Research On Physician's Antimicrobial Prescription Behavior Based On Grounded Theory

Background:The development and application of antibacterials is one of most noble achievements in modern medical history.However with the increase use of antibacterial,its overuse and misuse became a prominent hazard.As a result,the issue of antimicrobial resistance is becoming a major concern among international medical science society.WHO warn that the misuse of antibiotics is threatening to render our most potent medicines useless and call on taking urgent action to reverse the problem.The yearly per capita consumption of antibacterial in China is ten times of international level.Therefore,it is extremely urgent to improve the condition.Since most drugs are prescribed and administered in hospital and it is of great duty for hospitals and doctors to push for antibiotics to be used in more scientific and rational ways.Objective:This study intends to explore the behavior of doctors when prescribing antibacterial and to answer the questions below:(1)why doctors prescribe antibiotics;(2)how they decide to use them;(3)how they choose the drugs;(4)what are the factors that affect the process and what is the relationship among the factors;(5)what are the doctors’ opinion upon antibacterial use in clinic.Methods:This study used a grounded theory approach,which is a qualitative procedure for generating a theoretical model grounded in the views of participants.24 doctors from seven hospitals in Xi’an city participated in the study.Each participant completed a one-on-one interview(14 to 61 minutes per interview).The data were collected during the time period from October 2009 to March 2011.At the same time,100 rural doctors from Shaan’xi Province and 110 junior doctors from a grade 3 hospital in Xi’an City were investigated using self-designed questionnaire.Then the investigation results were compared with that of interviews.MAXQDA database was used for analysis,which is a qualitative data analysis software that facilitates the storage,retrieval,and coding of unstructured text data.SPSS.15 was used for the statistical analysis.The above mentioned results were discussed finally based on Bronfenbrenner’s bioecological theory.Results:This study summarized that there were 20 types of antibiotics prescirbing behavior pattern,6 types of irrational performance and 6 kinds of factors that influence prescribing behavior.Also a prescription behavior ideograph and a causal chart of prescribing behavior were depicted.Twenty types of prescribing pattern include:experience-based model,profit-drived model,aetiology-based model,literature-based model,passive receiving model,a corresponding rise model,step by step model,strike-out model,doctor-patient negotiation model,mental comfort model,low price and low shelf model,drug combination model,comprehensive therapy model,experimental treatment model,follow-up model,consultation based model,antibacterial spectrum based model,custom based model,all-round consideration model,etc.Among above models,experience-based and profit-drived model covered the biggest proportion,involved in 65.2%and 60.9%doctors respectively.Irrational prescribing behaviors include:unclear indication,wrong drugs,incorrectly drug combination,using certain drugs only,irrational long course of treatment,incautious therapy,etc.Unclear indication and excessive course are the most common performances,accounting for 34.8%and 30.4%doctors respectively.There are six main factors that influence the behavior pattern of antibiotics prescribing,including doctor related factors,circumstance related factors,patient related factors,drug related factors,clinical related factors,and management related factors.Doctor related factors consist of drug knowledge,medication concept,aetiology awareness,prefessional ethics and value,attention to individual reputation,etc.Environmental factors consist of doctors’salary,working pressure and psychological problems,social climate,doctor-patient relationship,drug promotion activity,etc.Patient-related factors consist of medication notion,economy burden,pathological physiological condition,etc.Drug-related factors comprise price,efficacy,safety,etc.Clinical-related factors consist of clinical uncertainty,diagnosis difficulty,defects of etiological examination,antimicrobial resistance,etc.Management-related factors consist of administration system,drug approve administration,price control,drug circulation administration,clinical administration,medication guides,clinical training,medical insurance administration,hospital management,etc.Among above factors,management and environmental related factors are coded most frequently,with 138 and 133 times respectively.By analyzing the causal chart,the causes of irrational use of antibiotics can be explained from three aspects:①administration reason such as drug pricing,excessive drug types,insufficient investment in hospital,inadequate administration,drug promotion,etc.②clinical medicine reason such as clinical uncertainty,diagnosis difficulty,defects of etiological examination,drug knowledge and clinical thinking,etc.③social psychology reason such as tension of the doctor-patient relationship,medication concept,prescribing habit,working pressure,social climate,professional ethics,etc.Investigation found that drug information of rural doctors mainly come from related books,training and drug instructions,etc.Only 4.6%physicians express definitely that they will not prescribe antibiotics for patient with common cold.Some physicians experience fear of losing patient or losing face.The most frequently used antibacterials by rural doctors include penicillins and the first generation cephalosporins.Rural doctors crave for knowledge about rational use of drug,adverse drug reaction and treatment.Investigation to junior doctors in a 3-grade hospital revealed that 18.1%of the doctors were unfamiliar with guidelines for clinical use of antibacterials,and 81.9%believed the situation of inappropriately antibacterials use was serious or very serious.Among the factors influencing rational use of antibacterials,"lack of bacterial resistance information","heavy pressure of work"and "difficulty of pathogenic bacteria identification" got the highest scores.Among the measures to improve rational clinical use of antibacterials,the item "increasing the income of medical staff" got the highest score.It was obvious that most participants considered the income of medical staff had close relation with the rational use of antibacterials.The results of questionnaire survey were consistent with those of the qualitative study.Conclusions:There are many prescribling behavior models of antibacterials and complicated factors have been proved involved in the process.Irrational use of antibiotics was ascribed greatly to the system of administration.The tension of doctor-patient relationship constitutes negative background.Drug promotion activities aggravate the condition.In addition,the development status of clinical medicine unavoidably confines the rational use of the drug.It is impossible to shape a long-term,stable and correct prescribing behavior of antibacterials without fully recognizing the existence and the meaning of above factors and taking corresponding measures.Innovations of the research:(1)By combining quantitative study with qualitative study,this study explored the doctors’prescribing behaviors and gathered abundant firsthand materials and lay a good foundation for further research.(2)This study summarized the behavior models of antibiotics prescirbing,irrational performances and factors that influence prescribing behavior,and proposed a prescribing ideograph and a causal chart which intuitively displayed factors influencing the clinical use of antibacterials and their relationship.(3)By applying ecological systems theory,this study throughly analyzed the prescribing behavior at the level of microsystem,mesosystem and exosystem,and deepened our understanding of current situation of clinical use of antibacterials.(4)This study not only provide clue to improving prescribing of antibacterials but also provide reference for the research of other category of drugs.