TREATMENT DECISIONS IN PRIMARY CARE FOR VETERANS WITH UPPER RESPIRATORY INFECTIONS: A CRITICAL DECISION METHOD

Purpose: A substantial proportion of antibiotic prescribing in outpatient care environments is inappropriate and potentially harmful to individual patients and to population health. Our aim was to better understand reasons why providers did or did not prescribe antibiotic therapy for patients with upper respiratory infections.

Method: We interviewed primary care providers in the Veteran’s Healthcare Association to understand treatment decisions among primary care providers treating patients with upper respiratory infections (URIs).   A Critical Decision Method of Cognitive Task Analysis was conducted with a sample of 13 primary care providers with patients recently treated for a URI.  These providers reported situational cues that guided them to their treatment decision, difficult decision features (if any), decision information needs, explained their mental models for URI treatment, and addressed attitudes, beliefs and behaviors associated with their treatment, treatment uncertainty and efficacy, and their readiness to change antibiotic prescribing practices for respiratory infections. Qualitative analyses were performed to identify decision-related themes.

Result: Providers perceived these decisions to be relatively easy and driven by patient-reported symptoms.  Providers rarely reported that additional information would have aided their decision although one provider reported making a decision for which no clinical guidelines existed. Provider’s mental models for treatment were most often centered on perceived patient needs and risks (e.g., risk of C. difficile infection or side effects of antibiotic treatment), rather than population health needs.  A few providers did discuss increased antibiotic resistance in the population as important.  Providers who did prescribe antibiotics for their patient typically reported doing so because of comorbid conditions (e.g., COPD) or duration of illness (e.g., sinusitis longer than 10 days).

Conclusion: When making antibiotic prescribing decisions for patients with URIs, providers consider patient-level needs but rarely consider population health consequences of these decisions.  Implications include targeting decision support to increasing awareness of population health consequences integrated with patient level risks.