Table 2

Connecting Social/Professional role and identity to initiation and duration, and how they are considered within the Ontario Health (Quality) report

BehavioursSocial/Professional role and identityRole of the report
Appropriate prescriberEducatorChange driver
Decreasing the initiation of antibiotic prescriptions‘I’m looking at treating the patient and not the lab test.’ 006 (medical director)‘They (conversations with patients and families) seem to go well and it’s better than not having them because families feel more involved and keeping in the loop … There’s lots of room for families to input. Not just for the nurses, but with me and a nurse practitioner.’ 010 (medical director)‘As the individual physician I’m not sure how much … one individual is going to impact in the home especially homes that are run by other organisations if the person isn’t a medical director.’ 007Physicians did not think the report would have much impact on their antibiotic initiation. They were already aware of the need to decrease initiation.
‘I always worry though that when you have a frail elderly patient who’s coughing and you can hear it’s deep in their chest and they not eating and drinking well, that if you don’t treat them you will, and they had pneumonia, the chance is that they’re not going to do well. … I don’t think I can, not treat them.’ 004 (medical director)‘My impression has been that very little works. If I explain to one nurse the reason why I’m not prescribing an antibiotic, I may get a call the next day from somebody else with the same thing. … Education has to be ongoing and a lot of times it isn’t.’ 006 (medical director)‘I view the physician as kind of the lead or the guide. I don’t feel like I need a distinction between what I’m doing and what the team’s doing, because in the end I’m responsible for all of it. So if I want the team to be doing something, I’m the one that has to initiate that.’ 017The report encouraged avoiding treatment of asymptomatic bacteriuria of which physicians were already aware. The report also encourages implementation of programmes to reduce unnecessary urine culturing and discontinuation of routine annual urine screening. However, these programmes were already set up.
The report discourages prescribing for upper respiratory tract infections (URTI). Prescribing for URTIs is where there seems to be gaps in knowledge and room for improvement.
Decreasing the duration of antibiotic prescriptions‘My job is to be there and treat the patient and their family and not to just write the prescription easily because it would have been a lot faster honestly to just say, ‘Fine here’s another 3 days or 7 days or whatever’, but that wasn’t the appropriate thing to do.’ 007(Education seemed to focus more on initiation, and more about an individual physician increasing their own knowledge, less about the duration knowledge of others).‘I think you can probably have the pharmacy involved and so, for example, the physician writes a 10-day prescription, the pharmacy could bounce that back and say, 7 days is sufficient.’ 011 (medical director)The report shows the physician’s own prescribing practice for antibiotics prescribed 7+ days and provides suggestions for practice change.
‘Most physicians only show up once a week, shortening the course of the antibiotic treatment for 2 days, you’re not going to possibly even remember to do that, unless you have the staff onboard to do it … To help you do that.’ 001 (medical director)The report encourages practice change by prescribing shorter courses when appropriate (this is new information for some) including specific conditions and how long to prescribe along with some resources.