What influences locum GPs’ antibiotic prescribing and engagement with antibiotic stewardship? A mixed-methods study

Problem

Most antibiotics are prescribed in primary care, contributing to developing antimicrobial resistance. Different strategies have helped optimise antibiotic prescribing in general practices in recent years, but it remains a challenge for some prescribers and practices. Turnover of locum general practitioners (GPs) has been suggested as one of the challenges to optimising antibiotic prescribing in high-prescribing practices. This study aimed to identify (i) how locums’ prescribing compares to other general practice prescribers, and (ii) what influences their antibiotic prescribing and engagement with antimicrobial stewardship.

Approach

This was a mixed-methods study. Firstly, data on antibiotic prescribing, diagnoses and patient, practice and prescriber characteristics were extracted from The Health Improvement Network (THIN) database. A mixed effects logistic model was used to assess whether locums are more likely to prescribe antibiotics than other healthcare professionals for conditions that generally do not require antibiotics. We excluded patients with comorbidities and recurrent/chronic cases to reduce the probability that difference would be explained by case-mix. Secondly, locum GPs were recruited through GP newsletters and mailing lists, purposefully sampled to ensure varied characteristics, and interviewed by phone using a semi-structured topic guide. Interviews were recorded, transcribed and analysed thematically.

Findings

Locum GPs accounted for 11% of consultations analysed. Locums prescribed antibiotics more often for cough, sore throat, asthma exacerbations and acute bronchitis, compared to other GPs and nurse prescribers. The percentage of patients receiving antibiotics for these conditions were 4% higher (on absolute scale) when consulting with locum GPs compared to other GPs, while prescribing percentages were similar for other conditions. Nineteen locums were interviewed. The findings showed that although antibiotic prescribing is an individual clinical decision and GPs use individual strategies to optimise prescribing, different contextual factors, specific to locums, influence their approach to prescribing antibiotics and antimicrobial stewardship. These are captured by the three themes: (1) the nature and patterns of locum work (e.g., unfamiliarity between patients and locums, flexibility and control over working pattern); (2) relationships between practices and locums (e.g., lack of embeddedness within practice teams, limited communication, influence of prescribing cultures in practices); and (3) opportunities for training and engagement with antimicrobial stewardship (e.g., professional isolation, limited opportunities for peer learning, access to training and professional networks).

Consequences

Prescribing data suggests that locum GPs may contribute to higher antibiotic prescribing. Qualitative data suggests that locums face specific challenges to optimising antibiotic prescribing, but also perceive opportunities for contributing to antimicrobial stewardship. More focus is needed to address these barriers and facilitators (e.g., with more communication, feedback and training). As locum GPs are a growing proportion of GPs, they have an important role in optimising antibiotic prescribing and antimicrobial stewardship which needs to be better addressed.