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Using qualitative methods to understand antibiotic prescribing

A video summary of how we can use qualitative methods to understand antibiotic prescribing and if they could change intervention outcomes.
Hi, my name is Esmita Charani, and I’m going to be talking in this presentation about using qualitative methods to understand antibiotic prescribing in hospitals. The reason we are looking at this, and we are interested to apply social science methods to investigate antibiotic prescribing in hospitals, and also to look at how we can develop contextually fit stewardship interventions is that, although policy and guidelines and the recommendations about antimicrobial stewardship go a long way in implementing change, it is important to bear in mind that clinical decision making is a very complicated process and providing policy and guidelines, alone, often may not be sufficient to change the behaviours of individual physicians.
The clinical environment is very cluttered with many different people working to different priorities, using different targets. And sometimes the policy and guidelines could be a bit like the traffic light system in this picture. If I was to use real clinical examples to describe the chaos in clinical decision making, I would use this graph about the policy and guidelines that has been implemented at a national or international level around antibiotic stewardship and sepsis in the last 10 years. And this, of course, needs to be updated. But it gives you an idea of the amount of noise and directions that are coming out at health care professionals around expectations on how they should be prescribing antibiotics and treating infections.
And the blue text in the bottom reflects the actual policies and interventions that have been implemented in one hospital in London around the antibiotic stewardship at the same time. So there’s lots of messages that we’re sending out to clinicians. And some of these messages can be conflicting, especially around the surviving sepsis campaigns and anti-microbial stewardship campaigns. Whereby in antimicrobial stewardship campaigns, we’re trying to rationalise antibiotic use and narrow the spectrum of therapy as soon as we can. And in the sepsis campaigns, we are trying to encourage clinicians to use broad-spectrum antibiotics to treat sepsis.
And there have been studies to indicate that this may cause confusion, for example, for junior doctors in emergency services, whereby antibiotics may be prescribed too often, unnecessarily, for patients who may have suspected sepsis. So what we would like to do is to apply social science methods to see how we can better understand the decision making process of physicians who look after patients on a daily basis. When we began looking at this at our centre, we realised that the literature around antibiotic stewardship in hospitals overwhelmingly relied on international studies and quantitative research. So we wanted to look at what qualitative evidence there was, if any studies had been done already around the determinants of antibiotic use in hospitals.
And we conducted a systematic review that includes both qualitative and quantitative studies investigating and reporting on the implementation of antimicrobial stewardship in hospitals. And what we found is that in the literature at the time– this is nearly 10 years ago– there were very few, very limited number of studies that had qualitatively tried to understand the decision making that underpins the behaviours we observe in terms of antibiotic stewardship and antibiotic prescribing. And what we also found is that in the quantitative papers, there was very little explanation for the rationale of the interventions that were used. So people were implementing antibiotic stewardship without really trying to understand or having an understanding of the drivers for those behaviours, or for antibiotic prescribing behaviours.
We followed this up with our own study adopting qualitative face-to-face interviews with clinicians that we considered to have an important role or a key role in antibiotic prescribing in hospitals, and also with nurses and pharmacists, who in the UK have a role in implementing and promoting antibiotic stewardship. And what we identified is that antibiotic prescribing must be recognised as a behaviour. It is not a linear process. It’s very complex. There are many different actors and actions that determine the prescribing outcomes. And it’s a very dynamic process, in that it isn’t a single act at a single time.
The whole decision from the beginning of diagnosing an infection, making sure that the right culture and sensitivity tests are sent and the data are used to inform decision making, to review the patients on antibiotics, and the decision to stop antibiotics, involves a lot of health care professionals along the health care pathway. And we also reported on the importance of a set of unwritten rules. And we were able to do this because we interviewed physicians, pharmacists, and nurses individually, who were able to tell us what they consider to be important determinants and important factors when making decisions around diagnosis and treatment of infections.
And across all of these health care professionals, there was an understanding of a set of unwritten rules around the factors, in addition to policy and guidelines and directives from the organisation and beyond, that determined what and how antibiotics should– what antibiotics should be prescribed and how they should be prescribed for individual patients with infections. And we termed this prescribing etiquette. But really, what prescribing etiquette describes is that there is a hierarchy in antibiotic prescribing, in that it’s often the senior doctors who decide whether antibiotic needs to be prescribed. But the actual act of prescribing is then delegated to junior doctors. And they have to make those decisions often without any further input from the senior physicians that they work with.
We also described the need for clinicians to feel that they have autonomy and ownership of the decisions that they make. They don’t like to have their decision for their individual– the patients that they look after be questioned by other specialties. And that can influence how antibiotic stewardship teams are able to interact with other clinicians whose behaviours they want to change to optimise antibiotic use in hospitals. So this influence of hierarchy is quite prominent. And this is something that we want to investigate further, to see how we can work with champions and opinion leaders to be able to implement change across different specialties. And it’s very interesting and very encouraging to see that WHO has recognised this.
And this report was published not long ago, about the need to understand contextual factors that influence antibiotic decision making in hospitals. And often what happens is that the policy and guidelines from high income countries are transferred to low and middle income countries. And there isn’t enough consideration for the contextual factors that influence decision making in different settings. The workforce available in different settings and the resources available all have an impact on outcomes. And we need to have a dialogue for engagement and ownership about antibiotic use with health care professionals and clinicians from different specialties. And recognising this, we went beyond our study in the UK.
And we identified health care professionals in different countries who had a role in antibiotic prescribing, to be able to conduct this wider or bigger study, to look at what determines decision making in anti-microbial stewardship in different settings. And the reason why we did this is that the majority of the evidence from the comprehensive systematic review which we have conducted over the last 10 years– there’s been three comprehensive systematic reviews– the majority of the evidence comes from the developed health care systems, countries that represent developed health care systems from North America and Europe. There is very little evidence from the rest of the world about antimicrobial interventions and what works and what doesn’t.
So in our study, we identified stakeholders who had a role in implementing antibiotic stewardship in their countries. And we chose India, Burkina Faso, England, France, and Norway, because these countries represent different health care system economies but also different burden of infectious diseases. So in this graph– and we could have used any infection marker to represent and get the same pattern– but really the burden of infectious disease is highest where the resources are least available. And that’s another factor that needs to be taken into consideration when developing antibiotic stewardship programmes in different settings.
When we looked at the availability of existing stewardship programmes in these different countries– and we had specifically chosen to work, to carry out the study in institutions in these countries that were recognised to have an established stewardship programme in place– we compared the availability and the maturity of the stewardship programmes against the, at the time, up-to-date 2014 CDC key components of antimicrobial stewardship. And what we found is that there were gaps in each setting, particularly around the availability of resources in implementing antimicrobial stewardship, but also in antimicrobial stewardship being very much limited by professional boundaries. There are very few countries, still, whereby nurses and pharmacists have an active role in antibiotic stewardship.
And that’s something that we would like to change and to be able to demonstrate the feasibility and the utility of being able to use the wider health care professionals in implementing antimicrobial stewardship. There was also a lack of heterogeneity in the shape and structure of the programmes available. And this varied across the board in different countries, whether it was having national guidelines or also having institutional level guidelines, whether it was the cadre of health care professionals who were involved in antibiotic stewardship. So in most of the world, it’s still only doctors who have a role. And that’s something we want to change.
And what was most interesting to us is that across all of these countries, there wasn’t enough sufficient engagement with the surgical teams in antimicrobial stewardship. The gaps in implementing antibiotics stewardship in surgery was recognised across the board in this study that we conducted. So in conclusion, our studies so far, using qualitative methods, have shown that antibiotic prescribing is a social process. And hierarchies and team dynamics still matter in how antibiotic stewardship interventions can be implemented and the shape and outcome of those interventions. And contextual factors are also important in determining prescribing outcomes.
And this is something that I’m going to be talking a lot more about in my next presentation, when we talk about the ethnographic research that we have done across surgical and medical specialties to investigate antibiotic prescribing. Thank you very much for listening.

In this presentation, Dr Esmita Charani will summarise the existing research that has been conducted at Imperial (and elsewhere). The aim was to better understand how qualitative research inquiry can provide unique and fresh insights into social factors that can influence antibiotic prescribing behaviours and shape intervention outcomes.

There is a lot of pressure on health care professionals to know when, how and what antibiotics they should be prescribing. Some of the messages sent to clinicians can be conflicting. It is important to be able to use social science methods to see how we can understand the decision-making process of clinicians.

When first looking at research, it was found that the topic lacked huge amounts of qualitative research and so at Imperial a study was followed with qualitative face-to-face interviews. The key findings from this were that antibiotic prescribing is a behaviour; it is a non-linear, complex and dynamic process that involves many actors and actions, and it is not a single act at a given time.

Please find a pdf of the PowerPoint slides in the downloads section below.

In the comments below please let us know:

  • Has ethnography ever been used as a research method in your healthcare setting?
  • What was being investigated?
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Tackling Antimicrobial Resistance: A Social Science Approach

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