Table 2 Acute sinusitis interviews – domains, themes/sub-themes and representative quotes

Themes/sub-themes

Representative quotes

Patient expectations:

From the provider perspective, patient expectations are one of the most significant non-clinical factors driving antibiotic prescribing patterns.

…some patients are very honest, ‘I am here for antibiotics…so those patients I wouldn’t even try to argue because they came with a made up mind and they want to go home with antibiotics… … I will spend the 10 or 15 minutes or whatever to educate and stuff, but at the end of that, if the patient is still really just persistent and unhappy and upset, I mean, you know, I have given in before.

Patient satisfaction:

…but just to give a medication to shut a patient up and get them out the door I think is highly inappropriate…and the problem is there are people who do that. And we have a wider responsibility than just pleasing the patient…I mean, we have doctors who get absolute fantastic, you know, ratings that their prescribing habits may be not what we would consider guideline based. …And the negative consequence is that, then, I have that patient come to me a year later and say ‘Yeah, but when I go to this doctor, I get antibiotics and then I get better.’ And so we have the double problem at that point – not only do we have the normal conversation, but we want to be respectful of our colleagues, but at the same time we have to kind of explain, ‘Well, I don’t know what was going on then, but the good news is today, it is this.’ And, but it is harder. …some patients… are like, ‘Well, I’ll just go to this doctor and they are going to write me whatever.’ And it is like, then…you can go ahead and go to that doctor because that is not me… and sometimes… our physician in charge…will actually get complaints. ‘Oh that doctor…she was mean…she wouldn’t give me the antibiotic when I asked for it.’ And it is kind of like, great, that complaint is being held against me that I actually gave appropriate medical care.

• Patients want ‘tangible’ treatment

Many patients reportedly want something tangible or concrete (often in their minds a ‘prescription’) when they see their doctor and physicians struggle with the desire to meet these patient expectations.

• Member appraisal of physician/provider services satisfaction scores

Also, while providers are split regarding how influential these scores are on antibiotic prescribing patterns, they do believe that they play a role.

• Get antibiotics somewhere else

Finally, providers are sometimes resigned to providing antibiotics against current guidelines because they suspect patients will seek antibiotics from another provider (and patients often threaten to do so).

Patient/provider communication:

…If I have known this patient for… years…I can talk her out of [a prescription] even if I am like supremely busy and I have many patients falling behind that is okay because I know her and she won’t mind and I know she wants the appropriate kind of treatment.

Providers spoke at length about the challenges communicating with patients who expect antibiotics, but do not clinically need them.

• My own patient?

Complicating the conversation is the degree to which there is a provider and patient connection – physicians find it difficult to influence patients toward alternative treatments when they do not have an established history with the patient.

Clinical guidelines:

…But again, the idea that sinusitis requires decongestants, not antibiotics, is still relatively new. And usually from the time of a guideline, it takes like 10 years for implementation, but the more important thing is not the patient education, as it is the doctor education…

While providers had a basic understanding of the guidelines and sources available, they find it challenging to stay abreast of the most current recommendations and, therefore, tend to rely more on their clinical experience for making evaluation and treatment decisions.

If we read them [the guidelines]…if it comes to us! Because sometimes I know that there are many, many guidelines out there, it doesn’t quite come to us in a conveniently readable way, so then I wouldn’t know that it is out there.

• Guidelines take a long time to become common, accepted practice

• Hard to keep up with guidelines

• Cannot find them when I need them

Themes/sub-themes

Representative quotes

Patient level:

We used to have a little graph for URI that says that you will not get better until about 2 weeks later – the average duration of sickness is about 17 days – so if patients come in with URI symptoms and they are asking when should I get better I will just point out this graph… And the majority of the times, if I know the patient and the patient knows me, they are pretty okay [and say] ‘Oh really, it takes that much time for me to get better, okay, no problem, in that case you know I will just go home and chill.’

There was consensus among providers that patients need additional education on the natural course of acute sinusitis and recommended treatment options.

• Posters on acute sinusitis/education materials

• Providers need ‘back-up’ from trusted sources

Provider level:

…but I think in terms if I am just focusing on acute sinusitis, how to manage people with acute sinusitis, two things would be helpful, physician in-service, because it is always good to learn more, and the visual card [pocket card], not to put up in the exam room to aid with the patient education, more to educate ourselves, what is the appropriate thing to do…

In addition to patient education, providers would like to see more emphasis placed on provider education, including in-service education opportunities and improved access to guidelines.

• In-services/continuing medical education credit

• Easier access to guidelines/recommendations

System level:

You know, I think, I don’t remember which situation it was, but if, perhaps with the diagnosis, you know if you had a diagnosis of sinusitis, and that was under your problem list for the day or something like that; if there was some easy way to bring up guidelines, right from there, I think that would be very useful.

Providers generally support the idea that integrating clinical decision aids into the electronic medical record can be an effective way to impact antibiotic prescribing. Several providers explained how they use the electronic medical record system to educate patients directly for other conditions and how it could be applied in the case of acute sinusitis as well. ‘Click fatigue’ was noted as a potential barrier, but one suggestion was to allow a ‘soft stop’ in the best practice alert workflow to avoid this issue.

…so similar you know, if sinusitis, if we don’t want to order antibiotics and something pops up [in the electronic medical record] and says you know antibiotics is not necessary in the first 14 days, do this and this at home, we can just say ‘Look, this is what is recommended’… Absolutely, it is not your personal opinion…. No, not necessarily, because you can just one click and cancel it if it is not relevant to what I am doing right now. It is always very helpful to have those, you know, not guideline, the guide – just the guide through, okay I should do this first and I should not do you know x, y, and z first. It is always helpful, because we cannot really keep up with many topics that are happening out in the world…

• Role of electronic medical records systems