Communicating With Families Regarding Antibiotic Resistance as a Provider

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Research Commodity

Communication training and the prescribing design of antibiotic prescription in primary health care

• Christoph Strumann,
• Jost Steinhaeuser,
• Timo Emcke,
• Andreas Sönnichsen,
• Katja Goetz

ten

• Published: May 19, 2020
• https://doi.org/10.1371/periodical.pone.0233345

Figures

Abstruse

Background

The handling of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Not-clinical factors, such every bit fourth dimension pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, tin promote resistance and crusade serious side effects. The aim of the study was to analyze whether the antibiotic prescription rate for infections of the upper respiratory tract tin be lowered past ways of a short (two x 2.25h) communication grooming based on the MAAS-Global-D for main intendance physicians.

Methods

In total, 1554 main intendance physicians were invited to participate in the study. The command group was formed from observational data. To estimate intervention furnishings we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary intendance physicians for URTIs.

Results

Univariate estimates detected an eleven-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -half dozen.5% and statistically significant. The estimated effects were most identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the handling of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger.

Conclusions

Our results suggest that communication skills, implemented through a short communication preparation with the MAAS-Global-D-training, atomic number 82 to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could non but avert unnecessary side effects but could too assistance reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be practical in the postgraduate training scheme of primary care physicians.

Commendation: Strumann C, Steinhaeuser J, Emcke T, Sönnichsen A, Goetz K (2020) Communication training and the prescribing design of antibiotic prescription in primary wellness care. PLoS ONE 15(5): e0233345. https://doi.org/10.1371/journal.pone.0233345

Editor: Martin Chalumeau, Universite Paris Descartes, FRANCE

Received: Dec 20, 2019; Accepted: May 3, 2020; Published: May 19, 2020

Copyright: © 2020 Strumann et al. This is an open access article distributed nether the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The dataset used and analyzed during the current study is extracted from administrative information and provided past the Association of Statutory Health Insurance Physicians of the Federal Country of Schleswig-Holstein. The information are secured by strict German data protection regulation and we are not allowed to share the data with other researchers. However, a request to ac-assessment the data for scientific purposes and to replicate the findings can be made to the Associa-tion of Statutory Wellness Insurance Physicians (ASHIP) in official writing at Dr. Monika Schliffke, service@kvsh.de, ASHIP, Bismarckallee 1-6, 23795 Bad Segeberg. The relevant software codes and technical back up to replicate the findings are stored in the Supporting Information files.

Funding: The written report was funded by the German Federal Ministry of Health (grant-number: ZMVI1-2515NIK002). The funder of the study had no function in report pattern, data collection, data assay, data interpretation, or writing of the report.

Competing interests: CS, KG, TE and JS: the authors declare that they have no competing interests. I have read the journal'due south policy and the writer As of this manuscript have the following competing interests: AS is an editor of the German version of EbMG. The online admission is provided free of charge to the study PCPs by Verlagshaus der Aerzte, Vienna. This does not alter our adherence to PLOS ONE policies on sharing information and materials.

Introduction

The widespread use of antibiotics and the lack of new drug development serve as the main causes for the emergence of drug resistant leaner [1], limiting the effectiveness of antimicrobial therapy [2]. The rapid increase of resistant leaner is regarded equally one of the greatest threats to global health [iii]. Infections with antibiotic-resistant bacteria may cause higher severity of affliction, bloodshed rates, chance of complications, admissions to infirmary, hospital length of stay and health care costs [2, four–7].

Especially, not indicated antibody utilise is considered to be a chief cause of increasing risk of bacterial resistance [viii]. Therefore, several initiatives address the improvement of prescribing practices of antibiotics worldwide [9–11]. A prominent example for an irrational utilize of antibiotics tin can be found in primary care, where primary care physicians (PCPs) often treat upper respiratory tract infections (URTIs) with antibiotics [12]. URTIs are 1 of the most common reasons for encounter in primary care and are mostly caused past viral infections, making antibiotic-therapy advisable for only a small number of high risk patients [13]. However, the treatment of URTIs accounts for the majority of antibiotic prescriptions in primary care [12, 14, 15], although in that location is very express evidence for their benefits [16–xviii]. Besides characteristics of the physicians (eastward.k., specialty, training, experience), patients (e.thousand., sex, historic period, insurance status, comorbidities) and environmental factors (e.g. access to and quality of care), patient knowledge and expectations, besides as the physicians' assumptions regarding these expectations play a crucial role in the prescribing process [19–21]. Furthermore, evidence strongly suggests that antibiotic prescriptions are associated with a communication trouble. Almost patients seem to possess insufficient knowledge nigh the deviation between viral and bacterial infections [22]. Due to the patients' conventionalities that a previously received antibiotic drug cured their infection, their expectations to receive antibiotic therapy when next presenting with URTI symptoms will increase [23]. Additionally, physicians may wrongly assume that the patient will demand antibiotics and preemptively prescribe the medicine [24–26]. Moreover, due to an overload of patients, physicians might not accept the time to change the patient's expectations by explaining the differences between viruses and bacteria in an understandable and effective fashion [27–29]. Therefore, patient expectations could strongly influence physicians, who are willing to prescribe an antibiotic to maintain a good relationship and to save time [xx, 30, 31].

Communication trainings accept been found to be effective in decreasing the antibiotic prescription charge per unit [32–37]. Although the benefits of adequate advice skills are well known, they are not part of the postgraduate preparation scheme of any medical specialty in Germany [38]. In the Netherlands, a mandatory instrument for training and measuring physicians' communication and medical skills is widely used in under- and postgraduate preparation [39]. This instrument, named Maastricht history taking and advice scoring list (MAAS-Global), has been recently translated and adapted for use in Germany (MAAS-Global-D) [xl].

The aim of this study was to investigate whether a advice training based on the MAAS-Global-D can reduce the rate of antibiotic prescribing for URTIs. Since the expectations of the patients and their perceptions of the physicians are subjective and might differ between patients, we additionally evaluate the intervention effect past the patient's age and sex to increase the insights of the advice upshot.

Materials and methods

Data source

This study was based on the analysis of routine data of the years 2013 to 2016 from the Association of Statutory Health Insurance Physicians (ASHIP) of the federal country Schleswig-Holstein, located in Northern Germany. The ASHIP is in charge for the reimbursement of services that are provided to patients within the statutory health insurance arrangement. The dataset covers 85% of the population and 83% of the PCPs of Schleswig-Holstein [41, 42]. The URTI cases were identified by the target-diagnoses of astute bronchitis, sinusitis and pharyngitis (classified by the International Classification of Diseases, version x (ICD-ten) codes: J01.-; J02.-; J20.- [43]). Nosotros concentrate the analysis to these diagnoses, since simply in some cases the use of antibiotics is suggested by corresponding guidelines within these diagnoses. For cases of acute bronchitis (J20) an antibiotic prescription is indicated for elderly patients besides every bit for those with a severe cardiac or respiratory affliction or a congenital or acquired immunodeficiency [44]. In the example of acute pharyngitis (J02), the indications for an antibiotic therapy are: pharyngitis due to grouping A streptococcus bacterial infections (GAS pharyngitis), red fever, peritonsillar abscess, a suspected serious illness or clinical worsening as well as consumptive diseases, immunosuppression and acute rheumatic fever in the personal or family unit history [45]. For acute sinusitis (J01), an antibiotic therapy should be considered for patients with specific risk factors, likewise as complications such as astringent headache, facial swelling, languor and acute exacerbation of recurrent sinusitis. Moreover, severe pain and an increased inflammation score complaints in the course of the affliction and with fever above 38.5°C [46].

Since the antibiotic prescriptions accept been inferred based on the visit diagnoses, we excluded cases with additional diagnoses. This includes the presence of diagnoses regarding puerperium/pregnancy (O00-O99), further (bacterial) infections (A00 to A37, A39 to A79, J15, J17, J18) or chronic diseases (I50, J44, J45, C00 to C75). If the diagnosis had been fabricated several times or more one diagnosis had been made from the iii groups (J01, J02, J20), the corresponding cases were also excluded. To increase the comparability of the included cases and, thus, minimize a potential interpretation bias of the communication preparation upshot, only cases of patients that were older than xviii years are included in the analysis.

Recruitment and inclusion criteria

All primary intendance physicians in individual practices, working in a contract with statutory public health insurance and with a work experience of at to the lowest degree v years, who have patients with at least 1 of the target-diagnoses between 2013 and 2015 were considered for the intervention. In total, 1554 (76%) main care physicians of Schleswig-Holstein take been invited by letter to participate in a study named "Effects of communication training with the MAAS-Global-D on the prescription of antibiotics for respiratory infections".

Study design and estimation strategy

The intervention and the previously planned randomized controlled trial (RCT) has been described past Hammersen et al. [47] (Trial registration: DRKS00009566). The study was originally designed to consist of two interventional report arms. In addition to the communication grooming, the 2nd intervention group received an educational introduction into the use of and online-access to EbMG online (Evidence–based Medicine Guidelines) [48]. This point-of-care online tool provides further information material on the prescribing of antibiotics for elementary respiratory infections. Since the inclusion rate was lower than initially expected, both intervention groups have been consolidated. Furthermore, a comparison between the pooled intervention group and the control group did not yield pregnant results due to a lack of power because of the small sample size. Instead, we formed a control grouping from observational data and applied a combination of deviation-in-difference (DiD) estimation and matching approach that is considered to reproduce the results of RCTs very well under certain assumptions [49]. For example, under the assumption that the average outcomes for the intervention and control grouping would have followed parallel trends over time before intervention, the DiD calculator identifies causal effects by contrasting the change for the intervention and command groups in pre- and mail-intervention outcomes [50]. Yet, the assumption of parallel trends might be implausible in our setting. For example, if physicians recognized a also high antibiotic prescription rate for URTIs, they presumably tried reducing it. Therefore, they might accept been more likely to reply to the preparation offer that advertised a reduction of the prescription rate through improved communication skills. Consequently, the evolutions of the prescription rates were suspected to differ between the intervention and control grouping if the control grouping, as in this case, had non been built upon a controlled randomization. An culling identifying assumption is that the potential outcomes are independent of intervention condition, conditional on by outcomes and covariates [51]. Past means of balancing the intervention and control group according to pre-intervention outcomes and covariates all potential outcome trends are perfectly aligned and the DiD estimates tin exist interpreted as causal effects [49, 52]. Withal, recent studies showed that the combination of DiD and matching might also deliver biased estimates [53]. In society to enhance the robustness of our findings and minimize the risk of estimation bias we compared DiD estimates from both unmatched and matched (on pre- intervention outcomes) data [54].

In the search for relevant variables determining the decision to prescribe an antibiotic for a specific URTI case (our dependent variable) nosotros showtime estimated a multi-level random effects logistic regression model based on case-, patient- and physician-level data of the pre-intervention period. A logistic regression model was called to account for the binary nature of the dependent variable. Moreover, the logit model showed computational merits and, unlike the probit model, information technology did not endure from whatsoever convergence failures. Random effects were specified on the physician level to account for intra-medico variability [55]. In a 2d step, we aggregated the information on the physician level and matched the intervention and control groups according to aggregated pre- intervention outcomes and covariates by ways of entropy balancing [56]. Based on the counterbalanced data, in the tertiary step, we estimated a multi-level random effects logistic DiD regression model using the weights of the doc-level from entropy balancing. Alternatively, we too specified stock-still md effects in the pre-intervention assay and the DiD regression models. For all models the results between fixed and random effects models are very like and we conclude there is no correlation between the explanatory variables and the individual effects. The physicians, who had previously been selected to the command group were excluded from the third step of the analysis, since we could not rule out that their prescribing behavior might have been affected by the cancellation of participation in the communication training.

The report was approved past the ideals committee of Luebeck University before the recruitment of participants on 9 June 2015 (number of blessing: xv–139). Statistical analyses were performed with STATA 15 (StataCorp LLC, Higher Station, TX, USA).

Intervention

The intervention group received a communication training with an interactive workshop character (ii times 2.25 hours), which was held at the Establish of Family unit Medicine in February and March of 2016. It was delivered face-to-face up by members of the research team, including an expert in physician-patient communication. The curriculum of the preparation was derived from the German version (MAAS-Global-D [40]) of the Dutch instrument MAAS-Global [39]. After establishing the relevance and success of medico-patient communication, the participant were provided with data concerning the associated bear witness base regarding handling of URTIs. Furthermore, they learned about the dissimilar chatty phases of a consultation, corresponding communication skills equally well as full general advice skills for the whole consultation (e.yard. adequate provision of information, structuring and empathy, shared decision-making).

Measurements

Equally the consequence variable we considered the binary pick whether an antibiotic was prescribed for a URTI case. The selection of potential determinants serving as command variables in both the pre- intervention and the DiD regression analyses was based on related previous literature [25, 57]. They tin be classified into 3 categories: (i) case related (year, quarter, diagnosis and its certainty, emergency service), (two) patient specific (insurance status, age, sex) and (iii) md characteristics (age, sex, number of URTI-patients in that quarter). Seasonal furnishings and a full general trend in the prescribing pattern were considered by respective dummy variables identifying the quarter and the year of the consultation, respectively. As the prescription rate might differ between the considered diagnoses, we introduced dummy variables for sinusitis and pharyngitis with bronchitis serving equally reference. According to the German coding policy, principal care physicians are required to designate their diagnoses equally validated (certain) or suspected (cases without an established definite diagnosis). We controlled for the cases with a certain diagnosis by including a respective dummy variable. Further, nosotros distinguish whether the patient visited an emergency care center during the out-of-hours intendance (emergency service). Demographic variables of the patient were comprised of the sexual practice (sex = 1: female person), the historic period and the insurance status (normal, family or retired). The age was grouped by respective dummy variables for patients aged <35, 35–65, 65+ to allow for nonlinear age effects. In Germany, the insurance status signifies whether the patient is ordinary insured, retired or coinsured. Children and grandchildren aged beneath 25 likewise equally spouses that are unemployed, not cocky-employed and are not exceeding an income of EUR 450 per month are coinsured with an ordinary insurance member. The considered age and insurance status based clusters reflect different stages of life that might get along with unlike expectations about the handling. At the doctor level, nosotros controlled for the specialty, since primary care physician workforce in Deutschland consists of full general practitioners, physicians in full general internal medicine and a failing number of practitioners without special grooming in master care (12%). Previous studies have shown substantial differences in prescribing behavior between general internists and general practitioners [58]. Further, nosotros considered the historic period and the sexual practice of the physician. Finally, to guess the workload of the medico's practice we included the number of total URTI patients in the respective quarter. The logarithmic office to this variable accounts for diff variation.

In the intervention analysis, the DiD dummy variable identifies observations of the intervention group for the post-intervention period. To command for any other fourth dimension-invariant differences between both groups a dummy variable trained is additionally included.

Results

In the offset role of the analysis (pre-intervention), the sample of the pre-intervention analysis (2013 to 2015) consisted of 315,752 developed patients with 476,260 cases from 2,189 PCPs. For the second office of the written report, we invited 1,554 PCPs in SH to participate in the preparation. The grouping of interested participants has been divided randomly in a control and an intervention group with each 17 PCPs. Due to a lack of power, we alternatively course the control group from observational data. Practice to so, we excluded the prior control group physicians (north = 17) and practitioners without special grooming in primary care, since they are defective in the intervention group (due north = 198). Moreover, 492 PCPs are not considered because they are non treating URTIs in each of the considered years, for instance since they are entering or leaving the ASHIP payment arrangement during the study catamenia. Finally, the intervention/control group in the intervention assay consisted of 17/1,460 PCPs with 1,807/170,683 patients with two,284/235,355 cases in the pre-intervention menstruation (2013:q1 to 2015:q4) and 585/61,755 patients with 698/75,167 cases later on the intervention (2016:q2 to 2016:q4) (Fig one).

Pre-intervention analysis

The mean values of the considered variables in the pre-intervention analysis and the regression results are shown in Table 1. An antibiotic was prescribed in half of the considered cases (49%).

The results of two logistic regression models with specified random effects on the physician level are shown in the third and fourth column of Table 1. In both models, the estimated intra-form coefficients (21.6%) propose that provisional on the covariates, nigh 1 quarter of total variation in antibiotic prescription could exist explained by the individual physician's practice mode. The estimated regression coefficients indicated that patients aged over 35 years were significantly more likely to receive an antibiotic prescription than younger patients. The strongest upshot was achieved for patients aged between 35–65 years. Female patients were likewise more likely to receive an antibiotic. The interaction effects between the patients' gender and age groups in Model (2) signified that the gender difference only exists for patients younger than 35 years. As indicated by the smaller Akaike Information Benchmark (AIC), the fit of the model was significantly improved, leading to our last model that was considered for the intervention assay.

Matching

The entropy balancing was applied to match physicians of the intervention grouping with physicians of the control grouping in the pre-intervention period. In improver to the control variables, the pre-intervention prescription rates served equally conditional variables used in the matching. Example- and patient-level variables were aggregated on the dr. level. Table 2 shows the ways of the variables for the intervention every bit well as the matched and non-matched control grouping. Further, the differences between intervention grouping and unmatched controls too every bit the share of missing observations are shown for each variable.

The intervention group is characterized by higher boilerplate prescriptions per doctor in comparison with the control grouping. This hints for a selection of the participants in the intervention grouping due to their pre-intervention upshot. Furthermore, the change over time differed betwixt both groups, underlining that the assumption of parallel trends might not agree. The boilerplate number of patients was higher in the control group. However, none of the differences were meaning, except for the fraction of patients with a certain diagnosis and family insurance. This might accept been due to the low number of observations at the dr. level in the intervention group (n = 17). Yet, after applying the reweighting approach based on entropy balancing the means in the command grouping equaled the means in the intervention group.

Univariate DiD analysis

To appraise the sensitivity of the DiD assay due to model specifications and the balancing nosotros started presenting univariate DiD estimates (elementary mean comparison) based on unmatched and matched sample data in Tabular array 3. Neglecting medico-specific effects and other covariates, the reduction in the overall prescription rate of the intervention group betwixt the pre-intervention and post-intervention catamenia was xi.2%. For the command group a reduction of four.7% could exist detected. The difference betwixt both groups in the difference between the periods is the DiD figurer, which is -6.5% [95% CI: (-10.vii%; -ii.3%)], and significant. Reweighting the observations of the case-level by the entropy weights on the doctor-level increased the prescription rate of the matched control group to 52.9%. This was also slightly smaller than the rate of the intervention group (55.4%), which might be, because the matching was done at the physician level and not at the case level. However, the DiD judge for the matched sample was rather like (-6.1% [95% CI: (-12.0%; -0.2%)],) and too significant. Concluding, both univariate DiD estimates propose a significant reduction of antibody prescriptions after the advice training.

Multilevel DiD regression analysis

To have into account the control variables and the random effects on the physician-level, we estimated the specification of Model (2) based on the extended data set, also as the DiD and preparation dummy variable. Tabular array 4 shows the estimated DiD furnishings and the moderation effects. To ease the interpretation of the estimated DiD coefficient, the marginal effect on the prescription rate was also shown for the direct furnishings.

All specifications obtained a significant reduction of the prescription rate due to the intervention. There were no substantial differences between the estimates of the matched and unmatched sample. The marginal effects were close to the estimated univariate DiD effects.

The results of a moderation event of the DiD outcome past the historic period and sex activity of the patients are also shown in Table 4. They suggest that the intervention had a significantly stronger effect on the treatment of female person patients aged below 35.

Discussion

In this report, we estimated the effect and its moderations of a advice grooming based on the MAAS-Global-D instrument on the antibiotic prescription rate of chief care physicians for the treatment of upper respiratory tract infections. Since the command group was formed from observational data, we applied a combination of difference-in-difference interpretation and statistical matching based on entropy balancing to guess the intervention outcome. Relevant variables for the matching were selected subsequently estimating a multi-level logistic regression model for the antibiotic prescribing decision, based on instance-, patient- and physician-level information of the pre-intervention menstruum in the first stage. In the 2nd phase, the aforementioned model was estimated, based on matched information and extended by the intervention flow and DiD specification.

Pre-intervention analysis

During the pre-intervention period, an antibody was prescribed in almost one-half of the considered cases. This relatively high number of antibiotic prescriptions is as well observed in related studies [57, 59]. In both groups (intervention and control), the prescription rate slightly decreased over fourth dimension. This is like to the declining trend of general antibiotic utilize in other countries [60] and might be explained by an increased sensation of antimicrobial resistance [61], eastward.g. due to successful antibody stewardship programs as the German Strategy against Antibiotics Resistance [62]. The estimated intra-class coefficient of the multilevel regression model shows that the individual physician's practice style explains almost 22% of the total variance in antibiotic prescription and is similar to the results of related studies [25, 35, 63]. It suggests the prospect of a successful reduction in the prescription rate by changing the individual physician'southward prescribing beliefs. Most of the observable characteristics of the doc practise not explain the variance in prescribing behavior. Only the number of URTI patients (serving as a proxy of the physician's workload) increases the probability of antibody prescription. This effect underlines the hypothesis that insufficient communication determines the antibiotic prescription. It is more complicated for physicians defective sufficient fourth dimension for the consultation due to an overload of patients, to modify the patients' expectations [28, 64]. A similar mechanism might explicate the positive clan of emergency service and the antibiotic prescription probability. In Germany, PCPs face an overload of patients, particularly when providing out-of-hours care in emergency service [65]. Patients visiting the emergency service for respiratory complaints might be more than severe and therefore might have a strong expectation of receiving an antibiotic [66]. The expectations might also differ between patients, as suggested by the estimated effects of the patient characteristics.

Patients higher up the historic period of 35 years receive a significantly college number of antibody prescriptions than younger patients do. For patients belonging to a higher-risk group (due east.thou., elderly patients) respective guidelines advise the use of antibiotics in some cases [44–46]. Therefore, the application of guidelines cannot explain the lower prescription rates for patients anile above 65 in comparison with patients aged betwixt 35 and 65 (Model (1): 0.28 vs. 0.33). Differences between the patients' expectations in the age-groups below and above 35 respectively, might be more probable to serve equally an caption. Piece of work pressure and other related stress cause patients to desire rapid salvage from symptoms and cure of their sickness [67]. The perceived importance of the patient's job promotes the decision to prescribe an antibody [30, 68]. This might explain that the antibiotic prescription rate considerably exceeds the clinically justified amount for young and heart-aged adults with respiratory infections in the UK [69].

Our results further suggest that women receive more frequent an antibiotic prescription. Women are more probable to visit a physician for URTI than men [57] and are found to be more skeptical towards the physician'south suggestions [70]. This patient grouping might combine higher expectations and wariness that might lead to additional communication requirements. This hypothesis is in line with the college antibiotic prescription rate that is observed for female person patients in our data. However, the underlying mechanisms were non aim of our enquiry focus and is, therefore, subjected to future research. Similar to other studies, the gender gap vanishes with the increasing patient-historic period [71]. Simply female patients below the historic period of 35 receive a significantly higher number of antibiotic prescriptions. This effect might indicate that the advice problem is more often than not pronounced for the handling of this group of patients. In the post-obit, we discuss the effects of the communication training on the antibiotic prescription probability.

Intervention analysis

Nosotros applied dissimilar approaches and specifications to robustly gauge the result of the advice training on the antibiotic prescribing beliefs. The univariate approach estimates an 11-percentage-point reduction of prescriptions for the intervention group subsequently the preparation. This effect is very similar to a related written report [72]. All our approaches (univariate and multivariate) estimate a decrease of effectually 6.5 percent-points in the prescription probability of the trained physicians. These robust estimates are in line with the findings of other related studies applying RCT methodology [32, 35, 73]. The moderation analysis confirms that the effect of the communication training is stronger for the treatment of patients marked past a larger communication problem. The impact of the training on the reduction of antibiotic prescription is significantly stronger for the treatment of young women. Thus, physicians with improved communication skills might be able to improve address the potentially college expectations of immature female patients to receive an antibiotic therapy and their wariness towards the physician'due south suggestions [70].

As argued past Fritz and Holton [74], the lack of trust in the patient-md relationship enhances the likelihood of overprescribing. A patient trusting in the doc'southward clinical judgment, can be reassured to take not-prescribing [75]. Furthermore, secured trust between the patient and medico could reduce the probability of the doctor to misperceive the patient'southward expectation to receive antibiotic handling. To establish a trustful relationship it is of import for the patient to recognize the dr.'due south trust in them and believe that the physician acts in their best involvement [76]. Signals of trustworthiness are given by verbal and nonverbal communication and serve to constitute patients' trust, and, thus, influence the md-patient relationship [77]. For this purpose, the MAAS-Global-D might exist a promising tool to improve effective advice since both verbal and nonverbal communication skills are function of the training. To cover emotions too every bit feelings and to react adequately, the MAAS-global-D-manual proposes the dr. to render the feelings expressed by the patient during the consultation either in words or nonverbally [39]. Trust is considered for most patients to be an integral office of an ongoing relationship with a physician [78]. An increased continuity of care enables, on the i hand, physicians to better evaluate the patient's expectations of receiving an antibiotic by the more intimate knowledge of their living atmospheric condition. On the other hand, patients tin build upwardly a deep understanding of appropriate antibiotic use and will modify their expectations permanently. The findings of Robert et al. [79] suggest that receiving information about antibiotics from family physicians is usually non associated with an increased knowledge of the patients. A trustful and continued relationship might exist helpful for physicians to provide information almost the employ of antibiotics, and to amend knowledge about antibiotics peculiarly amidst target groups [79, 80]. As we institute in our pre-intervention data analysis, ane specific target group consists of young female person patients.

Limitations and strengths

The study estimated the effects of a communication training for primary intendance physicians on the antibiotic prescription rate for infections of the upper respiratory tract and its moderation by historic period and gender of the patients.

The report has strengths also as limitations. In contrast to the previously planned randomized controlled trial [47], in this written report we formed a control grouping from observational information. In dissimilarity to the control group physicians the members of the intervention group did know that their prescription information would exist analyzed for the periods before and after the training. Therefore, we cannot exclude that behavior modify in the intervention grouping is due to the physicians' awareness of being under observation rather than solely due to the intervention (Hawthorne effect) [81]. Withal, since we considered the data of the physicians up to one year after the preparation, nosotros practise non believe that this effect is responsible for persistent behavior changes. Farther, the approach that has been applied to estimate the intervention effect is more than sophisticated and is, thus, more susceptible to misspecification than an RCT [82]. To minimize the risk of biased estimates we practical several culling approaches (univariate, multivariate, matching, no-matching) and specifications (fixed and random furnishings) equally robustness checks. All estimated effects of the intervention are very similar. Therefore, we believe that misspecification is non a big event hither.

A strength of this study is that it relies on routine data collected from all primary care physicians in a specific region of Deutschland. The relatively large number of physicians of the (matched) command group (north = one,460) might ensure a higher external validity of our findings than the rather pocket-size sample sizes of other related studies applying an RCT [32, 33, 35, 36]. However, the small number of the intervention group highlights the trouble to convince PCPs to participate in intervention studies [83, 84]. Another reason for the depression response rate might take been rooted in the PCPs' (who already faced an overload of patients) concerns that improved communication skills would prolong the consultation, although so far, there is no evidence to support this claim [85].

While on the ane mitt, the focus on the federal state of Schleswig-Holstein constrained the representativeness of the findings, it on the other paw also reduced practise variations based on regional differences and state-specific regulations [86]. The analyzed moderation of the patient's age and gender on the communication training result further increased the insights of antibody prescribing behavior. In line with the findings of our pre-intervention information analysis, our results suggest that improved advice skills are by and large effective in cases where the underlying communication problem is particularly pronounced due to high expectations of the patient to receive an antibiotic or due to the physicians' perceptions. To clarify the moderating office of expectation and its perception for the communication training result on antibody usage futurity research should include direct measures of these variables [25].

Conclusion

In this study, nosotros estimated the effect and its moderations of a advice preparation on the antibiotic prescription charge per unit of primary care physicians for the treatment of upper respiratory tract infections, i.eastward. acute bronchitis, sinusitis and pharyngitis. The short communication training has been based on the MAAS-Global-D [40], the German version of the Dutch musical instrument MAAS-Global [39]. Since the control grouping has been formed from observational data, a combination of departure-in-divergence (DiD) and matching has been applied to estimate the intervention effect. To minimize the chance of biased estimates we applied several alternative approaches and specifications as robustness checks that all reveal similar intervention effects. The results bear witness that the communication training decreases the prescribing probability past effectually 6.5-pct-points for the physicians of the intervention grouping. For the treatment of female patients aged beneath 35, the intervention has a stronger impact.

Our results suggest that communication skills implemented via MAAS-Global-D-preparation lead to more prudent prescribing of antibiotics for URTIs. Therefore, the MAAS-Global-D-grooming could non but avoid unnecessary side effects but could besides help to reduce the emergence of drug resistant bacteria. The instrument MAAS-Global-D has been proven to provide a valid tool for a grooming of physicians that encourages an constructive advice with the patient. In holland, communication training is an integral part in the postgraduate-training program of general practitioners. A similar communication grooming based on the MAAS-Global-D could also be applied in Federal republic of germany, as well as in other countries, where postgraduate training schemes of PCPs lack in training of communication skills. The instrument and the explanatory manual in German language are available for gratis download [87].

Trial registration

The intervention and the previously planned randomized controlled trial (RCT) has been registered in the German language Clinical Trial Register (DRKS00009566).

Supporting information

References

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