaka S, et al. Expectations for antibiotics increase their prescribing: causal evidence about localized impact. Health Psychol. 2017;36(4):402–9.PubMed
62.
Hardy-Holbrook R, Aristidi S, Chandnani V, et al. Antibiotic resistance and prescribing in Australia: current attitudes and practice of GPs. Infect Dis Health. 2013;18(4):147–51.
63.
Akkerman AE, Kuyvenhoven MM, van der Wouden JC, et al. Determinants of antibiotic overprescribing in respiratory tract infections in general practice. J Antimicrob Chemother. 2005;56(5):930–6.PubMed
64.
Miller E, Mackeigan LD, Rosser W, et al. Effects of perceived patient demand on prescribing anti-infective drugs. CMAJ. 1999;161(2):139–42.PubMedPubMedCentral
65.
Denig P, Witteman CL, Schouten HW. Scope and nature of prescribing decisions made by general practitioners. Qual Saf Health Care. 2002;11(2):137–43.PubMedPubMedCentral
66.
Duane S, Domegan C, Callan A, Galvin S, et al. Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections. BMJ Open. 2016;6:e008894.PubMedPubMedCentral
67.
Jaye C, Tilyard M. A qualitative comparative investigation of variation in general practitioners’ prescribing patterns. Br J Gen Pract. 2002;52(478):381–6.PubMedPubMedCentral
68.
Buusman A, Andersen M, Merrild C, et al. Factors influencing GPs’ choice between drugs in a therapeutic drug group. A qualitative study. Scand J Prim Health Care. 2007;25(4):208–13.PubMedPubMedCentral
69.
Mason A. New medicines in primary care: a review of influences on general practitioner prescribing. J Clin Pharm Ther. 2008;33(1):1–10.PubMed
70.
Jacoby A, Smith M, Eccles M. A qualitative study to explore influences on general practitioners’ decisions to prescribe new drugs. Br J Gen Pract. 2003;53(487):120–5.PubMedPubMedCentral
71.
Garcia-Retamero R, Galesic M. On defensive decision making how doctors make decisions for their patients. Health Expect. 2014;17(5):664–9.PubMed
72.
Björnsdóttir I, Kristinsson KG, Hansen EH. Diagnosing infections: a qualitative view on prescription decisions in general practice over time. Pharm World Sci. 2010;32:805–14.PubMed
73.
De Sutter AI, De Meyere MJ, De Maeseneer JM, et al. Antibiotic prescribing in acute infections of the nose or sinuses: a matter of personal habit? Fam Pract. 2001;18(2):209–13.PubMed
74.
Larsen PO, von Ins M. The rate of growth in scientific publication and the decline in coverage provided by science citation index. Scientometrics. 2010;84(3):575–603.PubMedPubMedCentral
75.
Geertz C. Chapter 1: thick description: toward an interpretive theory of culture. In: The interpretation of cultures: selected essays. New York: Basic Books; 1973.
76.
Thaler RH, Sunstein CR and Balz JP. Choice architecture. The behavioural foundations of public policy, ch. 25, elder Shafir, ed. 2012.
77.
McWhinney IR. An Acquaintance with particulars. Fam Med. 1989;21(4):296–8.PubMed
78.
Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet. 2001;358:397–400.PubMed
79.
80.
Durning S, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE guide no. 52. Med Teach. 2011;33:188–99.PubMed
81.
ten Cate O, Durning SJ. Understanding clinical reasoning from multiple perspectives: a conceptual and theoretical review. In: ten Cate O, Custer E, Durning S, editors. Principles and practice of case-based clinical reasoning education: a method for preclinical students: Springer International Publishing; 2018. p. 35–46.
82.
Reilly BM, Evans AT, Schaider JJ, et al. Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department. JAMA. 2002;288(3):342–50.PubMed
83.
84.
Haynes RB, Devereaux PJ, Guyatt GH. Clinical expertise in the era of evidence-based medicine and patient choice. BMJ Evid Based Med. 2002;7:36–78.
85.
Metadata
Title
Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing
Authors
Resha Al-Azzawi
Peder A. Halvorsen
Torsten Risør
Publication date
01-12-2021
Publisher
BioMed Central
Keyword
Antibiotic
Published in
BMC Primary Care / Issue 1/2021
Electronic ISSN: 2731-4553
DOI
https://doi.org/10.1186/s12875-021-01574-x

Other articles of this Issue 1/2021

BMC Primary Care 1/2021 Go to the issue

Research article

Sedentary behaviour among general practitioners: a systematic review

Research

How practice setting affects family physicians’ views on genetic screening: a qualitative study

Research article

Access to chronic medicines: patients’ preferences for a last kilometre medicine delivery service in Cape Town, South Africa

Research

Experiences of family caregivers of patients with COVID-19

Research

Improving patient self-reporting of antihypertensive adverse drug events in primary care: a stepped wedge cluster randomised trial

Research

How concerned significant others experience Community Reinforcement and Family Training (CRAFT) – a qualitative study