Uncertainty as a critical determinant of antibiotic prescribing in patients with an asthma exacerbation: a qualitative study

Abstract

Objective

To identify factors that influence providers’ decisions to prescribe antibiotics in patients presenting to the hospital with an asthma exacerbation.

Methods

We performed semi-structured interviews with a purposive sample of providers including sixteen hospitalists, emergency room providers, or pulmonologists, and one focus group with internal medicine residents recruited from one large, urban, teaching hospital and one small, rural, community hospital. Questions were informed by the Theoretical Domains Framework to determine factors that may influence behaviors. Directed content analysis was used to code and analyze transcripts of the interviews.

Results

Uncertainty regarding the diagnostic (asthma vs. COPD) and the cause of exacerbation (bacterial vs. viral infection) emerged as the main driver for prescribing behavior. Provider response to uncertainty included: “watchful waiting” or immediate antibiotic prescribing. The following factors played important roles in providers’ prescribing decision: 1) awareness/agreement with existing guidelines 2) confidence in their ability to apply the guidelines in challenging cases; 3) perceived risk of patient deterioration without antibiotics; 4) fear of litigation; 5) habit and clinical inertia 6) prescribing within the group 7) lack of information of antibiotic prescribing rates and 8) lack of time and/or resources.

Conclusions

We identified diagnostic uncertainty as the primary determinant of antibiotic prescribing in asthma exacerbations and developed a conceptual model to explain provider responses and factors that influenced their responses. These results enhance our understanding of the factors that can contribute to low-value and wasteful practices like superfluous antibiotic prescribing and will support the development of interventions to de-implement such practices.

Keywords:

• Uncertainty
• antibiotics
• asthma
• exacerbation
• qualitative
• interviews
• semi-structured
• behavior
• de-implement
• guidelines
• model

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Funding

Peter Lindenauer is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K24 HL132008-01.