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Understanding variation in primary medical care: a nine-country qualitative study of clinicians’ accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection
  1. Lucy Brookes-Howell1,
  2. Kerenza Hood1,
  3. Lucy Cooper2,
  4. Paul Little3,
  5. Theo Verheij4,
  6. Samuel Coenen5,6,
  7. Maciek Godycki-Cwirko7,
  8. Hasse Melbye8,
  9. Alicia Borras-Santos9,
  10. Patricia Worby10,
  11. Kristin Jakobsen8,
  12. Herman Goossens6,
  13. Christopher C Butler11
  1. 1South East Wales Trials Unit, Institute for Translation, Innovation, Methodology and Engagement (TIME), Cardiff University, Cardiff, Wales, UK
  2. 2Institute of Psychology, Health and Society, University of Liverpool, Liverpool, England, UK
  3. 3Community Clinical Sciences Division, University of Southampton, Southampton, England, UK
  4. 4Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
  5. 5Centre for General Practice, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
  6. 6Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
  7. 7Department of Family and Community Medicine, Medical University of Łódź, Łódź, Poland
  8. 8Institute of Community Medicine, University of Tromsø, Tromsø, Norway
  9. 9IAMR, Applied Research in Respiratory Diseases, Barcelona, Spain
  10. 10Research and Innovation Services, University of Southampton, Southampton, England, UK
  11. 11Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales, UK
  1. Correspondence to Dr Lucy Brookes-Howell, South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement (TIME), School of Medicine, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, UK; Brookes-HowellLC{at}


Objectives There is a wide variation between European countries in antibiotic prescribing for patients in primary care with lower respiratory tract infection (LRTI) that is not explained by case mix and clinical factors alone. Variation in antibiotic prescribing that is not warranted by differences in illness and clinical presentation may increase selection of resistant organisms, contributing to the problem of antibiotic resistance. This study aimed to investigate clinicians’ accounts of non-clinical factors that influence their antibiotic prescribing decision for patients with LRTI, to understand variation and identify opportunities for addressing possible unhelpful variation.

Design Multicountry qualitative semistructured interview study, with data subjected to a five-stage analytic framework approach (familiarisation, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation), and with interviewers commenting on preliminary analytic themes.

Setting Primary care.

Participants Eighty primary care clinicians randomly selected from primary care research networks based in nine European cities.

Results Clinicians’ accounts identified non-clinical factors imposed by the healthcare system operating within specific regional primary care research networks, including patient access to antibiotics before consulting a doctor (Barcelona and Milan), systems to reduce patient expectations for antibiotics (Southampton and Antwerp) and lack of consistent treatment guidelines (Balatonfüred and Łódź). Secondly, accounts revealed factors related to specific characteristics of clinicians regardless of network (professional ethos, self-belief in decision-making and commitment to shared decision-making).

Conclusions Addressing healthcare system factors (eg, limiting patients’ self-management with antibiotics before consulting in primary care, increased public awareness and provision of more consistent guidelines) may assist in reducing unhelpful variation in antibiotic prescribing. Promoting clinicians’ receptivity to change, confidence in decision-making and readiness to invest in explaining prescribing decisions may also be beneficial. As factors were emphasised differently between networks, local flexibility in interventions is likely to maximise effectiveness.

  • Primary Care
  • Thoracic Medicine
  • Respiratory infections
  • Qualitative Research

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