Our struggle to implement best practices: the example of antibiotic prescription for respiratory tract infection.

As a profession, family physicians agree to follow evidence-based guidelines for the delivery of optimal care. However, as practicing family physicians we often struggle to do so. Why is this? We may start to understand the scope of the problem and the factors involved by inspection of a specific example. One of the most common family practice encounters is the assessment of respiratory tract infection (RTI), accounting for about 15% of all visits (1). Over-prescription of antibiotics for RTI is a serious problem (2). In this issue, and with articles from our previous issue, we present several analyses shining evidence on both our progress as a discipline towards evidence-based care and potential reasons for the lack thereof, as illustrated by this important problem (3–7). Dekker et al. (3) of the Netherlands present a well-conducted prospective observation study ‘Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients’. Through analysis of detailed guideline-linked encounter data on over 2700 consultations for RTI among four dozen Dutch primary care practices during 2008–10, they are able to credibly compare observed to ideal care. They demonstrated that compared to the guideline recommendations, nearly half (46%) of the observed prescription of antibiotics were not indicated. This level of disparity appears relatively unchanged from selected RTI condition findings by Akkerman et al. (8) of nearly a decade prior. Dekker’s rigorous methods and detailed analyses provide the first comprehensive quantification of inappropriate prescribing among the full range of RTI encounters. Most usefully, they highlight key determinants of overprescribing. Family physicians may be assisted in striving to achieve evidence-based prescribing to be aware that the most common settings for inappropriate prescription were among adults 18–65 years, and those presenting with fever and symptoms for longer than 1 week. Dekker’s findings corroborate those of the comprehensive analysis of Swedish electronic medical records with integrated prescription data presented by Neumark et al. (4) ‘Antibiotic prescribing in primary care by international medical graduates and graduates from Swedish medical schools’ in the previous issue of Family Practice. Although not designed to capture detailed clinical signs and symptoms required to directly compare antibiotics prescribed to guideline indication, their inclusion of over 21 600 general practice encounters for RTI contributes a population perspective on the scope of the problem. Their retrospective study determined that 48% of patients presenting to primary care for RTI received antibiotics. This closely mirrors the prospective clinically defined analysis of Dekker et al. and further supports systematic over-prescription for antibiotics in RTI. Interestingly, Neumark et al. were able to compare these 2011–12 findings with their previous 2005 study, observing about one-third fewer antibiotic prescriptions in RTI consultations (9,10). Thus, the cycle where clinical questions lead to research, which lead to improved clinical care and to subsequent research, can be demonstrated to be associated with incrementally advancing evidence-based care. Approaches to better diagnostic assessment are explored by both the Danish team led by Strykowski (5) in this issue and by Mistik and her Turkish colleagues (6) in our June issue. In ‘An intervention with access to C-reactive protein rapid test reduces antibiotic over-prescribing in acute exacerbations of chronic bronchitis and COPD’, Strykowski et al. (5) present their evaluation on the reduction of over-prescribing for acute chronic obstructive pulmonary disease exacerbations. Their prospective study tracked three intervention cohorts to examine the diagnostic value of the addition of a 3-minute ‘finger-prick and card’ rapid test to usual guideline-based diagnoses, among Spanish primary care clinics. They demonstrated a clear reduction in over-prescribing with use of the rapid C-reactive protein test, with no apparent increase in under-prescribing, although their study was not sufficiently powered to detect under-prescribing differences. Similarly, Mistik et al. (6) add a diagnostic tool to the general practitioner armamentarium in ‘Sore throat in primary care project: a clinical score to diagnose viral sore throat’, where they describe the development and validation of a symptom-based score system highly sensitive and specific for viral RTI. Thus, we see a wealth of data on our inability to follow guidelines and helpful new tools to advance our confidence to deliver guideline-based care. What is it that separates the care we deliver from best practice recommendations? de Bont et al. (7) present some insights to this quandary in their excellent qualitative analysis ‘Childhood fever: a qualitative study on GPs’ experiences during out-of-hours care’. Although not limited to RTI, their outstanding qualitative methodology documents rich details on the perspective of family physicians attempting to balance evidence-based guidelines with the demands of after-hours consultations in the highly analogous case of childhood fever. Physicians participating in focus groups agreed that antibiotics were over-prescribed in after-hours consultations. Inductive analyses of their extensive collection of data indicated several key reasons general practitioners over-prescribe in these situations, ranging from the time pressure of the after-hours setting and lack of knowledge that would have been present in a long-term relationship, to frustrated parents, Family Practice, 2015, Vol. 32, No. 4, 365–366 doi:10.1093/fampra/cmv055 Advance Access publication 10 July 2015