Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa.
Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa.
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DOI：
10.1136/bmjgh-2023-012374
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发表时间：
2023-07
影响因子：
8.1
通讯作者：
Blaauw, Duane
中科院分区：
文献类型：
--
作者：
Lagarde, Mylene;Blaauw, Duane
尽管初级保健中抗生素供应过剩是抗生素耐药性的一个关键驱动因素，但在低收入和中等收入国家，人们对其决定因素知之甚少。患者需求和对提供者的经济激励往往被认为是过度提供的原因。然而，在他们缺席的情况下，提供不足的情况下存在，并可能因护理质量问题和提供者对患者期望的错误信念而加剧。我们在南非的私营和公共部门探索了这些问题，方法是进行一项横断面研究，使用标准化患者(SPS)--经过培训向提供者描述有脚本的临床病例的健康个人--在公共和私营部门诊所的样本中呈现病毒呼吸道感染的症状。我们将SP访问的数据与丰富的调查数据联系起来，以比较这两个行业的做法及其预测因素。不必要的抗生素使用率在公共部门(78%)和私营部门(67%)同样很高，但私营部门开出的抗生素越多，产生耐药性的风险就越高。在私营部门，当会诊更彻底时，抗生素过度处方的情况会减少，但在当天晚些时候安排的会诊中，过度开抗生素的情况会增加，这表明提供者的努力和决策疲劳的效果截然不同。我们观察到了可能导致过度开药的不同看法：在公共部门，大多数提供者(护士)错误地认为抗生素可以帮助患者更快地康复。在私营部门，大多数医生认为，如果患者不接受抗生素治疗，他们就不会回来。总体而言，这一证据表明，不同的因素可能是导致公共和私营部门抗生素过度处方率高的原因。迫切需要量身定做的管理干预措施，以解决提供者根深蒂固的习惯和错误的信念。
Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients’ expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)—healthy individuals trained to portray a scripted clinical case to providers—presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers’ engrained habits and incorrect beliefs.
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