Intrinsic and external determinants of antibiotic prescribing: a multi-level path analysis of primary care prescriptions in Hubei, China
Intrinsic and external determinants of antibiotic prescribing: a multi-level path analysis of primary care prescriptions in Hubei, China
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DOI：
10.1186/s13756-019-0592-5
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发表时间：
2019-08-07
影响因子：
5.5
通讯作者：
Zhang, Xinping
中科院分区：
文献类型：
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作者：
Liu, Chenxi;Liu, Chaojie;Zhang, Xinping
背景抗生素的不合理使用是抗生素耐药性的主要驱动因素，严重威胁着世界范围内人群的健康。了解医生的抗生素处方决定的机制日益强调，以促进谨慎使用抗生素。因此，目前的研究旨在填补这一空白，模拟医生的抗生素处方，并确定潜在的内在和外部决定因素抗生素处方在初级保健。方法对湖北省65家基层医疗机构499名处方者的428,475张处方进行审计。特谢拉抗生素处方行为模型（Teixeira Antibiotic Prescribing Behavioral Model， TAPBM）是识别抗生素处方的内在和外部预测因素的理论基础。通过问卷调查，涵盖潜在医师的内在决定因素（知识、态度和个体特征）和个体层面（患者压力、时间压力和经济激励）和机构层面（环境和当地社会经济发展）的外部因素。进行了两级路径分析，将抗生素使用的潜在决定因素与医生的实际操作联系起来。结果44.28%的处方中含有抗菌药物，9.28%的处方中含有两种及以上抗菌药物。多层级路径分析结果显示，知识是态度的显著预测因子（beta = 0.154, p < 0.05），但较高的知识和态度并不能转化为抗生素处方行为（beta = - 0.076 ~ 0.039, p < 0.05）。相反，外部因素发挥了更重要的作用，医生的抗生素使用与患者压力（beta = 0.102, p = 0.022）、时间压力（beta = - 0.164, p = 0.002）、财务激励（beta = - 0.133- - 0.155, p = 0.027）和机构环境（农村地区，beta = 0.408, p = 0.002；以及高社会经济环境，beta = - 0.641 - -0.578, p < 0.001）显著相关。男性（beta = - 0.168, p = 0.007）或资质较低（beta = - 0.114, p = 0.028）的开处方者也比其他开处方者更有可能开抗生素。结论抗生素处方实践是一个复杂的过程，与内在因素（开处方者）和外在因素（患者和机构环境）有关。需要一种系统的方法来控制抗生素的过度使用。除了教育开处方者，同样重要的是，如果不是更重要的话，教育患者，打破激励机制，培养组织内的专业文化，以减少抗生素的过度使用。
Background Irrational use of antibiotics is a major driver of development of antibiotic resistance, which heavily threatens population health worldwide. Understanding the mechanism of physician's antibiotic prescribing decisions is increasingly highlighted to promote prudent use of antibiotics. Therefore, the current study aimed to fill the gap, modelling physician's antibiotic prescribing and identifying the potential intrinsic and external determinants of antibiotic prescribing in primary care. Methods A total of 428,475 prescriptions from 499 prescribers in 65 primary care facilities in Hubei of China were audited. Teixeira Antibiotic Prescribing Behavioral Model (TAPBM) was referred as theoretical basis to identify intrinsic and external predictors of antibiotic prescriptions. A questionnaire survey was conducted, covering potential physician's intrinsic determinants (knowledge, attitudes and individual characteristics) and external factors both in individual level (patient pressure, time pressure and financial incentives) and institutional level (setting and local socio-economic development). A two-level path analysis was performed linking potential determinants of antibiotic use with physician's actual practices. Results About 44.28% of the prescriptions contained antibiotics, with 9.28% containing two or more antibiotics. The multi-level path analysis revealed that knowledge was a significant predictor of attitudes (beta = 0.154, p < 0.05), but higher knowledge and attitudes failed to translate into antibiotic prescribing practices ((beta = - 0.076 - 0.039, p > 0.05). Instead, external factors played a more important role and physician's antibiotic use was significantly associated with patient pressure (beta = 0.102, p = 0.022), time pressure (beta = - 0.164, p = 0.002), financial incentives (beta = - 0.133- - 0.155, p = 0.027) and institutional environments (rural area, beta = 0.408, p = 0.002; and high socioeconomic setting, beta = - 0.641 - -0.578, p < 0.001 ). The prescribers who were male (beta = - 0.168, p = 0.007) or had lower qualification (beta = - 0.114, p = 0.028) were also more likely to prescribe antibiotics than others. Conclusion Antibiotic prescribing practices are complex process and associated with both intrinsic (prescriber) and external (patients and institutional environment) factors. A systematic approach is required to curb over-prescription of antibiotics. Apart from educating prescribers, it is equally important, if not more, to educate patients, break incentives and nurture professional culture within organization to reduce the overuse of antibiotics.