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The University of Manchester Research
Factors associated with antibiotic prescribing for adultswith acute conditions: an umbrella review across primarycare and a systematic review focusing on primary dentalcareDOI:10.1093/jac/dkz152
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Citation for published version (APA):Thompson, W., Tonkin-Crine, S., Pavitt, S. H., McEachan, R. R. C., Douglas, G. V. A., Aggarwal, V. R., & Sandoe,J. A. T. (2019). Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella reviewacross primary care and a systematic review focusing on primary dental care. Journal of AntimicrobialChemotherapy. https://doi.org/10.1093/jac/dkz152Published in:Journal of Antimicrobial Chemotherapy
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Download date:23. Aug. 2020
Factors associated with antibiotic prescribing for adults with acuteconditions: an umbrella review across primary care and a
systematic review focusing on primary dental care
W. Thompson 1*, S. Tonkin-Crine 2, S. H. Pavitt1, R. R. C. McEachan3, G. V. A. Douglas1, V. R. Aggarwal1 andJ. A. T. Sandoe4
1University of Leeds, School of Dentistry, Leeds, UK; 2University of Oxford, NIHR Health Protection Research Unit in HealthcareAssociated Infections and Antimicrobial Resistance, Oxford, UK; 3Bradford Institute for Health Research, Bradford Royal Infirmary,
Bradford, UK; 4University of Leeds/Leeds Teaching Hospitals NHS Trust, Leeds, UK
*Corresponding author. E-mail: [email protected] orcid.org/0000-0001-6799-4087
Received 9 January 2019; returned 25 February 2019; revised 14 March 2019; accepted 18 March 2019
Introduction: One way to slow the spread of resistant bacteria is by improved stewardship of antibiotics: usingthem more carefully and reducing the number of prescriptions. With an estimated 7%–10% of antibiotic pre-scriptions globally originating from dental practices and up to 80% prescribed unnecessarily, dentistry has animportant role to play. To support the design of new stewardship interventions through knowledge transfer be-tween contexts, this study aimed to identify factors associated with the decision to prescribe antibiotics to adultspresenting with acute conditions across primary care (including dentistry).
Methods: Two reviews were undertaken: an umbrella review across primary healthcare and a systematic reviewin dentistry. Two authors independently selected and quality assessed the included studies. Factors wereidentified using an inductive thematic approach and mapped to the Theoretical Domains Framework(TDF). Comparisons between dental and other settings were explored. Registration number: PROSPERO_CRD42016037174.
Results: Searches identified 689 publications across primary care and 432 across dental care. Included studies(nine and seven, respectively) were assessed as of variable quality. They covered 46 countries, of which 12 werelow and middle-income countries (LMICs). Across the two reviews, 30 factors were identified, with ‘patient/con-dition characteristics’, ‘patient influence’ and ‘guidelines & information’ the most frequent. Two factors wereunique to dental studies: ‘procedure possible’ and ‘treatment skills’. No factor related only to LMICs.
Conclusions: A comprehensive list of factors associated with antibiotic prescribing to adults with acute condi-tions in primary care settings around the world has been collated and should assist theory-informed design ofnew context-specific stewardship interventions.
Introduction
Use of antibiotics is contributing to the rise in drug-resistant infec-tions.1,2 One way to slow the spread of resistant bacteria is byimproved stewardship of antibiotics: using them more carefullyand reducing the number of prescriptions. Globally, dentists aremajor prescribers of antibiotics, accounting for an estimated 7%–10% of all antibiotic prescriptions.3 Worryingly, some countries,including the USA and Canada, are currently seeing increases indental antibiotic use.3–6 Across NHS England during 2017, 5.2% ofantibiotic prescriptions were from primary dental care.7 Most of
these were systemic drugs prescribed for adult patients presentingat urgent appointments with severe pain and/or acute infection.8,9
Antibiotics are not, however, appropriate for the treatment of painand guidance states that a dental procedure is more usually indi-cated to remove the source of the problem; antibiotics are onlyrequired in the presence of a spreading or systemic infection.10–12
It has been estimated that antibiotics may be prescribed unneces-sarily for as many as 80% of dental patients in the UK.13,14 Dentalantibiotic stewardship interventions are therefore necessary.
VC The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided theoriginal work is properly cited. For commercial re-use, please contact [email protected]
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The behavioural and social sciences are increasingly appreci-ated as fundamental to the development of interventions aimedat improving people’s health and modifying clinician/patientbehaviours.15 Although interventions attempting to change anti-biotic prescribing behaviour are regularly reported in the scientificliterature, largely in hospital and primary medical care settings,few have been explicitly designed using behaviour change the-ory16,17 or tested in primary dental care.18 A more comprehensiveunderstanding of the determinants of antibiotic prescribing behav-iour should improve the effectiveness and sustainability of futureinterventions.19
With antibiotic resistance being a global problem that requiresa global solution, the health research community has turned itsfocus towards understanding specific issues for its emergence andspread in hotspots such as South-East Asia.20,21 An increase ininterest about antibiotic prescribing in these areas has become ap-parent, including from the WHO and a number of low- and middle-income countries (LMICs).20–22 Including international studies inthe review enabled comparisons between factors in different partsof the world.
Prescribing of antibiotics for paediatric patients is particularlyhigh in primary medical care.23 In contrast, NHS England prescrib-ing statistics show 87% of dental antibiotics in 2015/16 were pre-scribed to adults, with most linked to urgent rather than routinedental care.8,9 This study aimed, therefore, to identify the factorsassociated with decisions about whether to prescribe systemicantibiotics for adult patients during urgent appointments/withacute conditions. In order to maximize the opportunity to translateexisting knowledge between primary care settings, first the factorsinfluencing antibiotic prescribing decisions for urgent consultationsin all primary care settings were explored. Owing to the plethora ofstudies relating to antibiotic prescribing across primary medicalcare, an umbrella review (systematic review of systematic reviews)was chosen as an efficient way to identify factors and summarizethe extensive evidence base. Next, a systematic review was under-taken to collate the sparse dental-specific evidence base. Finally,the factors were compared and contrasted between clinical set-tings and between countries (including LMICs) in order to informthe development of future antibiotic stewardship interventions.
Methods
Protocol and research questions
The protocol for this two-part systematic review was registered inPROSPERO CRD42016037174. An umbrella review (also known as a system-atic review of systematic reviews or overview of systematic reviews) wasundertaken to answer the first research question: ‘What is known from pub-lished systematic reviews about the factors associated with the decisionwhether to prescribe systemic antibiotics to adult patients across urgentprimary care?’. A systematic review was undertaken for the second: ‘Whatis known from the published literature about the factors associated withthe decision to prescribe systemic antibiotics to adult patients in urgent pri-mary dental care?’. Primary care was defined as ‘the first point of contact inthe healthcare system . . .. including general practice, community phar-macy, dental and optometry services.’.24 Urgent primary dental careincluded out-of-hours (OOH)/emergency dental services provided in com-munity settings.
Both reviews conformed to the Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) statement.25 In addition,
the umbrella review was guided by the Joanna Briggs Institute method-ology for umbrella reviews.26
Search strategiesIn July 2018, five databases were searched from their earliest dates: OvidMEDLINE, Ovid EMBASE, Ovid PsychINFO, Web of Science and the BritishLibrary e-thesis on-line service (EThOS). Separate search strategies and in-clusion/exclusion criteria were developed for each review in collaborationwith an information specialist (Tables S1 and S2, available asSupplementary data at JAC Online). The search strategies used a ‘human’search limit as animal studies were not eligible for the reviews and an‘English language’ limit due to a lack of resources for translation. The refer-ence lists of included studies were manually searched for additional poten-tially relevant studies; other papers were also identified through discussionamong the authors. After performing the full search for each review, titlesand abstracts retrieved from each database were combined in EndNote X7and duplicates were removed. Separate EndNote libraries were used for theumbrella review across primary care and the systematic review in primarydental care.
Study selectionStudies published as original research articles in peer-reviewed journalswere included if they contained factors associated with decisions aboutwhether to prescribe systemic antibiotics for the treatment of adultpatients with acute conditions in non-specialist primary care settings.Studies related to specialist care delivered in primary care settings and/orprimary care services delivered in hospital settings were excluded.
For the umbrella review, a sensitive approach to the search wasemployed: systematic reviews were included if they reported, as a min-imum, factors relating to the provision of care for adults with acute condi-tions in primary care settings. Two authors (W. T. and J. A. T. S.) screened alltitles and abstracts independently for potential relevance. The full texts ofall studies identified as potentially relevant were then assessed for inclusioneligibility independently by the same two authors. Discrepancies or dis-agreements were resolved through discussion.
For the systematic review, a more specific application of the eligibilitycriteria was employed: primary research studies (qualitative, quantitativeand mixed methods) were included only if they reported on the provision ofcare for adults with acute dental conditions (pain and/or infection) in pri-mary dental care settings. Studies that included additional types of care,such as prophylactic use of antibiotics for routine procedures or the provi-sion of care in specialist as well as primary dental care settings, wereexcluded. Case studies were also excluded. Two authors (W. T. and G. V. A.D.) screened all titles and abstracts independently for potential relevance.The full texts of all studies identified as potentially relevant were thenassessed for inclusion eligibility independently by the same two authors.Discrepancies or disagreements were resolved through discussion.
Quality assessmentQuality assessment of the systematic reviews included in the umbrella re-view used the Critical Appraisal Skills Programme (CASP) Checklist forSystematic Reviews (Table S3).27 Two authors (W. T. and J. A. T. S.) inde-pendently quality assessed the studies included in the umbrella review,with discrepancies or disagreements resolved through discussion.
Quality assessment of the primary research studies included in the sys-tematic review of primary dental care used the 16 criteria of the QualityAssessment Tool for Studies with Diverse Design (QATSDD) (Table S4).28
One author (W. T.) quality assessed all of the studies included in the sys-tematic review and another author (V. R. A.) independently assessed .50%(4/7), with discrepancies or disagreements resolved through discussion.
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Analysis and synthesisAll included papers were imported into NVivo 11 as electronic pdf versionsfor thematic coding and synthesis. Thematic synthesis was an inductive, it-erative process that broadly consisted of three stages: (i) free line-by-linecoding of the Results and Discussion sections of the included papers; (ii) or-ganization of these ‘free codes’ into related areas; and (iii) the identification,development and refinement of detailed descriptions of the factors associ-ated with antibiotic prescribing.29 To assist the organization of the freecodes into related areas, they were first grouped according to whether theyrelated to clinician, patient, clinical context or wider social/political context,as this structure was presented in several of the systematic reviewsincluded in the umbrella review across primary care.30–32 To assist the iden-tification, development and refinement of the factors associated with anti-biotic prescribing, the Theoretical Domains Framework (TDF) was used toensure clarity of meaning for each influence on behaviour being character-ized. The TDF is a theory-informed approach to identify determinants of be-haviour and support behaviour change intervention design.33
Given the heterogeneous nature of the included studies, many of thefindings in these studies were irrelevant to the research question; only find-ings of direct relevance to the aims of the umbrella and systematic reviewwere coded.
Synthesis of the studies in the umbrella review acrossprimary careCodes were produced initially for the umbrella review across primary careby two authors (W. T. and J. A. T. S.) working independently; discrepanciesor disagreements were resolved through discussion. To ensure that the fac-tors identified related to the population of interest, identified factors werecross-checked back to the underpinning references within the umbrellareview’s constituent systematic reviews. Codes that were found not to re-late to the specific criteria of this review (e.g. studies only about paediatricpatients, hospital settings or prophylactic prescribing) were excluded fromthe synthesis.
Synthesis of studies in the systematic review of primarydental careThe dental care studies were analysed using the bank of codes producedfrom the umbrella review across primary care by two authors (W. T. and G.V. A. D.) working independently; discrepancies or disagreements wereresolved through discussion. Where necessary, additional codes wereincluded for new factors as they emerged from the dental studies.
Independent checksFollowing completion of synthesis of the umbrella and systematic reviews,a group of authors (W. T., S. H. P., R. R. C. M., G. V. A. D. and J. A. T. S.) and thestudy’s patient and public involvement (PPI) representatives undertook asense check of the full list of identified factors. An independent check of thefactors/definitions and how they mapped to the TDF was then undertakenby S. T.-C. Discrepancies or disagreements were resolved throughdiscussion.
Comparing the factorsThe final stage was to compare and contrast the factors identified betweenthe settings: across primary care versus primary dental care specific; andbetween countries (including UK versus other countries and high-incomecountries versus LMICs).34
Results
Study selection
For the umbrella review across primary care, 689 studies wereidentified for possible inclusion in the review. Of these, nine studiesmet the inclusion criteria and were included in the final synthe-sis.30–32,35–40 Details of the study selection process are shown inFigure 1.
For the systematic review of primary research studies, 432studies were identified for possible inclusion in the review. Of these,seven studies met the inclusion criteria and were included in thefinal synthesis.13,14,41–45 Details of the study selection process areshown in Figure 2.
Study characteristics
Umbrella review: characteristics of the includedsystematic reviews
The characteristics of the nine systematic reviews included in theumbrella review across primary care are described in Table 1.Within these systematic reviews, a total of 98 qualitative andquantitative primary research studies contributed factors relatingto adult patients with acute conditions in primary care settings.Across these 98 studies, the participants were primary care profes-sionals (including doctors, nurses and pharmacists) working in 45countries. Eleven of the countries were LMICs and 26 studies wereundertaken in the UK (Table S5). The studies had a date range of1990–2017.
Systematic review: characteristics of the included primaryresearch studies
The characteristics of the seven studies included in the systematicreview of primary dental care are described in Table 2. The studyparticipants were all dentists working in primary dental care(including OOH dental clinics). Two of the studies took place inLMICs (Turkey and Iran) and the other five were UK studies. Thestudies had a date range of 2000–16.
Overlap between the reviews
None of the seven dental studies of the systematic review wasincluded in any of the nine systematic reviews within the umbrellareview.
Overlap within the systematic reviews of the umbrellareview
Analysis of the overlap between primary research studies withinthe umbrella review’s systematic reviews found that 12/98 studiesappeared in two of the systematic reviews, 5/98 appeared in threeof them and none appeared in more than three (Table S5).
Quality assessment
For the umbrella review, the included systematic reviews weregenerally good quality. All of the CASP criteria were fulfilled (or notapplicable) for seven of the nine. The other two systematic reviewsfailed to show quality assessment of their included studies.
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For the systematic review within primary dental care, quality ofthe included studies was more variable, with QATSDD scores rang-ing from 11 to 39 out of a possible total of 40. General weaknessesacross the studies concerned identification of a theoretical frame-work, sample size, validity of measurement tools and evidence ofuser involvement in study design. Detailed results of these assess-ments are presented in Tables S3 and S4. No papers were excludedbased on these assessments as all included results that were rele-vant to meeting the aims of the systematic review.
Thematic analysis
A total of 30 factors associated with prescribing were identifiedacross both the umbrella review of primary care and the systemat-ic review of primary dental studies. Descriptors of each of thesefactors and how they map to the domains of the TDF are presentedin Table 3. Details of which factors were identified from each re-view are shown in Tables S6 and S7, respectively.
Three factors did not map to the TDF: clinician characteristics,patient/condition characteristics and practice characteristics.Upon inspection it was agreed by the authors that they should beclassed as non-modifiable factors. The most frequently identifiednon-modifiable factor, ‘patient/condition characteristics’, wasfound in all systematic reviews included within the umbrella
review and six out of seven dental studies within the systematicreview.
Identifying potential determinants of behaviour
The 27 factors that mapped to the TDF were classed as potentiallymodifiable determinants of antibiotic prescribing in primary care.Of these, 20 were identified in both reviews; 5 factors were identi-fied only from the umbrella review across primary care and 2 fac-tors only from the systematic review in primary dental care(Table 4). As with previously published systematic reviews aboutantibiotic prescribing, the factors were found to group intoclinician-related, patient-related, clinical context-related andwider social–political context-related.30–32,36
Potentially modifiable factors: across primary care
The ‘patient influence’ factor was found in all of the systematicreviews of the umbrella review (Table 2). As described in Table 1,this included but was not limited to demand for antibiotics and/orthe clinician’s perception of the patient’s desire for them. Five fac-tors were found only in the umbrella review: ‘accountability’, ‘anti-biotic awareness’, ‘antibiotic beliefs’, ‘conflict’ and ‘financialburden’ (Table 4).
Records identified throughdatabase searching
(n= 859)
Additional records identifiedthrough other sources
(n= 1)
Records after duplicates removed(n= 689)
Records screened(n= 689)
Records excluded basedon titles, abstracts or both
(n= 669)
Full-text articles assessedfor eligibility
(n= 20)
Full-text articles excluded (n= 11):
No factors associated with prescribing = 7Not primary care = 3
Not able to access reference = 1
Studies included innarrative synthesis
(n= 9)
Figure 1. PRISMA flow chart detailing selection of the systematic reviews included in the umbrella review of factors associated with the decisionwhether to prescribe systemic antibiotics for adult patients with acute conditions across primary care.
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Potentially modifiable factors: primary dental care
Only ‘guidelines & information’ was found in all of the dental stud-ies (Table 3). Two factors were found only in dental studies: ‘pro-cedure possible’ and ‘treatment skills’.13,42,43 Dentists’ beliefsabout whether it was possible to deliver operative dental proce-dures in accordance with guidelines (due to issues beyond the den-tist’s skill) were identified as important (‘procedure possible’).13,43
Similarly, ‘treatment skills’ to undertake difficult elements of ur-gent dental procedures, such as ‘achieving adequate anaesthesia’and ‘how to lance an abscess when swelling is present’, wereincluded in two of the dental studies.13,42,43 Antibiotics were identi-fied as a way of balancing the ‘competing demands’ of a busy listof patients booked for routine dental care with the addition of un-scheduled patients, sometimes as ‘sit and wait’ due to lack ofavailable appointment slots.13,14,41,43,44
Comparing potentially modifiable factors: betweenprimary care settings including dental care
Twenty factors were found in both the umbrella review across pri-mary care and the systematic review in primary dental care(Table 4). Of these, ‘patient influence’ was the most frequentlyidentified factor, being found in all of the systematic reviews of theumbrella review and six of the seven dental studies of the system-atic review (Table 3).
Communication with patients during urgent appointments,including managing anxious patients and negotiation towards ashared decision, were found to be important to the prescribing de-cision in both dental and wider healthcare settings (‘patient man-agement’).14,32,36,38,43 Clinicians’ fear about the potential foradverse outcomes, including when the patient had reduced accessto medical/dental services (such as when going away on holiday orat weekends/bank holidays) were frequently identified (‘fear aboutoutcome’ and ‘access’).30–32,35,38–41,43 Maintaining a good patient–clinician relationship, including by avoiding conflict, was an import-ant goal shared across primary care and primary dental care,where enduring relationships are central to the model of care pro-vision (‘relationship’).31,35,36,38,39,43
Potentially modifiable factors: comparing countries
‘Accountability’ was the only factor not identified from any of theUK-based studies included within the umbrella review’s systematicreviews.36 It has, however, been reported as important in at leastone recent UK study. When exploring the experience of prescribersin OOH primary care settings, it was found that nurse practitionersfelt greater accountability for their antibiotic prescribing than gen-eral practitioners (GPs).46
Eleven factors were identified from studies involving LMICs; nofactors were identified only from studies undertaken in LMICs(Table 5). Exploring the detail within the factors, however, found
Records identified throughdatabase searching
(n= 790)
Additional records identifiedthrough other sources
(n= 0)
Records after duplicates removed(n= 432)
Records screened(n= 432)
Records excluded based on titles,abstracts or both
(n= 373)
Full-text articles assessedfor eligibility
(n= 59)
Full-text articles excluded (n= 52):
No factors associated with prescribing = 11Included specialist/hospital care = 15Included non-acute conditions = 24
Can’t access reference = 2
Studies included innarrative synthesis
(n= 7)
Figure 2. PRISMA flow chart detailing selection of the primary research studies included in the systematic review of factors associated with the deci-sion whether to prescribe systemic antibiotics for adult patients with acute dental conditions/during urgent primary dental care appointments.
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tics
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20
18
35
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care
pra
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so
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nti
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for
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tere
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act
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nd
,Ita
ly,
No
rwa
y,N
eth
erla
nd
s
4q
ua
lita
tive
&q
ua
nti
-
tati
vest
ud
ies
Ro
dri
gu
es,
20
13
32
Toex
plo
rep
hys
icia
ns’
per
cep
-
tio
ns
of
fact
ors
infl
uen
cin
g
an
tib
ioti
cp
resc
rib
ing
.
ph
ysic
ian
sa
llh
ealt
hca
re1
20
01
–11
Ger
ma
ny,
Icel
an
d,I
nd
ia,
Net
her
lan
ds,
Spa
in,S
wed
en,
UK
,USA
13
qu
alit
ati
vest
ud
ies
Ton
kin
-Cri
ne,
20
11
39
Tou
nd
erst
an
dh
ow
GPs
per
ceiv
e
an
tib
ioti
cp
resc
rib
ing
.
GPs
of
pa
tien
tsw
ith
acu
teco
nd
itio
ns
pri
ma
ryca
re5
20
02
–10
Bel
giu
m,F
ran
ce,I
cela
nd
,
Ne
ther
lan
ds,
No
rwa
y,Po
lan
d,
Spa
in,U
K,U
SA
7q
ua
lita
tive
stu
die
s
Co
nti
nu
ed
Systematic review
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niversity of Manchester user on 19 June 2020
that access to internet-based ‘guidelines & information’ waslower in LMICs compared with high-income countries.38
Furthermore, pharmaceutical industry medical representativeswere identified by several non-UK studies as being an importantsource of ‘guidelines & information’, especially in LMICs wherelocal guidelines were not always available.30,32,35,38 Upon closerexamination of the studies included in the reviews, the medicalrepresentatives most often influenced decisions about what toprescribe; only one of the studies referenced within the umbrellareview’s systematic reviews was about whether to prescribeantibiotics.32,47
The ability to use a prescription more than once was identifiedfrom studies involving LMICs.32,38,48 Further differences betweenUK-based and other studies were found within the ‘healthcarecontext’ factor, including the availability of antibiotics without aprescription.35,42
Discussion
A comprehensive list of potentially modifiable and non-modifiable factors associated with the decision whether to pre-scribe systemic antibiotics for adults with acute conditions inprimary care has been collated. Mapping of the potentially modi-fiable factors to the TDF has provided a resource for those wish-ing to develop new antibiotic stewardship interventionsinformed by behavioural theory. By identifying variation withinnon-modifiable factors between clinical contexts, it providesaddition information to enable targeting of specific interventionsat specific groups. By comparing and contrasting the potentiallymodifiable factors between settings, the results should informthe design of future antibiotic stewardship interventions. Itshould also enable the identification of elements of existing anti-biotic stewardship interventions which could be amenable fortranslation into new settings.
With antibiotic resistance recognized as an important elem-ent of global sustainable development, a strength of this study isits inclusion of international studies, including studies fromLMICs.21,49 Most of the sparse dental literature base (five out ofseven studies) originated in the UK (Table 2). This pattern wasalso identified in a systematic review of dental antibiotic stew-ardship interventions, where all five of the intervention tests ingeneral dental practices were UK based.18 Researchers planningto implement existing dental antibiotic stewardship interven-tions in other countries (or to develop new ones) should first seekto understand which factors are relevant to the prescribers’ deci-sions in their specific context.
Owing to the heterogeneous nature of the included studies,attribution of causality between the factors found to be associ-ated with antibiotic prescribing and actual prescribing rates wasnot possible. Similarly, it was not possible to say whether factorsidentified from the umbrella review across primary care but notidentified in the systematic review of dental studies were rele-vant in dental settings; it could only be concluded that these fac-tors were not found in the published dental studies within thisreview. Although the 30 factors identified have been presentedas distinct, many are interlinked, such as the relationships be-tween ‘patient satisfaction’, ‘conflict’ and ‘incentives’. There wasa risk of the factors being either too generic to be useful or toospecific (and hence too numerous) to be manageable. ToTa
ble
1.
Co
nti
nu
ed
Au
tho
r(l
ead
),ye
ar
Ob
ject
ives
Part
icip
an
tch
ara
cter
isti
csSe
ttin
g/c
on
text
No
.of
da
ta-
ba
ses
sea
rch
ed
Rel
eva
nt
con
stit
uen
tst
ud
ies*
da
tera
ng
eco
un
trie
sin
clu
ded
nu
mb
er,t
ype
Tou
bo
ul-
Lun
dg
ren
,
20
15
40
Tod
escr
ibe
the
infl
uen
ceo
fcu
l-
ture
on
an
tib
ioti
cu
se,u
sin
ga
fra
mew
ork
of
cult
ura
l
dim
ensi
on
s.
un
clea
rp
rim
ary
care
10
19
97
–20
13
Au
stri
a,B
elg
ium
,Bu
lga
ria
,Cze
ch
Re
pu
blic
,Den
ma
rk,E
ast
Ger
ma
ny,
Esto
nia
,Fin
lan
d,
Fra
nce
,Ger
ma
ny,
Gre
ece,
Hu
ng
ary
,Ire
lan
d,I
sra
el,I
taly
,
Latv
ia,L
ith
ua
nia
,Lu
xem
bo
urg
,
Ma
lta
,Mo
rocc
o,N
epa
l,
Net
her
lan
ds,
Pola
nd
,Po
rtu
ga
l,
Ro
ma
nia
,Slo
vaki
a,S
love
nia
,
Spa
in,S
wed
en,T
ha
ilan
d,
Turk
ey,U
K,Y
ug
osl
avi
a(f
orm
er)
6q
ua
lita
tive
&q
ua
nti
-
tati
vest
ud
ies
*Rel
eva
nt
stu
die
sa
reth
e9
8p
rim
ary
rese
arc
hp
ap
ers
incl
ud
edw
ith
inth
esy
stem
ati
cre
view
sth
at
rela
teto
ad
ult
pa
tien
tsin
no
n-s
pec
ialis
tp
rim
ary
care
sett
ing
s.Fu
rth
erd
eta
ilso
fth
ose
98
pa
per
sa
rep
rovi
ded
inTa
ble
S5.
Systematic review JAC
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ic.oup.com/jac/article-abstract/74/8/2139/5475276 by U
niversity of Manchester user on 19 June 2020
Tab
le2
.C
ha
ract
eris
tics
of
stu
die
sin
clu
ded
inth
esy
stem
ati
cre
view
of
fact
ors
ass
oci
ate
dw
ith
pre
scri
bin
go
fsy
stem
ica
nti
bio
tics
toa
du
ltp
ati
ents
wit
ha
cute
den
talc
on
dit
ion
s/d
uri
ng
urg
ent
pri
ma
ryd
enta
lca
re
Au
tho
r(l
ead
),ye
ar
Ob
ject
ives
Co
un
try
Den
talc
are
sett
ing
Clin
icia
nch
ara
cter
isti
cs
Pati
ent
cha
rac-
teri
stic
s(i
fa
pp
lica
ble
)St
ud
yty
pe/
des
ign
Size
of
po
pu
lati
on
Co
ncl
usi
on
s
Co
pe,
20
16
13
Tod
escr
ibe
fact
ors
ass
oci
ate
dw
ith
an
tib
ioti
cp
resc
rip
tio
nin
the
ab
sen
ceo
fsp
rea
din
gin
-fe
ctio
no
rsy
stem
icin
volv
emen
t.
UK
ge
ner
ald
en-
talp
ract
ice
NH
So
rp
riva
teg
ener
ald
enta
lp
ract
itio
ner
s
ad
ult
sw
ith
pu
l-p
al,
ap
ica
lor
per
iod
on
tal
pa
tho
log
y
qu
an
tita
tive
/cr
oss
-sec
tio
na
lp
rosp
ecti
ve
42
gen
era
ld
enta
lpra
cti-
tio
ner
s/5
68
case
s
Fea
ture
so
fth
eh
ealt
hca
reen
viro
nm
ent,
such
as
clin
ica
ltim
ep
ress
ure
s,a
nd
pa
tien
t-re
late
dch
ara
cter
isti
cs,s
uch
as
exp
ecta
-ti
on
sfo
ra
nti
bio
tics
an
dre
fusa
lof
op
era
tive
trea
tmen
t,a
rea
sso
cia
ted
wit
ha
nti
bio
tic
pre
scri
bin
gin
the
ab
sen
ceo
fin
fect
ion
.D
aile
y,2
00
14
1To
inve
stig
ate
the
ther
ap
euti
cp
resc
rib
ng
of
an
tib
ioti
csto
pa
tien
tsp
rese
nti
ng
for
emer
-g
ency
den
talt
rea
tmen
t.
UK
OO
Hd
enta
lN
HS
den
tist
sw
alk
-in
emer
-g
ency
den
tal
pa
tien
ts
qu
an
tita
tive
/cr
oss
-sec
tio
na
lp
rosp
ecti
ve
55
den
tist
s/1
01
1ca
ses
The
ma
jori
tyo
fp
ati
ents
att
end
ing
the
emer
gen
cyd
enta
lclin
ics
ha
dp
ain
,wit
ha
larg
ep
rop
ort
ion
ha
vin
glo
caliz
edin
fect
ion
sei
ther
as
pu
lpit
iso
rlo
caliz
edd
enta
la
bsc
ess.
Ka
pta
n,
20
13
42
Tog
ath
erin
form
ati
on
ab
ou
tTu
rkis
hg
ener
ald
enta
lpra
cti-
tio
ner
s’tr
eatm
ent
ap
pro
ach
esto
wa
rds
end
od
on
tic
emer
-g
enci
es,a
nti
bio
tic-
pre
scri
bin
gh
ab
its,
an
dp
art
icip
ati
on
inlif
elo
ng
lea
rnin
gp
rog
ram
mes
.
Turk
eyg
en
era
lden
-ta
lpra
ctic
eg
ener
ald
enta
lp
ract
itio
ner
sN
Aq
ua
nti
tati
ve/
surv
ey5
89
an
a-
lyse
d/1
40
0d
istr
ibu
ted
Ther
eh
ave
bee
nd
iscr
epa
nci
esb
etw
een
tau
gh
ta
nd
ob
serv
edp
ract
ice.
Edu
cati
on
al
init
iati
ves
are
nee
ded
top
reve
nt
ina
pp
rop
ri-
ate
pre
scri
pti
on
of
an
tib
ioti
cs.
New
lan
ds,
20
16
43
Tou
nd
erst
an
dth
eb
arr
iers
toa
nd
faci
lita
tors
of
usi
ng
loca
lm
easu
res
inst
ead
of
pre
scri
b-
ing
an
tib
ioti
csto
ma
na
ge
ba
c-te
ria
lin
fect
ion
s.
UK
no
tcl
ear
gen
era
lden
tal
pra
ctit
ion
ers
NA
qu
alit
ati
ve/
sem
i-st
ruct
ure
din
terv
iew
s
30
inte
rvie
ws
Res
ult
ssu
gg
est
an
um
ber
of
inte
rven
tio
nfu
nct
ion
sth
rou
gh
wh
ich
futu
rein
terv
en-
tio
ns
cou
ldch
an
ge
gen
era
lden
talp
ract
i-ti
on
ers’
an
tib
ioti
cp
resc
rib
ing
for
ba
cter
ial
infe
ctio
ns,
incl
ud
ing
thro
ug
htr
ain
ing
,mo
d-
ellin
go
rin
cen
tivi
zati
on
.Pa
lmer
,2
00
04
4To
stu
dy
the
ther
ap
euti
cp
re-
scri
bin
go
fa
nti
bio
tics
by
gen
-er
ald
en
talp
ract
itio
ner
s.
UK
ge
ner
ald
en-
talp
ract
ice
gen
era
lden
tal
pra
ctit
ion
ers
pa
tien
tsw
ith
an
acu
ted
enta
lin
fect
ion
qu
an
tita
tive
/su
rvey
89
1a
na
-ly
sed
/15
46
dis
trib
ute
d
Ther
ap
euti
cp
resc
rib
ing
of
an
tib
ioti
csin
gen
era
lden
talp
ract
ice
vari
esw
idel
ya
nd
issu
bo
pti
ma
l.Pr
act
itio
ner
sw
ere
gen
era
llyn
ot
infl
uen
ced
by
pa
tien
t’s
exp
ecta
tio
ns
of
rece
ivin
ga
nti
bio
tics
,bu
tw
ou
ldp
resc
rib
ew
hen
un
der
pre
ssu
reo
fti
me,
ifth
eyw
ere
un
ab
leto
ma
kea
defi
nit
ive
dia
gn
osi
s,o
rif
trea
tmen
th
ad
tob
ed
ela
yed
.Tu
lip,2
00
81
4To
inve
stig
ate
the
clin
ica
lm
an
ag
em
ent
of
pa
tien
tsa
tten
din
gfo
rem
erg
ency
den
-ta
ltre
atm
ent.
UK
OO
Hd
enta
lg
ener
ald
enta
lp
ract
itio
ner
sp
ati
ents
wit
ha
na
cute
den
tal
con
dit
ion
qu
an
tita
tive
/re
tro
spec
tive
da
taa
na
lysi
s
11
67
pa
tien
tre
cord
sG
ener
ald
enta
lpra
ctit
ion
ers
wo
rkin
gw
ith
inth
eO
OH
serv
ices
are
no
ta
dh
erin
gto
cur-
ren
tcl
inic
ala
nd
bes
tp
ract
ice
gu
idel
ines
wit
hre
spec
tto
pa
tien
tex
am
ina
tio
n,d
iag
-n
osi
s,m
an
ag
emen
t,a
nd
inp
art
icu
lar
the
corr
ect
pre
scri
bin
go
fa
nti
bio
tics
for
den
tal
infe
ctio
ns.
Ves
sal,
20
11
45
Toe
valu
ate
the
kno
wle
dg
ea
nd
pra
ctic
eso
fd
enti
sts
inSh
ira
z,Ir
an
reg
ard
ing
thei
ru
seo
fa
nti
bio
tics
for
pa
tien
tsw
ith
den
toa
lveo
lar
infe
ctio
ns.
Ira
nn
ot
clea
rd
enta
lp
ract
itio
ner
sN
Aq
ua
nti
tati
ve/
surv
ey2
19
an
a-
lyse
d/4
50
dis
trib
ute
d
Gu
idel
ines
on
rati
on
ala
nti
bio
tic
use
are
nee
ded
for
den
talp
ract
itio
ner
sin
the
Isla
mic
Rep
ub
lico
fIr
an
.
Systematic review
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ic.oup.com/jac/article-abstract/74/8/2139/5475276 by U
niversity of Manchester user on 19 June 2020
Tab
le3
.Fa
cto
rsa
sso
cia
ted
wit
hp
resc
rib
ing
of
an
tib
ioti
csfo
ra
cute
con
dit
ion
sin
pri
ma
ryca
rese
ttin
g:s
ho
rtn
am
e,d
escr
ipto
ra
nd
ma
pp
ing
toth
eTD
F
Fact
or
sho
rtn
am
eD
escr
ipto
rTD
Fd
om
ain
Acc
ess
Acc
ess
toth
eri
gh
tca
refo
rth
eri
gh
tp
ati
ent
at
the
rig
ht
tim
e,in
clu
din
gw
hen
the
pra
ctic
eis
shu
t(e
.g.w
eeke
nd
s),
wh
ilst
the
pa
tien
tis
on
ho
lida
y,fo
rp
ati
ents
wh
oliv
ea
dis
tan
cefr
om
the
pra
ctic
eco
nti
nu
ity
of
care
by
asi
ng
lecl
in-
icia
n,a
nd
ifn
eces
sary
acc
ess
tosp
ecia
list
care
thro
ug
hre
ferr
als
ervi
ces
an
dla
bo
rato
ryeq
uip
men
ta
nd
/or
test
ing
.
Envi
ron
men
talc
on
text
&
reso
urc
es
Acc
ou
nta
bili
tyC
linic
ian
sh
eld
acc
ou
nta
ble
(or
feel
like
they
are
hel
da
cco
un
tab
le)
for
thei
ra
nti
bio
tic
pre
scri
bin
gp
att
ern
s.B
elie
fsa
bo
ut
con
seq
uen
ces
An
tib
ioti
ca
wa
ren
ess
Leve
lof
clin
icia
nkn
ow
led
ge
ab
ou
tth
ere
lati
on
ship
bet
wee
na
nti
bio
tic
use
an
dre
sist
an
tin
fect
ion
s.K
no
wle
dg
e
An
tib
ioti
cb
elie
fsLe
velo
fp
erso
na
lres
po
nsi
bili
tyto
wa
rds
an
tib
ioti
cs,i
ncl
ud
ing
bla
min
go
ther
sfo
rm
isu
seo
fa
nti
bio
tics
an
d/o
rre
sist
-
an
tin
fect
ion
s.B
elie
fth
at
an
tib
ioti
csa
relo
wri
sk:d
escr
ibin
gu
sea
s‘B
ette
rsa
feth
an
sorr
y’.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
Clin
icia
nch
ara
cter
isti
csC
linic
ian
ag
e,se
x,ye
ars
inp
ract
ice,
loca
tio
no
fp
rim
ary
den
talq
ua
lifica
tio
n,p
revi
ou
scl
inic
ale
xper
ien
ce.
Do
esn
ot
ma
pto
TDF
Co
mp
etin
gd
em
an
ds
Ava
ilab
ility
of
suffi
cien
tti
me
totr
eat
pa
tien
tin
acc
ord
an
cew
ith
gu
idel
ines
,in
clu
din
g‘s
ita
nd
wa
it’a
pp
roa
chto
bo
oki
ng
urg
ent
pa
tien
tsa
nd
oth
er
pa
tien
tsw
ait
ing
.
Envi
ron
men
talc
on
text
&
reso
urc
es
Co
nfl
ict
Fea
ro
fco
nfl
ict
wit
hp
ati
ent
du
eto
dis
sati
sfa
ctio
na
nd
sub
seq
uen
tlo
sso
fth
ep
ati
ent
toth
ep
ract
ice.
Emo
tio
n
Effi
cacy
of
op
tio
ns
Bel
iefs
ab
ou
tth
eef
fica
cyo
fd
iffe
ren
ttr
eatm
ent
op
tio
ns,
incl
ud
ing
,ab
ility
of
an
tib
ioti
csve
rsu
so
ther
ap
pro
ach
/pro
-
ced
ure
tore
solv
eco
nd
itio
ns
an
db
elie
fth
at
ap
roce
du
rem
ay
wo
rsen
sym
pto
ms.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
Fea
ra
bo
ut
ou
tco
me
Fea
ra
bo
ut
ad
vers
eo
utc
om
es,i
ncl
ud
ing
an
xiet
ya
bo
ut
ma
kin
ga
mis
take
an
dth
ep
rosp
ect
of
seri
ou
sco
mp
lica
tio
ns
ifp
ati
ents
wit
hsy
mp
tom
sg
ow
ith
ou
ta
nti
bio
tics
.Des
crib
eda
s‘ju
st-i
n-c
ase
’or
‘bel
t-a
nd
-bra
ces’
.
Emo
tio
n
Feel
ing
sa
bo
ut
dec
isio
ns
Feel
ing
ab
ou
tth
ea
pp
oin
tmen
ta
nd
dec
isio
ns,
incl
ud
ing
fru
stra
tio
na
tla
cko
fco
nse
nt
for
go
ldst
an
da
rdtr
eatm
ent
or
clin
icia
n’s
emo
tio
na
lsta
tea
tth
ea
pp
oin
tmen
tst
art
.
Emo
tio
n
Fin
an
cia
lbu
rden
Bel
iefs
ab
ou
tfi
na
nci
alb
urd
eno
np
ati
ents
,in
clu
din
ga
bili
tyto
pa
yfo
rcl
inic
alc
on
sult
ati
on
or
fees
for
lab
ora
tory
test
s.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
Fix
the
pro
ble
mG
oa
lfo
rth
ea
pp
oin
tmen
tis
tofi
xth
ep
ati
ent’
sp
rob
lem
:sym
pto
ma
tic
relie
fa
nd
/or
pre
ven
tin
gth
ep
rob
lem
retu
rnin
g.
Go
als
Gu
ida
nce
–pra
ctic
eg
ap
Ga
pb
etw
een
gu
ida
nce
an
dcl
inic
alp
ract
ice,
incl
ud
ing
clin
icia
nco
nce
rns
ab
ou
tth
ea
pp
lica
tio
no
fth
eg
uid
elin
esto
spec
ific
clin
ica
len
cou
nte
rsa
nd
bel
ief
ab
ou
tw
het
her
thei
rcl
inic
alp
ract
ice
(su
cha
sd
ela
yed
pre
scri
bin
gin
den
tist
ry)
ad
her
esto
rele
van
tg
uid
an
ce.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
Gu
idel
ines
&in
form
ati
on
Kn
ow
led
ge
ab
ou
tre
leva
nt
gu
idel
ines
an
do
ther
sou
rces
of
info
rma
tio
n(s
uch
as
fro
mth
ein
tern
eta
nd
ph
arm
ace
ut-
ica
lco
mp
an
ym
edic
alr
epre
sen
tati
ves)
,in
clu
din
ga
pp
rop
ria
tetr
eatm
ent
of
acu
teco
nd
itio
ns/
pre
scri
bin
g.
Kn
ow
led
ge
Ha
bit
sPr
escr
ibin
gh
ab
its
of
clin
icia
n,i
ncl
ud
ing
pa
tter
ns
of
pre
scri
bin
ga
nd
pra
ctit
ion
er-l
evel
vari
ati
on
.M
emo
ry,a
tten
tio
n&
dec
isio
n
pro
cess
es
Hea
lth
care
con
text
Hea
lth
care
syst
emco
nte
xtin
rela
tio
nto
pre
scri
pti
on
of
an
tib
ioti
cs,i
ncl
ud
ing
per
ceiv
edp
ress
ure
tore
du
cea
nti
bio
tic
pre
scri
bin
g,a
bili
tyto
reu
sea
pre
scri
pti
on
,an
da
vaila
bili
tyo
fa
nti
bio
tics
wit
ho
ut
ap
resc
rip
tio
n.
Envi
ron
men
talc
on
text
&
reso
urc
es
Ince
nti
ves
Ince
nti
ves
for
an
da
ga
inst
an
tib
ioti
cu
se,i
ncl
ud
ing
the
imp
act
of
a‘t
ime
ism
on
ey’b
usi
nes
sa
pp
roa
cho
nu
nsc
hed
-
ule
d/u
rgen
ta
pp
oin
tmen
tsa
nd
the
fin
an
cia
lris
ko
flo
sin
gd
issa
tisfi
edp
ati
ents
.
Rei
nfo
rcem
ent
Pati
ent/
con
dit
ion
cha
ract
eris
tics
Ch
ara
cter
isti
cso
fth
ep
ati
ent
(ag
e,se
x,et
hn
icit
y),t
hei
rp
rese
nti
ng
con
dit
ion
(sig
ns,
sym
pto
ms
an
dd
iag
no
sis)
,th
eir
med
ica
lhis
tory
/co
mo
rbid
itie
sa
nd
thei
rso
cio
eco
no
mic
ba
ckg
rou
nd
(lev
elo
fed
uca
tio
n,a
fflu
ence
/dep
riva
tio
net
c.).
Do
esn
ot
ma
pto
TDF
Pati
ent
infl
uen
ceIn
flu
ence
of
(per
cep
tio
ns
ab
ou
t)p
ati
ents
,in
clu
din
g:a
nti
bio
tic-
seek
ing
beh
avi
ou
r(e
xpec
tati
on
s/d
ema
nd
);n
ego
tia
t-
ing
skill
s;p
ati
ent
kno
wle
dg
e/a
ttit
ud
esto
wa
rds
an
tib
ioti
cs;f
ear
of
ad
vers
eo
utc
om
esw
ith
ou
ta
nti
bio
tics
;an
dw
ill-
ing
nes
s/a
bili
tyto
acc
ept
op
era
tive
den
talp
roce
du
re.A
lso
the
infl
uen
ceo
fp
oo
r/ir
reg
ula
ra
tten
der
sa
nd
the
imp
act
of
late
-ru
nn
ing
un
sch
edu
led
ap
po
intm
ents
ma
kin
go
ther
pa
tien
tsw
ho
are
wa
itin
gfo
rth
eir
sch
edu
led
ap
po
intm
ent
an
gry
.
Soci
ali
nfl
uen
ces
Co
nti
nu
ed
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Tab
le3
.C
on
tin
ued
Fact
or
sho
rtn
am
eD
escr
ipto
rTD
Fd
om
ain
Pati
en
tm
an
ag
eme
nt
Skill
sin
pa
tien
tm
an
ag
emen
t,d
iag
no
sis,
trea
tmen
tp
lan
nin
ga
nd
con
sen
t,in
clu
din
gel
icit
ing
con
cern
s,in
terp
reti
ng
the
pa
tien
t’s
des
crip
tio
no
fth
eir
sym
pto
ms,
ma
na
gin
ga
nxi
ou
sp
ati
ents
,ma
na
gin
gex
pec
tati
on
sa
nd
avo
idin
gco
n-
fro
nta
tio
n.N
ego
tia
tio
n,p
ersu
asi
on
,ed
uca
tio
na
nd
hed
gin
g.C
om
mu
nic
ati
on
skill
s.
Skill
s
Pati
ent
sati
sfa
ctio
nB
elie
fa
bo
ut
pa
tien
tsa
tisf
act
ion
,in
clu
din
gim
pa
cto
ffa
ilin
gto
mee
tp
ati
ent
exp
ecta
tio
ns,
imp
act
of
rep
eat
visi
ts
an
dfa
ilure
tore
lieve
sym
pto
ms.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
Peer
s&
colle
ag
ues
Infl
uen
ceo
fp
eers
an
do
ther
colle
ag
ues
inp
ract
ice,
incl
ud
ing
:pre
scri
bin
gp
att
ern
slo
cally
;pro
fess
ion
alc
ou
rtes
yb
y
avo
idin
gen
cro
ach
ing
wh
entr
eati
ng
an
oth
ercl
inic
ian
’sp
ati
ent;
con
fusi
on
cau
sed
by
dif
fere
nt
trea
tmen
tp
att
ern
s
by
dif
fere
nt
clin
icia
ns
(pa
tien
tsu
nce
rta
inw
ha
tis
corr
ect)
;an
du
tilit
yo
fp
eer
sup
po
rtw
hen
dea
ling
wit
hd
ema
nd
ing
situ
ati
on
s.
Soci
ali
nfl
uen
ces
Pla
nn
ing
&co
nse
nt
Bel
ief
ab
ou
ta
bili
tyto
pla
ntr
ea
tmen
ta
nd
ga
inco
nse
nt
du
rin
gu
rgen
ta
pp
oin
tmen
ts,i
ncl
ud
ing
‘do
no
thin
g’o
pti
on
s
an
dm
an
ag
ing
an
xio
us/
ph
ob
icp
ati
ents
.
Bel
iefs
ab
ou
tca
pa
bili
ties
Pra
ctic
ech
ara
cter
isti
csC
ha
ract
eris
tics
of
the
pra
ctic
e,in
clu
din
gp
ub
lic/p
riva
te/i
nsu
ran
cep
rovi
sio
n,g
eog
rap
hic
loca
tio
n(r
ura
lver
sus
urb
an
)
an
dco
un
try.
Do
esn
ot
ma
pto
TDF
Pro
ced
ure
po
ssib
leB
elie
fa
bo
ut
wh
eth
erit
isp
oss
ible
top
rovi
de
trea
tmen
td
ue
tois
sues
bey
on
dth
ed
enti
st’s
skill
sd
uri
ng
urg
ent
ap
po
intm
ents
,in
clu
din
gth
ea
bili
tyto
ach
ieve
ad
equ
ate
loca
lan
aes
thes
iaa
nd
/or
top
rovi
de
op
era
tive
trea
tmen
t
(in
acc
ord
an
cew
ith
gu
idel
ines
)to
den
tally
ph
ob
icp
ati
ents
wit
ho
ut
sed
ati
on
.
Bel
iefs
ab
ou
tca
pa
bili
ties
Pro
fess
ion
alr
ole
Infl
uen
ceo
fp
rofe
ssio
na
lro
leo
nm
an
ag
ing
urg
ent
ap
po
intm
ents
,in
clu
din
gw
ha
tis
the
mea
ns
toca
refo
rp
ati
ents
,
an
dfe
elin
g‘m
ora
llyo
blig
ed’t
oo
ffer
som
eth
ing
tan
gib
le(t
o‘d
on
oth
ing
’is
dif
ficu
lt).
The
ab
ility
top
resc
rib
ea
nti
bio
t-
ics
an
du
seo
wn
‘ru
les
of
thu
mb
’are
bo
thsi
gn
so
fex
per
tise
an
dp
ow
er.
Pro
fess
ion
al/
soci
alr
ole
&id
enti
ty
Rel
ati
on
ship
Des
ire
tob
uild
/ma
inta
ina
go
od
clin
icia
n-p
ati
ent
rela
tio
nsh
ip.
Go
als
Ris
kp
erce
pti
on
Bel
iefs
ab
ou
tri
sks
wh
enm
an
ag
ing
the
pa
tien
t’s
con
dit
ion
,in
clu
din
gw
ors
enin
go
fth
eco
nd
itio
n,f
ailu
reo
f(o
rin
ab
il-
ity
toco
mp
lete
)a
no
per
ati
vep
roce
du
re,a
nd
pa
ind
uri
ng
or
aft
erp
rovi
sio
no
fa
pro
ced
ure
or
med
ico
leg
al
com
pla
int.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
Trea
tmen
tsk
ills
Skill
sin
pro
vid
ing
urg
ent
pro
ced
ure
s,in
clu
din
gp
laci
ng
loca
lan
aes
thet
icb
yin
ject
ion
ind
iffi
cult
clin
ica
lsit
ua
tio
ns
or
lan
cin
ga
na
bsc
ess
inth
ep
rese
nce
of
swel
ling
.
Skill
s
Wo
rklo
ad
Bel
ief
ab
ou
tim
pa
cto
nw
ork
loa
d,i
ncl
ud
ing
tim
eta
ken
toex
pla
intr
eatm
ent
op
tio
ns,
ga
inin
form
edco
nse
nt,
del
iver
trea
tmen
to
pti
on
sa
nd
/or
trea
tth
ep
ati
ent
an
oth
erd
ay
on
reca
ll.
Bel
iefs
ab
ou
tco
nse
qu
ence
s
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address this, synthesis was guided iteratively through reference tothe TDF.
Social scientists are part of the contexts they study and it is notpossible to step outside in order to study the topic entirely
objectively.50 The authors were acutely aware, therefore, of theirunique knowledge, attitudes and expectations in relation to anti-biotic use. Recognizing this, the authors attempted to remainexact, sincere and impartial when handling the data.51 Resultswere checked for sense and understanding with non-clinical col-leagues, including the study’s PPI advisers. Nevertheless, theauthors acknowledge that the conclusions were inherently relatedto their specific interpretations and that other equally valid conclu-sions could be drawn from the same data.
The broad range of methodologies employed within theincluded studies [systematic reviews, meta-ethnographies andprimary research (both quantitative and qualitative)] complicatedthe quality assessment as well as extraction, interpretation andpresentation of the results. All of the included dental studies reliedon self-reporting by clinicians about real or simulated clinical casesthrough interviews and/or questionnaires. Studies that rely on self-reported perceptions are inherently at risk of bias in the way peopleaccount for their and others’ behaviour and people are usually notaware of what influences their unconscious/instinctive behav-iour.52 This was a recognized limitation of the included studies andcould account in part for the two most frequently found factorsacross the two reviews: ‘patient/condition characteristics’ and ‘pa-tient influence’. A study of clinical autonomy in relation to prescrib-ing in general practice found that to balance the requirements ofthe patients and the healthcare system, doctors may state ‘clinicalneed’ when it suits them to do so, otherwise they blame ‘patientdemand’.53 Studies of GP consultations and with patients havefound a mismatch between GP reports of patient expectations/de-mand for antibiotics and patient reports.54–56 Similar studies are
Table 4. Summary of potentially modifiable determinants of behaviour associated with the decision whether to prescribe systemic antibiotics foradult patients with acute conditions, showing a comparison between factors identified in the umbrella review across primary care and/or systematicreview of primary dental care
Both umbrella and systematic reviewUmbrella review across primary
care studies onlySystematic review of dental
care studies only
Access accountability procedure possible
Competing demands antibiotic awareness treatment skills
Efficacy of options antibiotic beliefs
Fear about outcome conflict
Feelings about decisions financial burden
Fix the problem
Guidance–practice gap
Guidelines & information
Habits
Healthcare context
Incentives
Patient influence
Patient management
Patient satisfaction
Peers & colleagues
Planning & consent
Professional role
Relationship
Risk perception
Workload
Table 5. Summary of potentially modifiable determinants of behaviourassociated with the decision whether to prescribe systemic antibioticsfor adult patients with acute conditions, showing a comparison betweenthose identified in studies of high-income countries and LMICs
High-income countries onlyHigh-income countries
and LMICs LMICs only
Accountability access
Antibiotic awareness antibiotic beliefs
Efficacy of options competing demands
Feeling about decisions conflict
Guidance–practice gap fear about outcome
Guidelines & information financial burden
Incentives fix the problem
Patient management habits
Patient satisfaction healthcare context
Peers & colleagues patient influence
Planning & consent treatment skills
Professional role
Relationship
Risk perception
Procedure possible
Workload
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required, therefore, to explore which factors influence actual pre-scribing decisions in general dental practice.
The results of these studies should assist the theory-informeddesign of new interventions (and the fine-tuning of existing inter-ventions) aimed at helping clinicians to optimize their prescribingof antibiotics during urgent appointments. They will draw on theexperience of existing multifactorial interventions developed forGPs that have been shown to be effective at reducing antibioticprescribing. One intervention for managing adults with acutecough, GRACE INTRO, used enhanced communication skills and apoint-of-care test for the C-reactive protein biomarker of bacterialinfection (CRP POCT). The intervention positively influenced threefactors identified in this review, as tested in the process evaluationof the trial: (i) increased clinician confidence to reduce antibioticprescribing (‘guidance–practice gap’); (ii) increased perceived im-portance of decreasing prescribing (‘antibiotic awareness’); and (iii)reduced perceived risk of decreasing prescriptions (‘riskperception’).50,51
Conclusions
This study provides a robust identification of the breadth of factorsassociated with the decision whether to prescribe systematic anti-biotics for adults presenting with acute conditions in a range of pri-mary care contexts around the world. Further studies are neededto provide more detailed understanding of which factors are rele-vant determinants of behaviour during actual clinical encountersto inform the theory-informed design of context-specific antibioticstewardship interventions.
AcknowledgementsThis research was carried out as part of a PhD by the first author. Withthanks to the PhD supervisors and PPI advisors, as well as to Judy Wrightand Natalie King for their guidance as information specialists.
FundingThis work was supported by a University of Leeds Anniversary ResearchScholarship as part of W. T.’s PhD research. W. T.’s on-going research issupported by the National Institute for Health Research (NIHR DoctoralResearch Fellowship, Mrs Wendy Thompson, DRF-2016–09-148). In add-ition, W. T., S. H. P., G. V. A. D. and J. A. T. S. are supported by the NIHR in-frastructure at Leeds. S. T.-C. is supported by NIHR through the HealthProtection Research Unit (NIHR HPRU) in Healthcare AssociatedInfections and Antimicrobial Resistance at the University of Oxford inpartnership with Public Health England (PHE)(HPRU-2012–10041).
Transparency declarationsW. T. received funds from Health Education England for speaking atcontinuing professional development events aimed at optimizing anti-microbial prescribing by primary care dentists and GPs in relation toacute dental conditions. W. T. had contracts with Bradford District CareNHS Trust, Cumbria Partnership NHS Trust and Integrated DentalHoldings Ltd to provide primary care dentistry on behalf of the NHS. S.H. P. oversees clinical trials/research funded by NIHR, industry (Solvay,GSK, Proctor & Gamble) and charities (Multiple Sclerosis Society andBritish Society for Oral & Dental Research). All other authors: none todeclare.
Author contributionsW. T. undertook all aspects of this study and production of this paper
for publication. All other authors contributed to design of the reviewsand the process of finalizing the set of potentially modifiable and non-modifiable behaviours, as well as more specifically: S. T.-C. provided inde-pendent assessment of the factors and their mapping to the TDF, con-tributed to analysis and drafting of the manuscript; S. H. P. provided asense check for the resulting themes and drafting of the manuscript; R.R. C. M. assisted with the iterative process of developing factors andmapping them to the TDF, contributed to analysis and drafting of themanuscript; G. V. A. D. provided independent assessment for elementsrelating to the systematic review of primary dental care studies anddrafting of the manuscript; V. R. A. participated in the quality assessmentof included studies for the systematic review of dental studies and critic-ally reviewed the manuscript from a clinical and methodological per-spective; J. A. T. S. provided independent assessments for all elementsrelating to the umbrella review across primary care, contributed to ana-lysis and drafting of the manuscript.
DisclaimerThe views expressed are those of the authors and not necessarily thoseof the NHS, NIHR or the Department of Health and Social Care.
Supplementary dataTables S1 to S7 are available as Supplementary data at JAC Online.
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