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Diagnosing infections: a qualitative view on prescription decisions in general practice over time

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Abstract

Objective Antibiotics may frequently be prescribed on the basis of vague diagnoses, possibly resulting in unnecessary antimicrobial resistance. Our aim is to map general practitioners’ (GPs’) decision-making for common infections, exploring their diagnostic basis for antibiotic prescriptions. Setting General practice in Iceland. Method Ten in-depth qualitative interviews with, and three observations of, GPs in 1995. Diagnostic issues extracted and analysed. In 2006, eight GPs commented on analysis and updated (email/telephone). Main outcome measure Diagnostic variability and reasons for prescribing antibiotics, consistency or changes over time. Results Wide variations were uncovered in diagnostic procedures, although each GP remained consistent through time. Some GPs had developed “rules-of-thumb”. They often balanced risks against issues like money, time, need for the workforce (perceived importance of the patient’s job), client’s need for job/earnings (perceived ability to afford a sick day) and doctor-patient relationship (risk of refusal adversely affecting the relationship). Perceptions of risk varied from focusing on resistance development to focusing on possible harm from untreated infections, also ranging between considering both to worrying about neither. Changes over time were not prominent but included increased point-of-care testing and the perception by GPs that patients were increasingly willing to “wait and see”. Conclusions Large variability and individuality characterized the GPs’ diagnostic procedures, contrasted by consistency through time. If modification of diagnostic routines is needed, provision of “scientific facts” and technological aids is insufficient. A prerequisite for changing practice is GPs’ acceptance of accuracy of information and of reliability, applicability, and relevance of technology, for physician and/or patient.

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Notes

  1. In 1995 there were discussions about referrals from a GP, for granting patient’s access to specialists in other fields. These discussions had created a tug-of-war between GPs and specialists

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Acknowledgments

We thank our informants for the participation and Maxine Ingalls, RN, for proofreading.

Funding

Research is a part of our duties within our ordinary paid jobs. This research was done within that scope.

Conflicts of interest

We have no conflicts of interests to declare.

Author information

Authors and Affiliations

  1. Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, University of Copenhagen, Copenhagen, Denmark

    Ingunn Björnsdóttir & Ebba Holme Hansen

  2. Research Institute for Pharmaceutical Outcomes and Policy, University of Iceland, Reykjavík, Iceland

    Ingunn Björnsdóttir & Karl G. Kristinsson

  3. FKL—Research Centre for Quality in Medicine Use, Copenhagen, Denmark

    Ebba Holme Hansen

  4. Clinical Microbiology, Landspitali University Hospital, Reykjavík, Iceland

    Karl G. Kristinsson

Authors
  1. Ingunn Björnsdóttir
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  2. Karl G. Kristinsson
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  3. Ebba Holme Hansen
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Corresponding author

Correspondence to Ingunn Björnsdóttir.

Appendix 1

Appendix 1

Original guide = questions asked in 1995

  • Years in general practice?

  • What is your view regarding use of antibacterials? (on the slightest suspicion, only when based on cultures or somewhere in-between)

  • How do you prescribe for sore throat? (symptoms, treatment) For sinusitis? For infections in the respiratory tract? For UTI? For dermatological infections? Other infections?

  • For children? (probe for otitis here) Elderly people? Women versus men?

  • Usability and disadvantages of specific antibiotics? (groups)

  • Recall the last 10 [antibiotic prescriptions]. Any uncomfortable?

  • Do patients press? If yes, what do you think the reason is? (certain types??)

  • Time pressure?

  • Telephone prescriptions. How decided?

  • Fear of resistance problems?

  • Laboratory facilities in the town?

  • Cost to patient?

  • Composition of wages?

  • The secretary/the telephone lady?

  • Co-operation between the physicians?

  • (The referral case?)Footnote 1

  • Co-operation with pharmacy?

  • Anything you would like to add, - or anything I forget to ask about?

Supplementary questions = questions asked in 2006

  • How have your prescribing habits regarding the most common infections changed during these 10–11 years from the initial interview?

  • (common infections: otitis, sinusitis, sore throat, UTIs, pneumonia, dermatological infections)

  • If changes—why do you think the changes occurred?

  • Have there been changes in your prescribing of azithromycin, ciprofloxacin and doxycyklin (official sales statistics indicate changes in the use of these drugs)

  • What is your view regarding the development in resistance to antibiotics?

  • What is your opinion regarding the authorities’ response to that development?

  • What is your view regarding your prescribing habits for antibiotics?

  • Do you think your prescribing is on a suitable level, or is your antibiotic prescribing on a level that you consider unfortunate in some way?

  • Why?

  • What is your view regarding your colleagues’ prescribing of antibiotics?

  • Is their prescribing on a suitable level, or is it unfortunate in some way?

  • Why?

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Björnsdóttir, I., Kristinsson, K.G. & Hansen, E.H. Diagnosing infections: a qualitative view on prescription decisions in general practice over time. Pharm World Sci 32, 805–814 (2010). https://doi.org/10.1007/s11096-010-9441-6

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