Factors influencing antibiotic prescribing in long-term care facilities: a qualitative in-depth study

Abstract

Background: Insight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors.

Methods: Semi-structured qualitative interviews were conducted with physicians (n = 13) and nursing staff (n = 13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff.

Results: The analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians' perceived risks, influence of others, and influence of the environment. Each category comprises several factors that may influence the decision to prescribe or not prescribe antibiotics directly (e.g. pressure of patients' family leading to antibiotic prescribing) or indirectly via influence on other factors (e.g. unfamiliarity with patients resulting in a higher physician perceived risk of non-treatment, in turn resulting in a higher tendency to prescribe antibiotics).

Conclusions: Our interview study shows that several non-rational factors may affect antibiotic prescribing decision making in long-term 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 relationships between those categories. This model may be used as a practical tool in long-term care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriate antibiotic prescribing.

Figure 1

Conceptual model of factors that influence antibiotic prescribing in nursing homes and residential care homes in the Netherlands. The model shows that the clinical situation and advance care plans constitute the basis of the antibiotic prescribing decision. The other four categories can exert a direct influence on this prescribing decision, or an indirect influence via other categories. The clinical situation can influence the use of diagnostic resources (e.g. no X-ray when a patient is severely ill) and vice versa (e.g. less information about the clinical situation when no diagnostic resources are used). The use of diagnostic resources can also be influenced by environmental factors (e.g. availability of on-site diagnostic resources). Physicians’ perceived risks can be influenced by the clinical situation (e.g. higher perceived risk of non-treatment if a patient is severely ill), the use of diagnostic resources (e.g. more uncertainty if no diagnostic resources are used), others (e.g. pressure from patients), and the environment (e.g. different risk perceptions when on call). The influence of others can be affected by the environment (e.g. the influence of nursing staff may differ when a consultation is by telephone compared to a physical consultation).