OBJECTIVES :

Overprescribing of antibiotics is an important driver of antibiotic resistance – a global public health crisis. While current research has outlined various clinical, behavioural, and social factors that influence antibiotic prescribing, the relative importance of prescribing determinants remain unknown. In this study, we attempted to determine the relative weight of various factors used by hospital-based physicians to make prescribing decisions.

METHODS :

We employed two forced choice discrete choice experiments (DCEs) administered within online surveys among hospital-based physicians in Tuscany, Italy. All attribute and associated levels were pre-validated through focus groups with target physicians. Participants were asked to select a preferred choice in which they would prescribe antibiotics between alternatives differing in levels of clinical uncertainty, patient expectations and past behaviour. We fitted a conditional logistic regression to analyze the choice data, reflecting the random utility model.

RESULTS :

The final study population included 1,436 hospital-based physicians. Patient expectation was associated with decreased odds of prescribing antibiotics (DCE1: OR=0.81, p= 0.001; DCE2: OR=0.79, p= 0.010). We did not find a consistent significant association with clinical uncertainty (DCE1: OR=1.03, p= 0.614 ; DCE2: OR=0.83, p= 0.049) and we found no significant association between past behaviour and odds of antibiotic prescribing (DCE1: OR=1.13, p= 0.068; DCE2: OR=1.20, p= 0.053). Among the three attributes, effect size was highest for patient expectations, followed by past behaviour then clinical uncertainty in both DCEs.

CONCLUSIONS :

Here we show that patient expectation has a significant negative association with antibiotic prescribing decisions among hospital-based physicians when past behaviour and clinical uncertainty is held constant. The surprising directionality in this association may be explained by the cultural context. Healthcare organizations may improve antibiotic prescribing practices by investing in culturally contextualized physician communication training and patient education.