Objectives There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement.
Design Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports.
Setting Primary care.
Participants 80 primary care clinicians randomly selected from primary care research networks based in nine European cities.
Results Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.
Conclusions Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.
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To cite: Brookes-Howell L, Hood K, Cooper L, et al. Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care. BMJ Open 2012;2:e000795. doi:10.1136/bmjopen-2011-000795
Contributors All authors contributed to either the conception and design or the analysis and interpretation of the data. All authors contributed to drafting and revising the manuscript. All authors have approved this final version of the manuscript.
Funding Financial support for this study was provided by the 6th Framework Programme of the European Commission (LSHM-CT-2005-518226). The South East Wales Trials Unit is funded by the National Institute for Social Care and Health Research. The Antwerp Network was funded by the University of Antwerp (KP BOF 2147). In Flanders (Belgium), this work was supported by the Research Foundation, Flanders (G.0274.08N). The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing and publishing the report.
Competing interests None.
Patient consent The participants in this study were clinicians not patients. All participants provided signed informed consent prior to participation in the study.
Ethics approval Ethics approval was provided by MREC for Wales.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data available.
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