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Chapter3 Factorsinfluencing antibioticprescribingin longtermcarefacilities: aqualitativeindepthstudy LauraW.vanBuul JennyT.vanderSteen SarahM.M.M.Doncker WilcoP.Achterberg FrançoisG.Schellevis RuthB.Veenhuizen CeesM.P.M.Hertogh PublishedinBMCGeriatr2014;14:136 45 Chapter3 Abstract Background: Insight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factorsthatinfluenceantibioticprescribinginlongtermcarefacilities,andpresenta conceptualmodelthatintegratesthesefactors. Methods:Semistructuredqualitativeinterviewswereconductedwithphysicians(n= 13)andnursingstaff(n=13)infivenursinghomesandtworesidentialcarehomesin the centralwest region of the Netherlands. An iterative analysis was applied to interviewswithphysicianstoidentifyandcategorizefactorsthatinfluenceantibiotic prescribing, and to integrate these into a conceptual model. This conceptual model wastriangulatedwiththeperspectivesofnursingstaff. Results:Theanalysisresultedintheidentificationofsixcategoriesoffactorsthatcan influencetheantibioticprescribingdecision:theclinicalsituation,advancecareplans, utilizationofdiagnosticresources,physicians’perceivedrisks,influenceofothers,and influence of the environment. Each category comprises several factors that may influencethedecisiontoprescribeornotprescribeantibioticsdirectly(e.g.pressure ofpatients’familyleadingtoantibioticprescribing)orindirectlyviainfluenceonother factors(e.g.unfamiliaritywithpatientsresultinginahigherphysicianperceivedriskof nontreatment,inturnresultinginahighertendencytoprescribeantibiotics). Conclusions: Our interview study shows that several nonrational factors may affect antibiotic prescribing decision making in longterm care facilities, suggesting opportunities to reduce inappropriate antibiotic use. We developed a conceptual model that integrates the identified categories of influencing factors and shows the relationshipsbetweenthosecategories.Thismodelmaybeusedasapracticaltoolin longterm care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriateantibioticprescribing. 46 Factorsinfluencingantibioticprescribinginlongtermcarefacilities Background Antibioticsarecommonlyprescribedinnursinghomesandresidentialcarehomes.As much as 47% to 79% of the people residing in these facilities receives at least one course of antibiotics per year, of which a substantial part in situations where antibiotictreatmentisnotindicated.1Thisinappropriateantibioticusecontributesto the development of antibiotic resistance, which is also common in longterm care settings. These insights have led to awareness regarding appropriate use of antibiotics,andtoseveralinitiativestopromoterationalantibioticprescribing. Tobeeffective,interventionsaimedatamorerationaluseofantibioticsshouldtake into account the factors that impede and facilitate appropriate prescribing. Such factors may apply to the patient, the physician, the care setting, and the larger cultural and socioeconomiccontext.2 Factors thatinfluenceantibiotic prescribing in general practice and hospitals have been studied extensively. Examples of such factorsincludepatients’symptomsandresultsofphysicalexamination,availabilityof resources,availabilityandawarenessofevidencewithregardtoantibiotictreatment, diagnostic uncertainty, peer practice, patient expectations, financial interests, and physicians’ perceptions regarding antibiotic prescribing and resistance.214 The diversity of these factors indicates that the antibiotic prescribing decision can be complexinthesesettings. Less research has been conducted on factors that influence antibiotic prescribing in nursinghomesandresidentialcarehomes.Whereasseveralfactorsidentifiedforthe generalpracticeandhospitalsettingarelikelytobevalid–atleastpartly–inlong term care settings, other factors may be involved that relate to the specific characteristics of these facilities, the physicians delivering care, and the patient population.Afewstudiesquantitativelyinvestigatedassociationsbetweenantibiotic prescribing and possible determinants in longterm care facilities.1520 These found thatprescribingdecisionscanbeaffectedby,forexample,theseverityofillnessand the ability to communicate with residents. Other studies qualitatively investigated factors that influence antibiotic prescribing for specific conditions (i.e. urinary tract infectionandpneumonia),andreportedthatantibioticprescribingdecisionsmaybe influenced by nursing staff, family wishes, and familiarity with the patient.2123 To date, factors that influence antibiotic prescribing in general have not been qualitativelyexploredindepthinlongtermcarefacilities. Basedonqualitativeinterviewswithphysiciansandnursingstaff,thisstudytherefore examines factors that influence antibiotic prescribing in general in longterm care facilities in the Netherlands, where prevalence of antibiotic prescribing is high comparedtoambulatorycaresettingsandaverageincomparisonwithlongtermcare facilities in other European countries.24,25 We present a conceptual model that 47 3 Chapter3 integrates these factors, which may guide the development and implementation of interventionsaimedatrationalizingantibioticuseinlongtermcarefacilities. Methods Studysetting The current interview study is part of a research project aimed at rationalizing antibiotic prescribing in longterm care facilities: the IMPACT study.26 The IMPACT studywasconductedin14longtermcarefacilities,ofwhichsevenwereallocatedto an intervention group and seven to a control group. In the interview study, which preceded implementation of interventions to improve prescribing practices, we includedonlyfacilitiesfromtheinterventiongroup(5nursinghomesand2residential care homes), to avoid undue influence of participation in qualitative research activitiesonprescribingbehaviorincontrolgroupfacilities. IntheNetherlands,organizationofmedicalcarediffersbetweennursinghomesand residentialcarehomes.Nursinghomesemployelderlycarephysicians(formerlycalled nursing home physicians), which is a distinct medical specialty in the Netherlands. Medical care in residential care homes is provided by general practitioners, who operatefromtheirownpractice.Intervieweeswerefrombothcaresettings. AllparticipatingfacilitieswerelocatedinthecentralwestregionoftheNetherlands. Asampleof13outofapproximately30physicianswaspurposefullyselectedbythe researchers to reflect variation in sex, age, years of professional experience, and professional specialism. One of the 13 initially selected physicians was not able to participate in an interview due to time constraints, and another physician was selected instead. The physicians in this final sample all provided written consent to participateintheinterviews.Asampleof13nursingstaffmemberswasadditionally selectedbyresearcherswiththehelpofalocationmanager,aphysician,oramedical secretary,similarlypursuingvariation.Theseparticipantsprovidedconsentinperson priortothestartoftheinterviews. Datacollection Ateamof researchers (LB,JS,SD,FS,CH) developedtwo topic lists (Additional file), oneforphysiciansandonefornursingstaff,basedonfieldexperienceoftheproject team,relevantliteratureonfactorsassociatedwithdrugprescribing,andaliterature based conceptual model developed by Zimmerman et al.27 Both topic lists aimed at exploring perceptions and motivations with regard to three themes: infectious diseases, antibiotic prescribing, and antibiotic resistance. For the theme ‘antibiotic prescribing’, respondents were asked to describe two recent cases: one in which antibiotics were prescribed and one in which antibiotics were not prescribed. The topic list was used to raise follow up questions to determine factors influencing prescribingdecisions. 48 Factorsinfluencingantibioticprescribinginlongtermcarefacilities Onesemistructuredinterviewperrespondentwasconductedbytrainedinterviewers (LB and SD). To achieve concordance, the interviewers conducted the first two interviewstogether.Allinterviewsweretaperecordedandtranscribedinfull,andwe removed any information from which the particular respondent or longterm care facilitycouldbeidentified. Dataanalysis We started the analysis with the recent cases that were described by physicians, as theseconstitutedthebasisoftheinterviews.Thesecasedescriptionswerestudiedby tworesearchers(LBandSD)toidentifyandcategorizefactorsthatinfluenceantibiotic prescribingdecisions.Theresultingcategorieswereregardedasbasicconsiderations for treatment decisions (i.e. they are generally considered in treatment decisions), andwerethereforeconsideredthecoreofaconceptualmodel.Aniterativeanalysis was applied to further elaborate this conceptual model. Hereby, the remaining materialofthephysicianinterviews–whichcontaineddescriptionsofotherpractice situationswithregardtoantibioticprescribingdecisions–wasstudiedinastepwise fashion:1)fragmentsofthematerialwerelabelledaccordingtotheircontent(open coding), 2) relationships were sought between the coded fragments (axial coding), and3)therelatedcodedfragmentswerecategorized(selectivecoding)andaddedto theconceptualmodel. Open coding was conducted by two researchers (LB and SD), who independently codedtranscriptsof3physicianinterviews,anddevelopedaseparatecodelist.These codelistswerecompared,discussed,andcombinedintoacollectivecodelist.The3 previouslycodedtranscriptsandtheremaining10transcriptswere(re)codedbyeach researcheraccordingtothecollectivecodelist.Aftereachthirdcodedtranscript,the researchers compared and discussed the transcripts and – where necessary – codes were added or adjusted according to reached consensus. Coding of the last few transcriptsyieldednonewcodes,whichindicatesdatasaturation.Axialandselective coding was conducted by one of the researchers (LB), and discussed with the other researcher (SD). The qualitative data analysis software program Atlas.ti, version 6 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used to processthecodedtranscripts. Sincephysiciansareresponsiblefortheprescribingdecision,thephysicianinterviews were used for the initial development of the conceptual model. Subsequently, this modelwastriangulatedwithperspectivesderivedfromthe13codedinterviewswith nursing staff. The coding procedure of these interviews was identical to and independentoftheprocedureofthephysicianinterviews.Theinformationretrieved from the interviews with nursing staff was used to support and enhance the understandingofantibioticprescribingdecisionsmadebyphysicians.Inaddition,the conceptualmodelwasstudiedbyallmembersofthestudyteamandadjustmentsto 49 3 Chapter3 themodelweremadeuponcriticaldiscussionoftheanalyticstepsandinterpretation oftheresults. Ethicalapproval TheIMPACTstudywasapprovedbytheMedicalEthicsReviewCommitteeoftheVU UniversityMedicalCenter(Amsterdam,theNetherlands). Results Table 1 shows the demographic characteristics of the interviewed physicians and nursing staff; there was substantial variation in age (range: 24 – 61) and years of professionalexperience(range:0–36).Thedurationoftheinterviewsvariedfrom19 minutes to 53 minutes, with a mean of 34 minutes overall (physicians: 39 minutes, nursingstaff:30minutes). Table1.Demographicsoftheinterviewedphysiciansandnursingstaff. Demographic Sex Age(yr) Yearsof professional experience Typeoffacility Male Female Mean(range) Mean(range) Physicians(n=13) 4 9 45(25–60) 15(0–36) Nursingstaff(n=13) 1 12 45(24–61) 17(0–32) Overall(n=26) 5 21 45(24–61) 16(0–36) Nursinghome Residentialcarehome Urbanarea Ruralarea Nursinghome 10 9 19 3 4 7 Facilitylocation 8 7 15 6 11 5 * Professional Elderlycarephysician(7) Nurse (4) Nurseassistant*(5) specialism Elderlycarephysicianintraining(1) Juniordoctor(1) Physicianassistant(1) Residentialcarehome Generalpractitioner(3) Nurseassistant* (4) *UnitedStatesequivalents:nurse=registerednurse,nurseassistant(levels2,3and4)=licensedpracticalnurse(level4)ornurseaid(levels2and3). Theanalysisofrecentcasesthatweredescribedbyphysiciansledtotheidentification oftwocorecategoriesoffactorsthatinfluencetheantibioticprescribingdecision:the clinicalsituation,andadvancecareplans.Thesecategorieswerealsoderivedfromthe analysisofotherpracticesituationsthatphysiciansdescribedwithregardtoantibiotic prescribing. The latter analysis additionally resulted in the identification of the following categories: utilization of diagnostic resources, physicians’ perceived risks, influenceofothers,andinfluenceoftheenvironment.Figure1showsourconceptual modelthatintegratesthesecategoriesanddemonstrateshowtheyareinterrelated. Interviews with nursing staff supported the identified categories and added no new informationtothemodel.Thecategoriesoffactorsthatwereidentifiedasinfluencing theantibioticprescribingdecisionaredescribedinmoredetailbelow. Clinicalsituation Boththecurrentclinicalsituationandthepatients’medicalhistoryappearedtoplaya crucial role in the decision to prescribe or not prescribe antibiotics. Table 2 shows considerationswithregardtotheclinicalsituationthataffecttheprescribingdecision 50 Factorsinfluencingantibioticprescribinginlongtermcarefacilities for urinary tract infection, respiratory tract infection, and skin infection. Two situations were described in which the clinical situation can be unclear: 1) when Table2.Elementsoftheclinicalsituationthatresultinthedecisiontoprescribeornotprescribeantibioticsforurinary tractinfections,respiratorytractinfections,andskininfections. Clinicalsituation Current Antibiotic Yes No Medicalhistory Yes No Urinarytractinfection Signsandsymptoms(orahighrisk ofsignsandsymptoms), positivedipsticktest(for leukocyteesterase,nitrite,or both)/dipslide/culture, patientexperiencesburden, patientfeelsill,hematuria, vulnerabilityofthepatient, comorbidity,nopriorantibiotic resistance Absenceof(relevant)signsand symptomswhetherornotin combinationwithapositive dipsticktest(forleukocyte esterase,nitrite,orboth), negativedipsticktest,awaiting cultureresultsincaseof no/minimalsignsand symptoms,patientdoesnot feelill,poorprognosis, acceptanceofresistant bacteriainurine Positiveeffectoftreatmentfor previousinfection,no/limited historyofinfection,ineffective previoustreatment Respiratorytractinfection Signsandsymptoms,patientfeels ill,vulnerabilityofthepatient, riskofdeath,comorbidity Skininfection Signsandsymptoms, vulnerabilityofthe patient Absenceof(relevant)signs andsymptoms Poorprognosis,suspectedviral infection,no/minimalsigns andsymptoms,patientdoes notfeel(severely)ill,physical inabilitytotakeoral medication,allowingimmune systemofthepatienttoclear infection Severecourseofpreviousinfection Nohistoryofinfection communication with patients is impaired, which is common in residents with dementia, and 2) when (typical) clinical signs and symptoms are absent. Such situationsresultindiagnosticuncertainty,whichcaneitherpromoteantibioticuseif uncertainty leads to prescribing, or impede antibiotic use if uncertainty leads to furtherobservingthecourseofinfection.Accordingtotheinterviewedphysicians,a reason for not prescribing antibiotics for urinary tract infection is the absence of clinical signs and symptoms despite a positive dipstick test (i.e. the presence of leukocyte esterase, nitrite, or both). Some physicians expressed dissatisfaction with nursing staff performing a dipstick test in such situations, especially when the rationaleforthetestwasachangeinurineodororappearance.Nursingstaff,onthe other hand, may not always be aware of this dissatisfaction, as some respondents indicatedachangeinurineodororappearanceasareasontoperformadipsticktest. Thisisillustratedinthefollowingquotations: Elderlycarephysician,female,53:“Thenursescallout‘yes,theurinestinks’.Andsotheystarted dipsticktesting[theurine].AndIsay‘wellIamnottreatingurine,Iamtreatingthepatient’.” Nurse, female, 53: “Sometimes the urine is checked because it is just very nasty. Very concentrated,oritsmellsreallybad.” 51 3 Chapter3 Advancecareplans Theinterviewsshowedthatadvancecareplanscanplayacentralroleinthedecision making process in nursing homes (they were not mentioned for residential care homes). These include the documentation of considerations to guide future (non) treatmentdecisions,asformulatedbythephysicianandthepatientorthepatients’ family. Antibiotic treatment may be included in the advance care plan, thereby anticipating situations in which antibiotic treatment potentially prolongs life. The interviewed physicians consulted the advance care plan when a patient develops a potentiallylifethreateninginfectionsuchaspneumonia.Theystatedtonotprescribe antibioticswhentheoverallcaregoalintheadvancecareplanwasdefinedascomfort ratherthanlifeprolongation. Utilizationofdiagnosticresources Theinterviewsdemonstratedthattheextenttowhichphysiciansresorttodiagnostic resources is limited in longterm care facilities. Consequently, physicians have less information to judge a clinical situation compared to situations in which additional diagnostic information would be available, which in turn contributes to diagnostic uncertainty. We abstracted from the interviews four explanations for not using diagnosticresourcestofacilitatetreatmentdecisions.First,certaindiagnosticscanbe tooburdensomeforthevulnerablelongtermcarepopulation(e.g.referringapatient tothehospitalforfurtherinvestigation).Asecondexplanationincludestheinabilityto obtainagoodsputumorurinesampleforculturefromelderlypatients.Inaddition, logisticconsiderationscanbeinvolvedinthedecisionnottousediagnosticresources. In this regard, physicians pointed to a lack of onsite diagnostic resources (e.g. C reactive protein pointofcare test, Xray, urine culture), difficulties to consult the laboratory outside regular visit days for collection of specimen of residents, higher workload for the physician when taking cultures, and the length of time needed to obtain laboratory culture results (i.e. approximately one week). Finally, financial considerations can also be involved, in particular related to laboratory costs of cultures. Physicians’perceivedrisks Theinterviewsshowedthatrisksperceivedbyphysicianscaninfluencetheantibiotic prescribing decision. These can be divided into perceived risks of treatment and perceivedrisksofnontreatment.Withregardtoperceivedrisksoftreatment,some physiciansdescribedsituationsinwhichtheriskofsideeffectswasmentionedasone ofthereasonstonotprescribeantibiotics.Further,somephysiciansraisedtheriskof antibiotic resistance development, which was considered from two points of view. The first point of view was that antibiotics should not be prescribed because of the risk of antibiotic resistance, if the clinical situation does not necessarily require antibiotic treatment. The second perception was that antibiotic resistance is not an important consideration in antibiotic prescribing, as the vulnerable longterm care populationhasashortlifeexpectancy.Forexample: 52 Factorsinfluencingantibioticprescribinginlongtermcarefacilities Generalpractitioner,female,38:“…ifthegentlemanisgoingtodieanywaythenanyantibiotic resistanceisnotrelevant.Soinmymindthatissomethingofamitigatingthing.” Perceived risks of nontreatment appeared to influence the antibiotic prescribing decision especially when physicians experience uncertainty, for example due to diagnosticuncertaintyorunfamiliaritywiththepatient.Weidentifiedthreesituations in which perceived risks of nontreatment resulted in treating more readily with antibiotics. The first situation involves a perceived risk of adverse outcomes. For example: Generalpractitioner,female,47:“SoevenifIinitiallythinkwellit’sonlyviral,butIfeelthereisa verysubstantialriskofasuperimposedinfectionincasetheyhavearespiratoryinfection,thenI amjustveryquick[toprescribeantibiotics].” The second situation involves a perceived sense of alarm (i.e. a “gut feeling”). For example: Elderly care physician, female, 36: “… if I am not completely sure and I simply don’t trust the situation,thenIwill[prescribeantibiotics].InthatcaseIthinkwell,bettersafethansorry.” Thethirdsituationinvolvesaperceivedriskofnotfulfillingthepatients’expectations. Thequotationbelowshowsthatthephysicianperceivesthatthepatientexpectsher to“dosomething,”whichsheinterpretedastheprescriptionofanantibiotic: Elderlycarephysicianintraining,female,25:“IfIdon’ttakeactionitlookslikeIdon’twantto helpthepatient,butperhapsIalreadyknow,wellisitgoingtoworkatall?” Influenceofothers Physicians described several situations that showed influence of others on the prescribing decision. These can be colleagues, the patient, the patients’ family, and nursingstaff.Somesituationsshowedthatphysiciansmaybemoresusceptibletothe opinion or wish of others in uncertain situations. Vice versa, the opinion or wish of othersmayalsoaffectthedegreeofuncertaintyexperiencedbyphysicians. Three situations in which colleagues influenced the prescribing decision were described: 1) following the advice of a colleague when in doubt about whether to treatwithantibioticsornot,2)anagreementtotreatpatientsaccordingtothehabits ofacolleaguewhencoveringforthiscolleague,3)adaptationtoprescribinghabitsof peers.Thelatterisillustratedbythefollowingquote: Physician assistant, male, 51: “That is during the weekend […] and then almost everybody prescribesAugmentin[i.e.amoxicillinclavulanate].That’swhy.Thatwasmymotivationtoo.” 53 3 Chapter3 Physicians and nursing staff described several situations in which patients or the patients’ family expressed their wish with regard to the treatment of an infection. Basedonthesedescriptions,weidentifiedthreescenariosofhowphysicianshandle thesesituations:1)physiciancomplieswithawishnottotreat,2)physiciancomplies withawishtotreat,and3)physiciandoesnotcomplywithawishtotreat.Theseare describedandillustratedwithrelevantquotationsinTable3. Table3.Scenariosofhowphysicianshandlesituationsinwhichpatientsorthepatients’familyexpresstheiropinionor wishregardingthetreatmentofaninfection. Scenario PhysicianCOMPLIES with patients’/family’s WISHNOTTOTREAT PhysicianCOMPLIES with patients’/family’s WISHTOTREAT Descriptionofsituation Physiciansindicatetonotprescribeantibiotics whenthepatientorhis/herfamilydoes notwantlifeprolongingantibiotic treatment(oftenrecordedinadvancecare plans). Antibiotictreatmentisconsiderednecessaryby physician. Antibiotictreatmentisconsidered(partly) medicallyfutilebyphysician,but: x familywantstohavetimeto deliberatewithafamilymemberthat cannotbereached,incaseofapoor prognosisofthepatient. x physicianiswillingtoconcedetothe wishoffamilyduetounfamiliaritywith thepatientandinabilitytopredictthe outcome. x physicianconsidersitunethicallyto ignorethereligionbasedwishofthe patient/family,incaseofapoor prognosisofthepatient. x aperceptionthatscientificresearch showedthattheoutcomeofa pneumoniaisnotmuchinfluencedby treatmentwithantibiotics[incaseof respiratorytractinfectionsattheend oflife]. familyshouldbeallowedtimetoget usedtotheideathattheconditionofa patientdeteriorates. x x PhysicianDOESNOT COMPLYwith patients’/family’s WISHTOTREAT patientsonrehabilitationunitsare usedtogetantibioticsfromtheir generalpractitionerandwillconsult thisgeneralpractitionerifnoantibiotic isprovided. Antibiotictreatmentisconsideredmedically futilebyphysician. Familyofamentallycompetentpatientwants treatmentwhereasthepatientdoesnot wanttreatment. Relevantquotations Juniordoctor,female,30:“…ifthefamilyreallydecidesnottodo it[treatwithantibiotics],thentheyaccepttheriskthathe [thepatient]willdieasaresultofit.AndwhoamItosaywell Iamgoingtogiveantibioticsanyway.Atthatpointthatisnot myrole.ThenIjusthavetoacceptwhattheywant.” Elderlycarephysicianintraining,female,25:“…thenIdecidedin consultationwithhissontostarttheantibiotics[…]because anothersonwasonholiday[…].Andwecouldn’tgetaholdof himonthephone.” Juniordoctor,female,30:“…ifthey[thefamily]insist,thenwe shoulddoit[prescribeantibiotics]becauseIdon’tknowthe man.Soit’sdifficulttopredict.Ithinkitwon’tmakemuchofa difference,butstill,ifthefamilyreallyinsists,thenIamquite willingtoprescribe[antibiotics].” Generalpractitioner,female,38:“…Ithinkitisveryunethicalto sayatamomentlikethatI’msorry,butyouarenotgetting them[antibiotics].Evenifeverythinginmesaysyou’renot goingtomakeit,thisisliterallythelastmile,butthe gentlemanfeelslike‘I’vedoneeverything,ifIdienowthenit mustbeGod’swill’.” Elderlycarephysician,male,51:“…nowwealsoknowfrom scientificresearchthatifyoutalkaboutpneumoniathatthe outcome[…]isnotreallydeterminedbywhetheryouusean antibioticornot.Andthatmakesitalittleeasierforustogive itevenwhenyouthink‘well,ifitwasmymotherIwouldn’t havedonethis’.” Elderlycarephysician,male,48:“…Ijusthappenedtohavehad somepatientsrecentlyofwhomIthoughtinretrospectIjust shouldn’thavedoneit[prescribedantibiotics].Butsometimes youdoitforthefamily.[…]InthepastIusedtobemore principledaboutthis,Iwouldsaylook,youshouldn’tdothis, andnowIthinkwell,it’saprocessforthemtooandIdotell them[thatthereisnotmuchpoint],butiftheycan’tgoalong withthatyetthenIdon’tpushharder.” Nurseassistant,female,35:“[Thatisbecause]peopleareabit morearticulateofcourse[ontherehabilitationunit]:‘[…]I justhaveaurinarytractinfection’.Andthisistreatedinthe homesituation.Sosometimesthatisthereasonthatthe physiciandoestreatithere,sometimes[…]” Elderlycarephysician,female,53:“…andsomepatients[…]then demandtreatment.[…]WhenIamconvincedthat‘thisis pointless,thisismedicallycompletelypointless’.ThenIdon’t doit[prescribeantibiotics].” Elderlycarephysician,female,53:“Wellitdepends[…],if someoneiscompetent.Andthispersonsays‘no’[no antibiotics]butthefamilysays‘yes’[giveantibiotics],thenI alsosayIwon’tdothat.Becauseyourmotherisquiteclear aboutit.” Theinterviewsshowedindirectanddirectinfluenceofnursesandnurseassistantson treatment decisions of physicians. Indirect influence includes the dependence of physiciansonnursingstaffforinformationabouttheclinicalsituationofapatient:the 54 Factorsinfluencingantibioticprescribinginlongtermcarefacilities poorer the quality of the information or the conveyance of information, the more difficultitcanbeforaphysiciantoassesstheclinicalsituationandmakeatreatment decision.Physicians’opinionsdifferedaboutthequalityofinformationobtainedand conveyed by nursing staff. Some mentioned that nursing staff is wellcapable of recognizing signs of infection and judging when the physician should see a patient, others indicated that the quality of information and conveyance of information dependsontheexperienceandlevelofeducationofthenursingstaffmember.The quality of information conveyance can also be influenced by the work schedule of nursingstaff;staffthathadthepreviousdaysoffmaynotbeasinformedaboutthe clinicalsituationofapatientasstaffthatpersonallywitnessedthecourseofillness. Furthermore, some physicians mentioned that their treatment decision is often complicated by the omission of nursing staff to register the patients’ temperature, bloodpressure,andpulse. With regardto direct influenceof nursing staff, several situations weredescribed in whichnursingstaffexpressedarequestforantibiotictreatment.Forexample: Nurse, female, 53: “Then I sometimes call directly to say ‘there are unmistakable signs of an infection,comeandprescribeantibiotics’.” Whereas some physicians reported not to comply with such requests in situations where they considered antibiotic treatment medically futile, others indicated that they value and comply with the opinion of nursing staff in certain situations, for example: Elderlycarephysician,female,36:“WhenanursehasseriousconcernsIthinkIwouldbemore tempted to prescribe an antibiotic, […] Nurses are often good judges of patients because they knowthemmuchlongerthanIdo.” Influenceoftheenvironment The interviews demonstrated that the antibiotic prescribing decision can be influencedbyseveralenvironmentalfactors.Theseincludetheavailabilityofevidence with regard to treatment of infections. Some physicians reported that treatment decisionsarecomplicatedbyalackofprescribingguidelinesfortheolderpopulation, andalackofinsightintolocalresistancepatterns.Anotherenvironmentalfactoristhe lackofonsitediagnosticresources,whichcontributestothelimitedextenttowhich diagnostic resources are utilized. In addition, limited accessibility of information in medical files can complicate antibiotic prescribing decision making. Two other environmentalfactors,whichareoftenrelated,aretheorganizationofcrosscovering, andfamiliaritywithpatients.Somephysiciansindicatedthattheytendtotreatmore readilywithantibioticswhenoncall,duetounfamiliaritywithpatients: 55 3 Chapter3 Elderlycarephysician,female,57:“Wehavediscussedthiswiththepartnersinourcallgroup. Thatyouaremuchquickertogiveantibioticsintheweekends.Justbecausethesepatients,these familiesarestrangers.Youdon’tknowthemverywell.” Further, the conduction of telephoneconsultations can affect the degree to which others influence treatment decisions. For example, some physicians indicated that theyaremoredependentonnursingstaffincaseofatelephoneconsultation.Afinal environmentalfactorthatcaninfluenceantibioticprescribingdecisionsisthedayof theweekaconsultationtakesplace.Forexample: Elderly care physician, male, 48: “Fridays it’s always more difficult than on Mondays [to use antibioticsprudently].[…]onFridaysIthink[…]well,someoneelseisgoingtocomeinandhave a look [during the weekend], he won’t be able to compare and will prescribe the antibiotics anyway, so I might as well prescribe it today. Otherwise this colleague will have to come in especiallytomorrow.” Figure1.Conceptualmodeloffactorsthatinfluenceantibioticprescribinginnursinghomesandresidentialcarehomes in the Netherlands. The model shows that the clinical situation and advance care plans constitute the basis of the antibioticprescribingdecision.Theotherfourcategoriescanexertadirectinfluenceonthisprescribingdecision,oran indirectinfluenceviaothercategories.Theclinicalsituationcaninfluencetheuseofdiagnosticresources(e.g.noXray when a patient is severely ill) and vice versa (e.g. less information about the clinical situation when no diagnostic resourcesareused).Theuseofdiagnosticresourcescanalsobeinfluencedbyenvironmentalfactors(e.g.availabilityof onsitediagnosticresources).Physicians’perceivedriskscanbeinfluencedbytheclinicalsituation(e.g.higherperceived riskofnontreatmentifapatientisseverelyill),theuseofdiagnosticresources(e.g.moreuncertaintyifnodiagnostic resourcesareused),others(e.g.pressurefrompatients),andtheenvironment(e.g.differentriskperceptionswhenon call).Theinfluenceofotherscanbeaffectedbytheenvironment(e.g.theinfluenceofnursingstaffmaydifferwhena consultationisbytelephonecomparedtoaphysicalconsultation). Discussion Qualitative interviews with physicians and nursing staff in seven longterm care facilities in the Netherlands showed the following categories of factors that can influence antibiotic prescribing decisions: the clinical situation, advance care plans, utilizationofdiagnosticresources,physicians’perceivedrisks,influenceofothers,and influence of the environment. Indepth analysis of these categories showed several 56 Factorsinfluencingantibioticprescribinginlongtermcarefacilities factors that may result in inappropriate antibiotic prescribing decisions, such as risk avoidance(‘bettersafethansorry’),adaptationtopeerpractice,andpressureexerted bypatients,familymembersornursingstaff.Wedevelopedaconceptualmodelthat integratesthecategoriesoffactorsanddemonstrateshowtheymayinterrelate.This model may be used as a practical tool, whereby facilities explore which local non rational factors influence their prescribing patterns, and subsequently intervene at thelevelofthosefactorstopromoteappropriateprescribing. Weidentifiedtheclinicalsituationandadvancecareplansasthetwocorecategories of factors that influence antibiotic prescribing, and these therefore constitute the basisoftheconceptualmodel.Inlinewithourfindings,thesecategorieswereamong the most important factors in a Dutch study that quantitatively investigated treatment decisions with regard to pneumonia in nursing home residents with dementia.18 We are not aware of any other studies that investigated the role of advancecareplansintheantibioticprescribingdecisionmakingprocessinlongterm care.Futureresearchmayfurtherelucidatethisrole. A lack of onsite diagnostic resources was previously described to result in limited utilizationofdiagnosticresourcesinlongtermcarefacilities.22,2830Otherfactorsthat reportedlycontributedtothislimitedutilizationincludethelengthoftimeneededto obtain laboratory results, and difficulties in obtaining appropriate specimens for culture, which corresponds with our findings.22,30 In addition, another Dutch study described limited use of procedures such as xray examination in the vulnerable nursinghomepopulation,whichindicatesthattheburdenofdiagnosticmeasuresfor residents can be a reason not to use these.19 Limited utilization of diagnostic resourcescontributestodiagnosticuncertainty.Wefoundthatothercontributorsto diagnosticuncertaintyincludeimpairedcommunication,andabsenceofclinicalsigns andsymptoms,whichissupportedbyotherlongtermcarestudies.21,29,30 Our finding that nursing staff, patients, and family can influence the antibiotic prescribing decision corresponds with previous longterm care studies.16,18,2023 We foundthatmostofthesituationsinwhichphysicianscompliedwithfamilywishesto prescribe antibiotics involved endoflife situations. Other situations in which physicianstooktheopinionofothersintoaccountincludeuncertainsituations,which issupportedbyaDutchstudyontreatmentdecisionsfornursinghomeresidentswith dementia who develop pneumonia.18 The influence of patients and family members onantibioticprescribingdecisionscandifferbetweencountries.Forexample,itwas foundthatprescribingdecisionsofphysiciansintheUnitedStatesweremorestrongly guidedbyfamilywishesthanwerethoseoftheirDutchcounterparts.18,23 Other previouslyreported factors that can influence prescribing decisions in long term care includephysiciansbeing moreinclined to prescribe antibioticsjust before theweekend,22andphysicianfamiliaritywiththepatientorthepatients’family.20In 57 3 Chapter3 ourstudy,alackoffamiliaritywiththepatientorthepatients’familyappearedtoplay a role particularly when a physician was crosscovering, and less so during regular work hours. This is likely due to the organization of nursing home care in the Netherlands;elderlycarephysiciansareemployedbythenursinghome,andastheir main site of practice, this facilitates thedevelopment of a relationship between the physician and their patients and patient’s family, and ensures that the physician is wellawareoftheirtreatmentpreferences.31Incountrieswherephysicianpracticein nursing homes is often organized differently, such as in the United States, unfamiliarity with nursing homes residents is common.20,23 In line with our findings, unfamiliaritywithpatientscanpromoteantibioticprescribingduetofearsofadverse outcomes.21 Some of the factors we identified in the present study have, to our knowledge, not beendescribedbeforeforthelongtermcarepopulation,buthavebeenreportedin the general practice or hospital setting. These include a lack of insight into local resistancepattersandalackofawarenessofprescribingguidelines.3,4,9,12Inaddition, prescribinghabitsofpeers,alsoreferredtoas“prescribingetiquette”,wasreported as an importantfactorin the antibioticprescribing decisionin hospitalsandgeneral practice.7,10,13 Other factors previouslyreported in these settings are related to physicians’ perceived risks. In line with our findings, the risk of antibiotic resistance developmentinfluencedtheprescribingofaminorityofphysiciansintwoqualitative generalpracticestudies.7,12Furthermore,theriskofadverseoutcomesincaseofnon treatment, and a perceived duty towards the patient were previously reported to influenceprescribingdecisions.24,710 Two factors that were reported to influence antibiotic prescribing in other settings were not found in the present study. We did not identify disagreement or distrust with regard to existing evidence,7,10,11 which may be explained by the opinion of interviewed physicians that there is not enough evidence regarding treatment of infectionsinlongtermcare.Second,theinterviewsdidnotshowevidenceofadirect influenceoffinancialconsiderationsonantibioticprescribing.3,10However,regarding utilization of diagnostic resources, financial considerations were mentioned in the presentstudy,andsomayaffectantibioticprescribingindirectly. A strength of the current study is that the antibiotic prescribing process was investigated from the perspective of both physicians and nursing staff. As these parties collaborate and depend on each other in daily practice, we believe that our findings provide a good insight into factors that influence antibiotic prescribing in longterm care facilities. An additional strength is that we focused on recent case descriptions in the interviews, and subsequently explored other practice situations. This approach facilitates a realistic representation of daily practice with regard to antibioticprescribingdecisions. 58 Factorsinfluencingantibioticprescribinginlongtermcarefacilities Alimitationofthestudy,inherenttoqualitativeresearch,isthatnoassumptionscan be made regarding the weight that each identified factor adds to the prescribing decision.Futurequantitativeresearchisneededtoelucidatethecontributionofeach factor to the antibiotic prescribing decision. Another limitation is that our study design did not allow for checking data saturation at the time of data collection. However, no new codes appeared when coding the last few interviews, which supports that a sufficient amount of data was collected for drawing conclusions on thistopic. Aproperanalysisofrelevantfactorsthatinfluenceantibioticprescribingiscrucialfor thedevelopmentofanantibioticprescribingimprovementprogram.3Severalstudies show that interventions that target factors that impede appropriate antibiotic prescribingarelikelytobemoreeffective.3234Theconceptualmodelpresentedinthis studymaybeusedasapracticaltool,wherebyfacilitiesexplore,foreachcategoryin the model, whichfactorsinfluencelocal antibiotic prescribing,and identifywhichof these are inappropriate. Subsequently, they can intervene at the level of inappropriate factors to promote rational antibiotic prescribing. For example, if pressure exerted by patients is identified as a factor leading to inappropriate prescribing,interventionssuchaspatienteducationcouldbeimplementedtoaddress thisfactor.Factorsresultingininappropriateprescribingmaydifferbetweenfacilities and nations.For instance,influenceof nursing staff onthe prescribingdecisionmay be more important in facilities where – unlike in the Netherlands – no onsite physiciansarepresent,andwheremanyconsultationsareconductedbytelephone.In addition, the extent to which diagnostic resources are used may differ between facilities, with some facilities having better access to such resources than others. Whereas the importance of each factor in decision making may differ between facilities and nations, we believe that our model in general is likely to be widely applicable as many of the factors that we incorporated in the model have been reported in a variety of settings and countries. In addition, it shows overlap with a literaturebased prescribing decision model developed in a longterm care study conductedintheUnitedStates,27aswellaswithelementsofamoregeneralmodel forphysicianadherencetoclinicalpracticeguidelines.35 Conclusions Ourqualitativestudyshowsavarietyoffactorsthatinfluenceantibioticprescribingin longterm care facilities, of which several may lead to inappropriate antibiotic use. Some of these factors have not been previously reported for the longterm care setting, but have been described in studies in the general practice and hospital setting,indicatingthatseveralfactorsinvolvedinthesesettingsalsoapplytothelong term care setting. We developed a conceptual model that shows the relationships betweentheidentifiedfactors.Thismodelmaybeusedasapracticaltooltoidentify local factors potentially leading to inappropriate prescribing, to guide the 59 3 Chapter3 development of antibiotic prescribing improvement programs that target these factors. Acknowledgements Theauthorsthankthephysiciansandnursingstaffwhoparticipatedintheinterviews andsharedtheirexperiencesandperceptions.TheauthorsacknowledgeprofPhilipD SloaneandprofSherylZimmerman,oftheUniversityofNorthCarolinaatChapelHill, fortheircontributiontotheconceptionanddesignoftheIMPACTstudy. 60 Factorsinfluencingantibioticprescribinginlongtermcarefacilities References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Van Buul LW, van der Steen JT, Veenhuizen RB, Achterberg WP, Schellevis FG, Essink RTGM, van Benthem BHB, Natsch S, Hertogh CMPM: Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc 2012,13(6):568.e1–13. Hulscher MEJL, van der Meer JWM, Grol RPTM: Antibiotic use: how to improve it? Int J Med Microbiol 2010,300(6):351–6. HulscherMEJL,GrolRPTM,vanderMeerJWM:Antibioticprescribinginhospitals:asocialandbehaviouralscientific approach.LancetInfectDis2010,10(3):167–75. 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GrimshawJM,ShirranL,ThomasR,MowattG,FraserC,BeroL,GrilliR,HarveyE,OxmanA,O’BrienMA:Changing providerbehavior:anoverviewofsystematicreviewsofinterventions.MedCare2001,39(8Suppl2):II2–45. 33. Arnold SR, Straus SE: Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane DatabaseSystRev2005,(4):CD003539. 34. Lim CJ, Kong DC, Stuart RL: Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives.ClinIntervAging2014,13(9):165177. 35. CabanaMD, RandCS, Powe NR,WU AW, WilsonMH,AbboudPA,Rubin HR:Why don’tphysicians follow clinical practiceguidelines?Aframeworkforimprovement.JAMA1999,282(15)145865. 62 Factorsinfluencingantibioticprescribinginlongtermcarefacilities Additionalfile.Topiclistsforphysician(A)andnursingstaff(B)interviews. A)Topiclistforphysicianinterviews Instruction:boldprintedtopicsrepresenttheessentialelementstobecoveredintheinterview;theremainingquestions canbeusedtoraisefollowupquestions.[Instructionstointerviewerareprintedinitalics] Infectiousdiseases x Canyoutellmesomethingabouttheoccurrenceofinfectiousdiseasesinresidentsofthisfacility? x x x Howoftendotheyoccur(incomparisonwithotherdiseases)? Whichtypesofinfectiousdiseasesoccurmostoften? Accordingtoyou,howdoestheoccurrenceofinfectiousdiseasesinthisfacilitycomparetothe occurrenceofinfectiousdiseasesinotherhealthcaresettings(othernursinghomes/residentialcare facilities,hospitals,generalpractices, etc.) 3 Antibiotics x Canyoudescribethemostrecentcaseinwhichyouprescribedantibiotics? Listencarefullytowhichofthebelowmentionedtopicsareraised,andrelatetotheseinfollowupquestions accordingly.Note:notallquestions(thosenotbolded)needtobecovered! x Whataspectsofthiscaseresultedinyourdecisiontoprescribeantibiotics?Inotherwords,whichconsiderations didyoumakepriortoyourdecisiontoprescribeantibiotics? Incasetheclinicalpresentation/statusofthepatientisconsideredintheprescribingdecision: (E.g.signsandsymptoms,additionaldiagnosticinformation,clinicalhistory) x Wastheclinicalpresentationclear? x Istheclinicalpresentationoften(also)clearinothercases? x Arethereanypatientgroupsinwhichtheclinicalpresentationisoftenlessclear? x Doyoufindproperdiagnosingdifficultiftheclinicalpresentationisambiguousornotclear? Inthedescribedcase,whatinformationdidyouneedfromthenursingstaff? x Didyouindeedgetthisinformation? x Howdoyoufeelaboutthequalityoftheinformationinthiscase?Isthisinlinewithyouropinionmore generally? x Arethereanydifferencesinthequalityofinformationifyouaskapatientforhis/hersymptoms yourselfcomparedtoifyouobtainthisinformationviathenursingstaff? x Inyouropinion,isnursingstaffcapableofadequatelyassessingsignsandsymptomsofinfections? x Inyouropinion,doesnursingstaffadequatelyreportsignsandsymptomsofinfectionstothe physicians? x Doestheprovisionofinformationbytelephoneaffectthequalityoftheinformation? Incaseofinfluenceofthepatient,familyand/ornursingstaffontheprescribingdecision: (ifthisdidnotappearfromthecasedescription,inquireaboutanyoccurrenceofinfluenceofthepatient,family and/ornursingstaffmoregenerally,andaskforanexampleifapplicable). x Whichpreferenceswereexpressedbypatients,familyand/ornursingstaff?Aresuchpreferences expressedmorefrequently? x Towhatextentdidthesepreferencesconcurwiththetreatmentyouwouldpropose?Dothey(also) concurinothercases? x Doyouexperienceitas‘difficult’tohandlethepreferencesofpatients,familyand/ornursingstaff?Why do/don’tyouexperiencethisas‘difficult’?Inwhichsituationsinparticular? x Doesthedurationorqualityofthephysicianpatientrelationshipaffectthewaypreferencesofpatients andfamilyaredealtwith?Andhowso? Incaseotherfactorsappearedtobeinvolvedintheprescribingdecision: (E.g.theriskofdevelopmentofantibioticresistance,organizationalfactors(timepressure,staffshortage,staff turnover,presence/availabilityofdiagnosticresources,financialconsiderations). Thoroughlyquestionhowandwhythesefactorswereconsidered! 63 Chapter3 x Inretrospect,doyoufeelthatprescribingantibioticswastherightdecisioninthiscase? x x x x x x x x x x Wasthischoicebasedonempiricalgrounds,ordidyouhaveanyinformationabouttheinfectiveagent (cultureresult)atthetimeofprescribing? Isyourprescribingoftenempirically/basedoninformationabouttheinfectiveagentinother situationsaswell? Whendoyoudecidetotakeaculture? Whatpreventsyoufromtakingcultures? Is…[infectiontypecase]aninfectiontypeforwhichyouoftenprescribeantibiotics? x x x x Canyouexplainthis?Whydoyoufeelthiswas(not)agooddecision? Incasetreatmenteffectivenesssupportedthefeelingthatprescribingantibioticswastheright decision: Basedonwhatdidyouconcludethatthetreatmentwaseffective? Whatisyourunderstandingofa‘good’prescribingpattern? (Basedonevidence,aformulary,routine,experience,observedeffectiveness,etc.) Generallyspoken(notspecificallyforthiscase),inretrospect,doyouconsideryourdecisionto prescribeantibioticsastheright/agooddecisionornottheright/agooddecision? x Canyouexplainthis? Canyoudescribeasituationinwhichyoufelt,inretrospect,thatyourdecisiontoprescribe antibioticswasnotagooddecision?Orthatyouwereindoubtaboutwhetheritwasagooddecision ornot? Doyoubelievethatthereareopportunitiestoimproveantibioticprescribingbyphysicians(including yourself)? x Canyougiveexamplesofsuchopportunities? x Howcouldthisbeachieved? x Doyoubelievephysiciansareopentosuchopportunities? Whydidyouselectthespecificantibioticagentprescribedinthedescribedcase? (E.g.formulary,patientallergies,patients’renalfunction,priorantibioticresistance) x x Whyis/isn’tthisaninfectiontypeforwhichyouoftenprescribeantibiotics? Forwhichinfectiontypesdoyoualsofrequently/morefrequentlyprescribeantibiotics? Ingeneral,areantibioticsfrequentlyprescribedfortheresidentsofthisfacility? x Accordingtoyou,howdoestheoccurrenceofantibioticsprescribinginthisfacilitycompareto theoccurrenceofantibioticprescribinginotherhealthcaresettings(othernursinghomes/ residentialcarefacilities,hospitals,generalpractices,etc.) Sofar,wediscussedsituationsinwhichantibioticswereprescribed.Canyoualsodescribethemostrecentcase [withaninfection]inwhichyoudidnotprescribeantibiotics? x x x Whydidyoudecidenottoprescribeantibiotics? Canyoudescribeothersituationsinwhichyoudonotprescribeantibiotics? Arethereanysituationsinwhichyoufinditdifficultnottoprescribeantibiotics?Canyoudescribe thesesituations?Whydoyouexperienceitasdifficulttonotprescribeantibioticsinthesesituations? (E.g.pressureoffamily(seealsopreviouspage),riskofnegativeoutcomeofinfection) 64 Factorsinfluencingantibioticprescribinginlongtermcarefacilities Antibioticresistance x Canyoutellmesomethingabouttheoccurrenceofantibioticresistanceinthisfacility? x x x x x Howoftendoesitoccur? Doyoubelievethereisanincreaseinantibioticresistance?Whatarethecauses? Accordingtoyou,howdoestheoccurrenceofantibioticresistanceinnursinghomes/residentialcare facilitiescomparetotheoccurrenceinhospitalsorthecommunity? Inyouropinion,howlargeistheresistanceprobleminnursinghomes/residentialcarefacilities?And howlargeintheNetherlandsingeneral? Doyoubelievethatyouarewellawareofthedevelopmentswithregardtoantibioticresistance?If not,whynot? x Doyou,asaphysician,experienceapersonalresponsibilityfortheemergenceofantibioticresistanceinthe facility?Andinsocietyingeneral? x Whois/arealso/moreresponsiblefortheemergenceofantibioticresistance? 65 3 Chapter3 B)Topiclistforinterviewswithnursingstaff Instruction:boldprintedtopicsrepresenttheessentialelementstobecoveredintheinterview;theremainingquestions canbeusedtoraisefollowupquestions.[Instructionstointerviewerareprintedinitalics] Infectiousdiseases x Canyoutellmesomethingabouttheoccurrenceofinfectiousdiseasesinresidentsofthisfacility? x x x x Dotheyoccuroften(incomparisonwithotherdiseases)? Whichtypesofinfectiousdiseasesoccurmostoften? Accordingtoyou,howdoestheoccurrenceofinfectiousdiseasesinthisfacilitycomparetothe occurrenceofinfectiousdiseasesinotherhealthcaresettings(othernursinghomes/residentialcare facilities,hospitals,generalpractices,etc.) x Whatisspecificforaurinarytractinfection? x Whendoyoudecidetoperformadipsticktest? Whatisspecificforarespiratorytractinfection? Whatisspecificforaskinorwoundinfection? Doyoubelievethatyou(andyourcolleagues)arewellcapableofassessingsignsandsymptomsof infections?Why(not)? x x x x Howdoyourecognizeaninfectioninaresident? Canyoudescribewhenyoureportsignsandsymptomsofinfectiontoaphysician? x Whenisitimportanttoconsultaphysicianincaseofsignsandsymptomsofaninfection? x Doyoufinditdifficulttodeterminewhenaphysicianshouldbeconsultedforaresident? x Canyoudescribeanexampleofsituationsinwhichaphysicianissometimesconsultedtoosoon? Andanexampleinwhichaphysicianisnotconsultedsoonenough? Doyoubelievethatyouarewellcapableofreportinginformationaboutsignsandsymptomsof infectionstoaphysician? x Doestheinformationthatyouprovidehelpthephysicianinmakingdecisionsregardingthe treatmentoftheinfection? x Doyoufeelthatthephysicianfindstheinformationthathe/shereceivesimportant? x Doyoubelievethatattimesyoucouldprovidemoreorbetterinformationtothephysician?Or, bycontrast,providelessinformation? x Howdoyoureporttheinformationtothephysician?Inperson,bytelephone,viawritten communication? x x Canyoudescribethemostrecentsituationinwhichyouconsultedaphysicianforapossibleinfectionina resident? x x x x x x x 66 Fromwhichtypeofinfectiondidtheresidentsuffer? Howdidyourecognizethisinfection? Howdidyouinformthephysician? Howdidthephysicianrespond? Didyouexpectthephysiciantoinitiateaspecifictreatment? Didthephysicianactaccordingtoyourexpectation? Canyougiveexamplesofsituationsinwhichthephysiciandidanddidnotactaccordingtowhatyou hadexpected? Factorsinfluencingantibioticprescribinginlongtermcarefacilities Antibiotics x Canyoutellmesomethingabouttheuseofantibioticsinthisfacility? x x x x x x 3 Canyougivesomeexamples? Howcouldthisbeachieved? Doyoubelievephysiciansareopentosuchactivities? Dophysicians,attimes,notprescribeanantibiotic,whileyoubelieveitwouldbebetterifhe/shedidso? (possibleoverlapwiththelastquestionofthesection‘infectiousdiseases’) x x x x Canyougiveanexampleofasituationinwhichsignsandsymptomswererelieved,andofasituation inwhichtheynot? Inthesituationinwhichsignsandsymptomswerenotrelieved;accordingtoyou,whynot? Inretrospect,doyouoftenbelievethatthedecisionofaphysiciantostartantibioticswasagood decision?Why(not)? x Whendoyoubelieveaphysicianshouldstartantibiotictreatment? (E.g.whenyoufeelthepatientneedsantibiotics,whenindicatedbyguidelines,whenantibiotic treatmentiseffective,etc.) Couldphysiciansimprovetheirantibioticprescribinginanymanner? x x x x Ifaresidentwithaninfectionreceivesantibiotics,towhatextentdoesthisalleviatethesignsandsymptoms? x x Areantibioticfrequently/infrequentlyprescribedfortheresidents? Doyouthinkthatthispatterndiffersfromothernursinghomes/residentialcarehomes,orother healthcaresettingssuchashospitalsorgeneralpractices? Forwhichtypeofinfectionareantibioticsprescribedmostfrequently? Canyougiveanexample? Doyouthenletthephysicianknowthatyoubelieveitwouldbebettertoprescribeantibiotics?And howdoyoulethim/herknow? Doyoufinditdifficulttoexpressyourdisagreementwiththephysician’streatmentdecision? Canyouthinkofanynegativeconsequencesoftheuseofantibiotics? (E.g.withregardtosideeffects,developmentofantibioticresistance,andcosts) Thoroughlyquestionwhythementionedconsequencesareanegativeeffectofantibioticuse! Antibioticresistance x Whenantibioticsareusedfrequently,antibioticresistancecanoccur.Canyouexplainwhatthismeans,according toyou? (Iftheydonotknow:antibioticresistancemeansthatbacteriathatcauseinfectionsarenotsusceptibleanymore tospecifictypesofantibiotics,andconsequently,patientswiththeseinfectionscannotbetreatedanymorewith thesetypesofantibiotics). (Possibleoverlapwiththepreviousquestion) x Canyoutellmesomethingabouttheoccurrenceofantibioticresistanceinthisfacility? x x x x Doesitoccuroften? Doyoubelievethereisanincreaseinantibioticresistance? Accordingtoyou,howdoestheoccurrenceofantibioticresistanceinnursinghomes/residentialcare facilitiescomparetotheoccurrenceinhospitalsorthecommunity? Inyouropinion,howlargeistheresistanceprobleminnursinghomes/residentialcarefacilities?And howlargeintheNetherlandsingeneral? 67 Chapter3 68