Antibiotics for coughing in general practice: a qualitative decision analysis

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Abstract
Background. In family practice, medical decisions are prompted most often by complaints about coughing. There is no single yardstick for the differential diagnosis of respiratory tract infections (RTIs). In 80% of cases, the excessive use of antibiotics in the treatment of RTIs is caused by the prescription behaviour of GPs. Objective. Our aim was to explicate GPs' diagnostic (and therapeutic) decisions regarding adult patients who consult them with complaints about coughing, and to investigate what determines decision making. Methods. Exploratory, descriptive focus groups were held with GPs. Hypotheses were generated on the basis of ‘qualitative content analysis’. Results. Twenty-four GPs participated in four semi-structured group discussions. In order to differentiate RTIs from other possible diagnoses, less likely diagnoses were not ruled out explicitly. In the case of suspected RTI, there was a low degree of certainty in the differentiation between RTIs (e.g. between bronchitis and pneumonia). Clinical signs and symptoms, which determine the probability of disease, often left GPs with reasonable diagnostic doubt. In the end, the decision whether or not to prescribe antibiotics was taken. GPs' prescription behaviour was also determined by doctor- and patient-related factors (e.g. having missed pneumonia once, patient expectations). The ‘chagrin factor’ explains why these factors lead to a shift in the action threshold, in favour of antibiotics. Conclusion. This inductive research method enabled the generation of meaningful hypotheses regarding the complex decision processes pursued by GPs. The authors are developing an educational intervention that builds on these findings, focusing on the prescribing decision.

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