Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
J Asthma. 2022 Feb;59(2):352-361. doi: 10.1080/02770903.2020.1847929. Epub 2020 Nov 19.
To identify factors that influence providers' decisions to prescribe antibiotics in patients presenting to the hospital with an asthma exacerbation.
We performed semi-structured interviews with a purposive sample of providers including sixteen hospitalists, emergency room providers, or pulmonologists, and one focus group with internal medicine residents recruited from one large, urban, teaching hospital and one small, rural, community hospital. Questions were informed by the Theoretical Domains Framework to determine factors that may influence behaviors. Directed content analysis was used to code and analyze transcripts of the interviews.
Uncertainty regarding the diagnostic (asthma vs. COPD) and the cause of exacerbation (bacterial vs. viral infection) emerged as the main driver for prescribing behavior. Provider response to uncertainty included: "watchful waiting" or immediate antibiotic prescribing. The following factors played important roles in providers' prescribing decision: 1) awareness/agreement with existing guidelines 2) confidence in their ability to apply the guidelines in challenging cases; 3) perceived risk of patient deterioration without antibiotics; 4) fear of litigation; 5) habit and clinical inertia 6) prescribing within the group 7) lack of information of antibiotic prescribing rates and 8) lack of time and/or resources.
We identified diagnostic uncertainty as the primary determinant of antibiotic prescribing in asthma exacerbations and developed a conceptual model to explain provider responses and factors that influenced their responses. These results enhance our understanding of the factors that can contribute to low-value and wasteful practices like superfluous antibiotic prescribing and will support the development of interventions to de-implement such practices.
确定影响提供者在因哮喘加重而就诊的患者中开具抗生素处方决策的因素。
我们对包括 16 名医院内科医生、急诊医生或肺病专家在内的提供者进行了半结构式访谈，并对来自一家大型城市教学医院和一家小型农村社区医院的内科住院医师进行了一次焦点小组访谈。问题是根据理论领域框架确定的，以确定可能影响行为的因素。采用定向内容分析法对访谈记录进行编码和分析。
诊断（哮喘与 COPD）和加重原因（细菌与病毒感染）的不确定性成为开具处方行为的主要驱动因素。提供者对不确定性的反应包括：“观望”或立即开抗生素。以下因素在提供者的处方决策中起着重要作用：1）对现有指南的认识/认同；2）在具有挑战性的病例中应用指南的信心；3）没有抗生素时患者恶化的风险感知；4）对诉讼的恐惧；5）习惯和临床惯性；6）在群体内开处方；7）缺乏抗生素处方率的信息；8）缺乏时间和/或资源。
我们确定诊断不确定性是哮喘加重中抗生素开具的主要决定因素，并开发了一个概念模型来解释提供者的反应以及影响他们反应的因素。这些结果增强了我们对可能导致低价值和浪费性实践（如过度使用抗生素）的因素的理解，并将支持开发干预措施来取消此类实践。
