Family Practice Vol. 17, No. 2, 210
© Oxford University Press 2000
Correspondence
Centre for General Practice, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium.
Antibiotics are being overprescribed by GPs, especially for respiratory tract infections (RTIs).1 Damoiseaux and co-workers explored the reasons, other than those stated in the guidelines of the Dutch College of GPs, for prescribing antibiotics for acute otitis media. They found that the participating GPs most often mentioned medical reasons for prescribing antibiotics, but that in a substantial number of cases they gave non-medical reasons as well.2
In order to be able to implement strategies to restrict inappropriate antibiotic prescriptions, we too believe insight into the reasons for the actual prescribing may be important. Medical decisions concerning RTIs, however, are prompted most often by complaints about coughing.3 Therefore, we performed a qualitative decision analysis using the focus group technique to explore the determinants of the diagnostic and therapeutic decisions of GPs regarding adult patients who consult them with complaints about coughing. The hypotheses we generated were based on ‘qualitative content analysis’.4
We also found medical as well as non-medical reasons for antibiotic prescriptions, but believe it is particularly insightful to elaborate upon the different nature of both categories of reasons.
In cases of suspected RTI, there was a low degree of certainty in the differentiation between RTIs according to the participants. A distinction between clinical syndromes such as bronchitis and pneumonia for example could not be achieved with certainty on the basis of arguments from the medical history and clinical examination: i.e. medical reasons, determining the probability of disease.
Dealing with this diagnostic uncertainty, their decisions were directed at whether or not to prescribe antibiotics. A logical decision according to Kassirer, since GPs considered antibiotics highly effective and almost risk free.5
If there was diagnostic doubt, GPs' prescription behaviour was determined mainly by doctor- and patient-related factors (e.g. having missed pneumonia once, patient expectations): i.e. non-medical reasons, not determining the probability of disease, but rather shifting the action thresholds at which to prescribe antibiotics or not.6
In our view, Feinstein's ‘Chagrin Factor’ explains why these non-medical reasons lead to a shift in the action threshold in favour of antibiotics.7 GPs considered it less appropriate, i.e. it is causing them more chagrin not to have prescribed antibiotics when this proved to be necessary, than having prescribed antibiotics when not necessary. Furthermore, ‘when necessary’ did not only mean necessary to cure the patient, but also necessary to function as a GP without losing patients as a result of unfulfilled expectations or undetected serious diseases.
In order to change their prescribing behaviour, doctors have to be explicitly aware that the action thresholds at which they prescribe antibiotics are determined by doctor- and patient-related factors, especially when there is insufficient medical reason. Learning to communicate their decision analysis and motives to the patient may lead to a more rational and shared antibiotic prescribing decision and, meanwhile, preserve good doctor–patient relationships.
References
1
Wise R, Hart T, Cars O, Streulens M, Helmuth R, Huovinen P et al. Antimicrobial resistance is a major threat to public health [editorial]. Br Med J 1998; 317: 609–610.
2
Damoiseaux R, de Melker R, Ausems M, van Balen F. Reasons for non-guideline-based antibiotic prescriptions for acute otitis media in The Netherlands. Fam Pract 1999; 16: 50–53.
3 Okkes I, Oskam S, Lamberts H. Van Klacht naar Diagnose. Episodegegevens uit de Huisartspraktijk. [From complaint to diagnosis. Episodic data from general practice.] Bussum: Coutinho, 1998.
4
Morgan D. Qualitative content analysis: a guide to paths not taken. Qual Health Res 1993; 3: 112–121.
5 Kassirer J. Our stubborn quest for diagnostic certainty. A cause of excessive testing. N Engl J Med 1989; 320: 1489–1491.[Web of Science][Medline]
6 Pauker S, Kassirer J. The threshold approach to clinical decision making. N Engl J Med 1980; 302: 1109–1117.[Abstract]
7
Feinstein A. The ‘Chagrin Factor’ and qualitative decision analysis. Arch Intern Med 1985; 145: 1257–1259.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||