Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

• Published in: BMC health services research Vol. 24; no. 1; p. 640
• Main Authors: Ward, Michael J, Matheny, Michael E, Rubenstein, Melissa D, Bonnet, Kemberlee, Dagostino, Chloe, Schlundt, David G, Anders, Shilo, Reese, Thomas, Mixon, Amanda S
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 18.05.2024; BioMed Central; BMC
• Subjects: Ambulatory medical care; Anti-Bacterial Agents - therapeutic use; Anti-Inflammatory Agents, Non-Steroidal - therapeutic use; Antibiotics; Antimicrobial agents; Dosage and administration; Drug stores; Drug therapy; Emergency Department; Emergency medical care; Female; Hospital administration; Humans; Iatrogenesis; Inappropriate Prescribing - prevention & control; Inappropriate Prescribing - statistics & numerical data; Interviews; Interviews as Topic; Male; Middle Aged; Non-Steroidal Anti-Inflammatory Drugs; Nonsteroidal anti-inflammatory drugs; Outpatients; Practice Patterns, Physicians' - statistics & numerical data; Prescriptions; Primary Care; Qualitative Methods; Qualitative Research; Staphylococcus infections; Tennessee; Theory of planned behavior; United States; United States Department of Veterans Affairs; Urgent Care; Utilization; Veterans; Viral infections; United States; Tennessee; United States > US; Non-Steroidal Anti-Inflammatory Drugs; Antibiotics; Prescribing Stewardship; Emergency Department; Qualitative Methods; Urgent Care; Primary Care
• ISSN: 1472-6963; 1472-6963
• DOI: 10.1186/s12913-024-11082-0

Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.