Antibiotic prescribing in Long Term Care Facilities: a meta-synthesis of qualitative research.
Authors: Aoife Fleming1, Colin Bradley2, Shane Cullinan1, Stephen Byrne1.
1 Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Ireland.
2 Department of General Practice, University College Cork, Ireland.
Corresponding author:
Aoife Fleming, Tel. 00353 21 4901690 Fax 00353 21 4901656
ESM1: Quality appraisal using the Critical Appraisal Skills Programme quality assessment tool (14).
The CASP screening questions are as follows:
1. Was there a clear statement of the aims of the research?
2. Is a qualitative methodology appropriate?
The more detailed questions are as follows (summary term in brackets links to table content):
3. Was the research design appropriate to address the aims of the research? (Research design)
4. Was the recruitment strategy appropriate to the aims of the research? (Sampling)
5. Was the data collected in a way that addressed the research issue? (Data collection)
6. Has the relationship between the researcher and participants been adequately considered? (Reflexivity)
7. Have ethical issues been taken into consideration? (Ethics)
8. Was the data analysis sufficiently rigorous? (Data analysis)
9. Is there a clear statement of findings? (Discussion of findings)
10. How valuable is the research? (Value)
Study / Screening Questions / Detailed QuestionsCarusoneet al. (part II) 2006 (18) / The research aims & methods clearly stated & appropriate / Research design: A qualitative design was used to conduct an in-depth exploration of the implementation of a care pathway for treating residents with pneumonia.
Sampling: Administrators and Medical directors were recruited from six of the ten LTCF involved in the study, the sample is clearly outlined.
Data collection: Interviews were undertaken, did not discuss why this method chosen. A broad topic guide was used, interviews were recorded and transcribed verbatim. Data saturation was discussed.
Ethics: Ethical approval and written informed consent obtained from all participants.
Data analysis: Written and audio versions of the interviews were compared for accuracy. A clear 5-stage process of thematic analysis and pattern coding, involving two researchers, was conducted. Supporting quotations and contradictory evidence are provided.
Discussion of findings: The findings are explicit and credible. Barriers and facilitators to the on-going implementation of the pathway are discussed.
Quality concerns / Reflexivity: The potential bias from the researcher was not discussed, it was not stated if they were involved in the trial.
Value: Addresses limitations, the policy context/research literature and future research not addressed. Future implementation of this pathway is discussed. The transferability of the findings to other infections/clinical pathways or other jurisdictions is not discussed. The authors did mention that the participants may be biased in favour of implementation as these LTCF had agreed to participate in a trial. The authors deal with this by presenting the findings for and against the implementation of the pathway.
Carusoneet al. (part I) 2006 (17) / The research aims & methods clearly stated & appropriate / Research design: A qualitative design was used to conduct an in-depth exploration of the implementation of a care pathway for treating residents with pneumonia.
Sampling: Nurses were recruited from six of the ten LTCF involved in the study, the sample is clearly outlined.
Data collection: Interviews were undertaken, did not discuss why this method chosen. A broad topic guide was used, interviews were recorded and transcribed verbatim. Data saturation was discussed.
Ethics: Ethical approval and written informed consent obtained from all participants
Data analysis: Written and audio versions of the interviews were compared for accuracy. A clear 5-stage process of thematic analysis and pattern coding, involving two researchers, was conducted. Supporting quotations and contradictory evidence are provided.
Discussion of findings: The findings are explicit and credible. Barriers and facilitators to the on-going implementation of the pathway are discussed.
Quality concerns / Reflexivity: The potential bias from the researcher was not discussed, it was not stated if they were involved in the trial.
Value: Addresses limitations, the policy context/research literature and future research not addressed. Future implementation of this pathway is discussed. The transferability of the findings to other infections/clinical pathways or other jurisdictions is not discussed.
Helton et al. 2006(19): / The research aims & methods clearly stated & appropriate / Research Design: A qualitative interview study was conducted to determine the factors influencing physicians decisions when looking after dementia patients with pneumonia.
Sampling: Participants were recruited from the US and the Netherlands in order to obtain a varied sample in terms of clinical experience, urban/rural setting.
Data collection: A topic guide was used. Interviews were recorded, transcribed and checked for accuracy. Data saturation was obtained.
Data analysis: Editing analysis was conducted by two researchers with an independent analysis by two other researchers conducted. Contradictory data is presented and there were sufficient supportive quotations.
Discussion of findings: The findings were discussed in detail and are credible. Differences and similarities between the groups were discussed.
Value: The value of this study in making recommendations for future research is set out by highlighting the impact of organisational culture and training on the care of LTCF patients with infection. More detail on the LTCF context of participants would help to judge the transferability of the study (e.g. LTCF funding source, bed number, doctor and nurse number).
Quality concerns / Reflexivity: The potential bias in data collection or recruitment was not addressed.
Ethics: Ethical approval was obtained. There was no mention of written consent.
Lim et al. 2014 (20) / The research aims & methods clearly stated & appropriate / Research design: A qualitative interview and focus group study was conducted in order to determine the factors influencing antibiotic prescribing in residential aged care facilities.
Sampling: Purposive and snowball strategies were used to recruit doctors, nurses and pharmacists, with some subsequent snowball sampling.
Data collection: A topic guide was used and interviews and focus groups (n=3) were conducted. All interviews were recorded and transcribed verbatim and transcripts were checked for accuracy. Data saturation was obtained.
Ethics: Ethical approval and informed consent was obtained.
Data analysis: Framework analysis was used with independent analysis being conducted before final themes were decided. Supportive quotations and contradictory data are presented.
Discussion of findings: A clear presentation of the positive and negative views of antimicrobial prescribing and antimicrobial resistance is provided, with barriers and facilitators to interventions explored.
Value: The contribution of this study to the design of antimicrobial stewardship interventions in LTCF is discussed. More detail on the LTCF context of participants would help to judge the transferability of the study (e.g. LTCF funding source, bed number, doctor and nurse number)
Quality concerns / Reflexivity: The potential bias of the researcher on the question formation or data collection was not discussed.
Lohfieldet al. 2007 (21) / The research aims & methods clearly stated & appropriate / Research design: A qualitative interview study was conducted to investigate the implementation of a pathway to treat UTIs in LTCF.
Sampling: Participants were recruited from 8 Canadian and 2 American facilities in the intervention arm of a trial testing the effect of a UTI pathway in LTCFs. The administrators were invited to conduct interviews. The administrators then invited the nurses to participate in focus groups, this method of recruitment could be biased by the administrators selection of nurses.
Data collection: An interview topic guide was used, and initially piloted. 19 interviews with administrators and 10 focus groups with nurses were conducted. Interviews and focus groups were recorded and transcribed verbatim.
Data analysis: The findings between the Canadian and American facilities were not different so they were pooled for analysis. Editing analysis was conducted by 3 researchers independently before deciding on the main themes.
Discussion of findings: Multiple sources of data, researchers and theory were used by the authors to support their findings. Supportive quotations and contradictory data are provided. The positive/negative views and barriers/facilitators regarding the pathway were presented.
Value: This study contributes to the design of antimicrobial stewardship interventions in LTCF. The transferability of the findings are compromised as the study relates to the implementation of a specific pathway. The study incudes LTCF from different countries without detailing the differences in organisation structure between them and how this may have impacted on the implementation of the pathway.
Quality concerns / Reflexivity: The potential bias of the researcher on the question formation and data collection was not discussed.
Ethics: There is no mention of ethical approval, but consent to record the interviews and focus groups were obtained from participants.
Russell et al. 2003 (22) / The research aims & methods clearly stated & appropriate / Research design: A qualitative study was conducted to investigate influencing factors on antibiotic prescribing in nursing homes.
Sampling: All participants who responded to a flyer advertising the study participated. This may have biased the responses as participants were self-selecting.
Data collection: Two focus groups were conducted; one with 8 nurses, one with 5 doctors, 13 LTCF were represented. A topic guide was used but not information regarding content is provided.
Ethics: Ethical approval was obtained.
Data analysis: The data were analysed for identify themes and investigator triangulation was conducted.
Discussion of findings: The results are supported by quotations and contradictory findings between and within the nurse and doctor groups are presented. The findings are not particularly biased towards any group. The topic guide and subsequent results have deviated from the original aim by focusing on MRSA management.
Quality concerns / Data collection: Data saturation is not mentioned. It is not stated whether interviews were recorded or not.
Reflexivity: The potential bias of the researcher on the question formation or data collection was not discussed.
Value: The study adds to the literature in terms of influencing factors on prescribing antibiotics. But it is limited by focusing on MRSA as opposed to encompassing all antibiotic prescribing/infections. Further details regarding the LTCF included are not presented which would have helped a judgement on transferability. There is little reference to existing literature made. Clear recommendations for practice are made.
Schweizeret al. 2003 (23) / The research aims & methods clearly stated & appropriate / Research design: To determine the steps involved in UTI management, to use this information in an economic evaluation. The justification of using qualitative methods is not explained; qualitative methods have been used to explore the factors influencing antibiotic prescribing, but not for the purpose of economic evaluation.
Sampling: Convenience and maximum variation sampling was used to recruit 10 LTCF (of varying bed size, private and public) and the nurse in charge was invited to participate. GPs from the recruited LTCF were then invited, 6 out of 20 contacted participated.
Data analysis: Thematic analysis was conducted by one researcher and independently checked by another.
Data collection: If data saturation was not obtained after 10 nurse interviews, further nurse interviews would be conducted. The same applied to the GP interviews. A topic guide was developed and piloted. Interviews were recorded and transcribed verbatim.
Discussion of findings: The findings are presented clearly with different views between and within the nurse and GP interviews presented.
Value: This study contributes an insight into the management of UTI in LTCF. It was only conducted in one administrative area or Trust in Northern Ireland however, and only included urban LTCF; this may reduce the transferability of the findings. The recommendations for further research and practice are clear and within the scope of the findings.
Quality concerns / Reflexivity: The potential bias of the researcher on question formation and data collection is not discussed.
Ethics: There is no mention of ethical approval or written informed consent.
Walker et al. 2000 (24) / The research aims & methods clearly stated & appropriate / Research design: This study used qualitative methods appropriately to identify the factors influencing the prescribing of antibiotics for asymptomatic bacteriuria in LTCF.
Sampling: 5 of 11 invited Medical directors (doctors) were recruited from 11 LTCF, all 17 invited doctors were invited from a meeting of an Ontario committee on geriatric long-term care, all 16 nurses invited from 2 LTCF participated.
Data collection: Separate focus groups were held for nurses and doctors. All discussions were recorded and transcribed verbatim.
Ethics: Ethical approval for the study was obtained. The interviews were recorded with participants permission.
Discussion of findings: The findings are presented clearly with the interpretation of the influences on antibiotic prescribing summarised explicitly. Both nurse and physician perspectives are presented.
Quality concerns / Reflexivity: The potential bias of the researcher on the question formation and data collection was not discussed.
Data Analysis: Content analysis was conducted; it was not stated how many researchers conducted this or whether it was done independently or otherwise. This compromises the rigour of the study paper. More supportive quotations could have been included.
Value: There was no detail provided on participants and LTCF context. There was no discussion around existing literature of factors influencing antibiotic prescribing in LTCF. Research questions have been generated but the transferability of the study findings to other setting is compromised.
ESM 2.Enhancing the transparency in reporting the synthesis of qualitative research: the ENTREQ statement.
Item / Guide and description- Aim
- Synthesis methodology
- Approach to searching
- Inclusion criteria
Population: LTCF health care professionals
Topic: Antibiotic prescribing, treatment of infection
No language or year limits
- Data sources
Reference lists of included papers were screened.
Last search July 2014.
- Electronic search strategy
(antibiotic* OR antibacterial* OR infection*) AND
(attitude of health personnel) AND
(nursing home* OR long term care facilit*) AND
(interview* OR ‘qualitative research’)
- Study screening methods
The full text review of 34 studies was conducted by the primary author with the details of excluded studies presented in Appendix 1.
The 8 full text papers were reviewed by all authors for relevance.
- Study characteristics
- Study selection results
- Rationale for appraisal
- Appraisal items
- Appraisal process
- Appraisal results
- Data extraction
Information regarding setting, participants, method of data collection and data analysis was extracted from the included studies and is presented to provide contextual information.
- Software
- Number of reviewers
- Coding
- Study comparison
- Derivation of themes
- Quotations
- Synthesis output
ESM 3: List of excluded studies.
Study detail / Reason for exclusion1 / Bjorkman I, Berg J, Viberg N, StalsbyLundborg C. Awareness of antibiotic resistance and antibiotic prescribing in UTI treatment: A qualitative study among primary care physicians in Sweden. Scand J Prim Health Care. 2013 Mar;31(1):50-5. / Not focussed on LTCFs
2 / Bjorkman I, Erntell M, Roing M, Lundborg CS. Infectious disease management in primary care: perceptions of GPs. BMC family practice. 2011;12:1. / Not focussed on LTCFs
3 / Bjornsdottir I, Hansen EH. Ethical dilemmas in antibiotic prescribing: Analysis of everyday practice. Journal of clinical pharmacy and therapeutics. 2002;27(6):431-40. / Not focussed on LTCFs
4 / Björnsdóttir I, Hansen EH. Telephone prescribing of antibiotics: General practitioners' views and reflections. European Journal of Public Health. 2001;11(3):260-3. / Not focussed on LTCFs
5 / Bjornsdottir I, Hansen EH, Grimsson A. Choosing among antibiotic products: General practitioners' path while prescribing. Journal of Social and Administrative Pharmacy. 2003;20(4):118-24. / Not focussed on LTCFs
6 / Bjornsdottir I, Holme Hansen E. Intentions, strategies and uncertainty inherent in antibiotic prescribing. European Journal of General Practice. 2002;8(1):18-24. / Not focussed on LTCFs
7 / Brookes-Howell L, Hood K, Cooper L, Coenen S, Little P, Verheij T, et al. Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: A nine country qualitative study of variation in care. BMJ Open. 2012;2(3). / Not focussed on LTCFs
8 / Brookes-Howell L, Hood K, Cooper L, Little P, Verheij T, Coenen S, et al. Understanding variation in primary medical care: A nine-country qualitative study of clinicians' accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection. BMJ Open. 2012;2(4). / Not focussed on LTCFs
9 / Hoye S, Frich JC, Lindboek M. Delayed prescribing for upper respiratory tract infections: A qualitative study of GPs' views and experiences. British Journal of General Practice. 2010;60(581):907-12. / Not focussed on LTCFs
10 / Hrisos S, Eccles M, Johnston M, Francis J, Kaner EF, Steen N, et al. An intervention modelling experiment to change GPs' intentions to implement evidence-based practice: using theory-based interventions to promote GP management of upper respiratory tract infection without prescribing antibiotics #2. BMC health services research. 2008;8:10. / Not focussed on LTCFs
11 / Hughes CM, Lapane K, Watson MC, Davies HT. Does organisational culture influence prescribing in care homes for older people? A new direction for research. Drugs & aging. 2007;24(2):81-93. / Not a primary research study
12 / Kistler CE, Sloane PD, Platts-Mills TF, Beeber AS, Khandelwal C, Weber DJ, et al. Challenges of Antibiotic Prescribing for Assisted Living Residents: Perspectives of Providers, Staff, Residents, and Family Members. Journal of the American Geriatrics Society. 2013. / Not qualitative
13 / Kuehlein T, Goetz K, Laux G, Gutscher A, Szecsenyi J, Joos S. Antibiotics in urinary-tract infections. Sustained change in prescribing habits by practice test and self-reflection: a mixed methods before-after study. BMJ QualSaf. 2011 Jun;20(6):522-6. / Not focussed on LTCFs
14 / Lambert BL, Salmon JW, Stubbings J, Gilomen-Study G, Valuck RJ, Kezlarian K. Factors associated with antibiotic prescribing in a managed care setting: an exploratory investigation. Social science & medicine (1982). 1997 Dec;45(12):1767-79. / Not focussed on LTCFs
15 / LeClair SM, Schicker JM, Duthie EH, Jr., Hoffmann RG, Franson TR. Survey of nursing personnel attitudes toward infections and their control in the elderly. American journal of infection control. 1988 Aug;16(4):159-66. / Not qualitative
16 / Longo DR, Young J, Mehr D, Lindbloom E, Salerno LD. Barriers to timely care of acute infections in nursing homes: a preliminary qualitative study. J Am Med Dir Assoc. 2004 Mar-Apr;5(2 Suppl.): S4-S10 / Did not meet CASP quality criteria
17 / Lugtenberg M, Burgers JS, Zegers-van Schaick JM, Westert GP. Guidelines on uncomplicated urinary tract infections are difficult to follow: perceived barriers and suggested interventions. BMC family practice. 2010;11(1):51. / Not focussed on LTCFs
18 / Marcus E-L, ClarfieldAM, Moses AE. Ethical issues relating to the use of antimicrobial therapy in older adults. Clinical Infectious Diseases. 2001 2001;33(10):1697-705. / Not a primary research paper; review.
19 / Mazzaglia G, Arcoraci V, Greco S, Cucinotta G, Cazzola M, Caputi AP. Prescribing habits of general practitioners in choosing an empirical antibiotic regimen for lower respiratory tract infections in adults in Sicily. Pharmacological Research. 1999;40(1):47-52. / Not focussed on LTCFs
20 / Mylotte JM. Reducing hospitalizations in nursing home patients with pneumonia. JAMA: The Journal of the American Medical Association. 2006 2006;296(18):2206-7. / Not a primary research study
21 / Petursson P. GPs' reasons for "non-pharmacological" prescribing of antibiotics. A phenomenological study / Not focussed on LTCFs
22 / Simpson SA, Wood F, Butler CC. General practitioners' perceptions of antimicrobial resistance: A qualitative study. Journal of Antimicrobial Chemotherapy. 2007;59(2):292-6. / Not focussed on LTCFs
23 / Wood F, Simpson S, Butler CC. Socially responsible antibiotic choices in primary care: A qualitative study of GPs' decisions to prescribe broad-spectrum and fluroquinolone antibiotics. Family practice. 2007;24(5):427-34. / Not focussed on LTCFs
24 / van der Steen JT, Ooms ME, Ribbe MW, van der Wal G. Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: evaluation of a guideline. Alzheimer Dis AssocDisord. 2001 Jul-Sep;15(3):119-28. / Not qualitative
25 / van der Steen, J. T., G. van der Wal, et al. (2005). "End-of-life decision making in nursing home residents with dementia and pneumonia: Dutch physicians' intentions regarding hastening death." Alzheimer Dis AssocDisord19(3): 148-155. / Not qualitative
26 / Van Der Steen JT, Meuleman-Peperkamp I, Ribbe MW. Trends in treatment of pneumonia among Dutch nursing home patients with dementia. Journal of Palliative Medicine. 2009;12(9):789-95. / Not qualitative
LTCFs = Long Term Care Facilities