Utilization of clinical practice guideline on antimicrobial and its determinants in China: A multilevel analysis

Abstract

Background: Nowadays, irrational use of antimicrobials has threatened public health. It’s necessary to expanding the use of clinical practice guideline (CPG) on antimicrobial for facilitating the proper use of antimicrobial. However, the utilization status of CPG on antimicrobial and the influencing factors are largely unknown.

Methods: A cross-sectional survey was conducted, using a structured questionnaire, on a sample among physicians from 16 public hospitals in eastern, central and western part of China. A multilevel regression model was employed to examine factors associated with physicians’ utilization of CPG on antimicrobial.

Results: A total of 815 physicians included in this study. About eighty percent of the surveyed physicians reported their strict adherence to the CPG on antimicrobial. Dimensions of “subjective norm”, “perceived risk” and “behavioral intention” from the domain of physician belief, dimension of “ease of use” from the domain of CPG traits, and dimensions of “top management support” and “organization & implementation” from the domain of hospital practice were significantly associated with physicians’ utilization of CPG on antimicrobial. And most demographics of physician were not found to be significantly related to the CPG use. In addition, results showed region is a significant factor affecting physicians’ CPG use.

Conclusions: This study depicted the current status of CPG on antimicrobial and comprehensively identified its potential determinants not only from the three domains, such as physician belief, at the individual level, but also from the location region at the organizational level. The results will provide direct reference on implementation of CPG on antimicrobial and will be generalizable to the setting of health care system. 

Background

Antimicrobial have left its own marks on the history of medical treatment, owing to effectively lowering the morbidity and mortality from infectious diseases [1]. Nowadays, however, the rise in the prevalence of irrational use of antimicrobial has weakened its original effectiveness and contributed to growing resistance that will undermine our ability to fight infections with varying degrees [2], or even worse.

As one of the world’s largest consumers of antimicrobial for human health [3], China has witnessed some of the most severe crisis brought on by the antimicrobial resistance (AMR). To address AMR, various measures have been taken by China’s health authorities, with varying degrees of success [4]. Clinical practice guideline (CPG) is recommendation for physicians based on best evidence, which do play a significant role in standardizing clinical treatment and improving the outcomes of medical services [5]. Although the CPG have been shown to be effective and Guiding Principles for Clinical Application of Antimicrobial have launched in 2015, it still remains largely unknown whether regulation implementation, nature of guidance with mandatory or other reasons make any difference to adherence to CPG on antimicrobial, which has made a barrier to expanding the CPG implementation.

Calling for effective interventions for promoting utilization of guidelines depends on a clear understanding of the determinants of guideline use. However, current researches usually focus on the factors within the domain of medical staff or the general public, especially their knowledge, attitude, and practice (KAP) on antimicrobial and its prescribing behavior [6-10], few studies have involved the potential factors within other domains, such as the organizational impact, CPG traits and so on. To bridge this knowledge gap caused by focusing on single domain, this study will comprehensively include sets of potential influencing factors from the domains of physician, hospital and CPG itself, and seek to investigate determinants associated with utilization of CPG on antimicrobial at different domains. These results are intended to play an important role when it comes to tailor interventions about advancing utilization of CPG on antimicrobial.

Methods

Study design

As China is a vast country with huge regional diversity at socioeconomic development, we conducted a cross-sectional questionnaire study using a multistage sampling method. In the first stage, provinces of Fujian, Hubei, Yunnan & Sichuan were selected on behalf of eastern, central and western regions of China, respectively. Secondly, 5~6 general hospitals (including tertiary and secondary hospitals) were selected from each of the selected region. Lastly, in each selected hospital, 16~20 physicians of tertiary hospitals and 10~15 physicians of secondary hospitals were randomly sampled from major departments of internal medicine and surgery, respectively. And 3~5 physicians of tertiary hospitals were randomly sampled from the other four sorts of departments as gynecology and obstetrics, ophthalmology and otorhinolaryngology, orthopedics, and others, respectively. While in each sampled secondary hospital, about 10 physicians were randomly selected from these four departments in total. Thus, 50~60 physicians from each tertiary hospital and 30~40 physicians from each secondary hospital were invited to participate in the survey.

Questionnaire

The questionnaire was developed on the basis of the literature review [11-24] and revised by experts in the fields of clinical medicine, health management, and epidemiology and health statistics. The structured questionnaire consisted of three parts 33 items. Part 1 covered 24 items 8 dimensions from 3 domains: physician belief (including dimensions of “attitude”, “subjective norm”, “perceived risk”, “behavioral intention”), CPG traits (including dimensions of “relative advantage”, “ease of use”), and hospital practice (including dimensions of “top management support”, “organization & implementation”). Part 2 covered 3 items to measure physicians’ utilization of CPG on antimicrobial. Part 3 was a personal information card consisted of 6 items, including several basic characteristics of participants as gender, age, education, professional title, department and years of practice. Questions in part 1 and part 2 were measured using a five-point Likert scale, where 1=Strongly disagree, 2=Disagree, 3=Neutral, 4=Agree, and 5=Strongly agree. The questionnaire showed satisfactory reliability with Cronbach’s α of each dimensions and the whole questionnaire above the recommended threshold of 0.7 [25].

Data Collection

Data collected from April 2018 and lasted nearly one year. With the support of sampled hospitals, each round for filling out the questionnaire was accompanied by trained facilitators to introduce the study purpose, ensuring participants’ understanding of this study and what to do. All responses were anonymous, but participants were invited to submit their contact information voluntarily if they were interested in the study and wanted to keep informed of the results.

Analysis

Descriptive statistics were performed to depict characteristics of physicians and hospitals. Each dimension scores were calculated as the mean item scores per dimension. Spearman Rank correlation was used to assess the relationships between socio-demographic characteristics and utilization of CPG on antimicrobial, Pearson correlation was used to assess the relationships between each dimension and utilization of CPG on antimicrobial. In addition, given the hierarchical nature of the data [26], multilevel linear regression model (SAS University Edition) was performed to identify the association between demographic characteristics, organizational characteristics, and dimension scores from three domains (independent variables) and utilization of CPG on antimicrobial (dependent variable). The rationale for using the multilevel approach in relation to the clustering effect is that physicians (individual level) in the same hospital (organizational level) tend to be more alike in their personal belief or perceptions of CPG use, as well as their assessments on CPG traits or hospital practice in promoting CPG use and real CPG utilization. Thus, multilevel approach would be more robust in determining whether factors at the organizational level or at the individual level are statistically significant. Statistical significance was set at P<0.05.

Results

Discussion

Since there was a dearth of literature on utilization of CPG on antimicrobial’ utilization and its potential determinants, this study described the current status of regarding CPG utilization and comprehensively identified its potential influencing factors from the domains of physician belief, CPG traits and hospital practice. The results of this study will not only provide direct guidance on implementation of CPG on antimicrobial, but also add the research knowledge and evidence on CPG use, and further provide beneficial reference for expanding CPG impact.

As demonstrated in this study, about eighty percent of the surveyed physicians reported their strict adherence to the CPG on antimicrobial and active participant in regarding training, and more than seventy percent of the participants have recommended the CPG on antimicrobial to their colleagues. These result indicated fairly high utilization level of CPG on antimicrobial. Many physicians had implemented the CPG in their work and actively took their efforts to expand the CPG use.

With respect to the determinants identification, dimensions of “subjective norm”, “perceived risk” and “behavioral intention” from the domain of physician belief, dimension of “ease of use” from the domain of CPG traits, and dimensions of “top management support” and “organization & implementation” from the domain of hospital practice showed significant association with physicians’ CPG use. And physicians who worked in different department have significant effects on their utilization of CPG on antimicrobial, while other demographic characteristics of physician were not found to be significantly related to the CPG use. Besides, for the potential influencing factors of the hospital characteristics, region is a significant factor affecting physicians’ CPG use as physicians in the eastern region had a lower utilization of CPG on antimicrobial. However, association between hospital rank and the CPG use was not found.

In consistence with many previous studies, this result also highlights the importance of organizational implementation and management support [17,27,28]. With regard to promoting the use of CPG on antimicrobials, the “organization & implementation” activities (routine information collection, inspection, supervision, evaluation, feedback, etc.) will greatly benefit shaping expected behavior and norms of the medical staff. And the concrete support (information, education, funds, personnel, etc.) from hospital administrators also expects to play a positive role in leading a smooth process of CPG uptake. Besides, having been deemed as powerful predictors in former studies, many factors on physician belief also demonstrated their significant effect on the use of CPG on antimicrobial in this research. Such as subjective norm, a kind of perceived norm and pressure from influential persons, it is unsurprisingly for its significant association with CPG use detected in this study. Especially in the setting of public hospitals with a clear hierarchical system [29], it seems inevitable for the individual to subject to invisible pressure from all around like colleagues or superiors, and comply with perceived norms and orders [30], such as strictly adherence to the CPG or greatly emphasis on physician autonomy. This point is also mutually verified with the previous content that significant impact of organizational activities on CPG use. Additionally to the hospital practice and physician belief, the impact of CPG traits on CPG use also can’t be ignored. This study also reveals that physicians tend to adopt the CPG easy to master and use. To avoid taking the first-line physicians too much time and effort to learn CPG and put it into practice, it will be wise to concise the CPG on antimicrobials as much as possible. And some brief explanations to the key points will be probably appreciated and further benefit the expanding use of CPG.

However, in contrary with previous researches [20,31], significant effects of attitude and relative advantage were not detected in this study. The plausible reason may be that many physicians are required to follow CPG on antimicrobial by their organization whatever their subjective attitude or assessment towards certain guideline [19]. Anyone who disobeys CPG will confront with great pressure from their organization [29]. This finding also further confirmed the impact of subjective norm and perceived risk. Additionally, there are also other contraries to former papers that younger physicians or with fewer years’ experience tended to be more likely to use guidelines [32,33]. Such difference may be resorted to the situation that physicians in East Asia be easily “institutionalized” when they first enrolled in the working hospital. These results also imply the great importance of organizational impact, which also explained the phenomena reported in the current studies that physicians working in different departments demonstrated great differences in compliance with CPG [34].

Generally speaking, the results of this study will not only guide the real practice of promoting the use of CPG on antimicrobials, but also intend to provide clues or inspirations for future research. In additional to its significance, this study is also strengthened by some features. On the one hand, with representation from 16 hospitals in eastern, central and western parts of the nation, the important facilitators and barriers to utilization of CPG on antimicrobial determined in this study will be generalizable to the setting of health care system in China. As the largest developing country with the largest population, China’s experience in promoting the use of CPG on antimicrobials will provide helpful reference for other countries, especially the most developing countries in the world. On the other hand, considering cluster bias, multilevel analysis model is applied in the data analysis, which will be more robust in investigating the potential influencing factors from different levels. However, there are still some limitations of this study. First of all, owing to the social desirability bias [35], the participants of this study may be unwilling to voice negative assessment about themselves and the hospitals, which may directly lead to overestimation of the attitude, belief, intention and utilization of CPG on antimicrobial. Secondly, clustering effects were found at the organizational (hospital) level, while the number of selected tertiary and secondary hospitals was not balanced well. Although rankings of the hospitals did not show its significance, it still cannot eliminate the effects caused by the rankings. Thirdly, this study is also limited by collecting cross-sectional data at a single point-in-time to determine the influencing factors, it may be more prudent to investigate the causality by panel session data or so on in future research.

Conclusions

This study depicted the current status of CPG on antimicrobial and comprehensively identified its potential determinants not only from the three domains, such as physician belief, at the individual level, but also from the location region at the organizational level. The results will provide direct reference on implementation of CPG on antimicrobial and will be generalizable to the setting of health care system.

Abbreviations

CPG: Clinical practice guideline

AMR: antimicrobial resistance

Declarations

Ethics approval and consent to participate

Ethics approval was obtained from the medical ethics committee, Fujian Medical University, China. Written informed consent was obtained from all study participants.

Consent to publish

Not applicable.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research was supported by National Natural Science Foundation of China (Grant Number: 71704026) and the Soft Science Project of Fujian Provincial Department of Science and Technology (Grant number: 2017R0044). And the funders had no involvement in study design, data collection, statistical analysis and manuscript writing.

Authors’ Contributions

LW designed and conducted the project, contributed to grasp the subject and revised the manuscript. DQ carried out the data analysis and drafted the manuscript. LW and DQ developed the questionnaire. All authors read and approved the manuscript before submission.

Acknowledgments

We acknowledge the support of each hospital for their involvement in this study, as well as all facilitators who contributed to coordination in the site. We also like to thank all physicians who agreed to the participation.

References

1. Bakhit M, Del MC, Gibson E, Hoffman T. Exploring patients’ understanding of antibiotic resistance and how this may influence attitudes towards antibiotic use for acute respiratory infections: a qualitative study in Australian general practice. BMJ open. 2019; 9: e026735.
2. Smith CR, Pogany L, Foley S, Wu J, Timmerman K, Gale-Rowe M, Demers A. Canadian physicians’ knowledge and counseling practices related to antibiotic use and antimicrobial resistance: two-cycle national survey. Can Fam Physician. 2017; 63: e526-e535.
3. Qiao M, Ying GG, Singer AC, Zhu YG. Review of antibiotic resistance in China and its environment. Environment international. 2018; 110: 160-172.
4. Sun Q, Dyar OJ, Zhao L, Tomson G, Nilsson LE, Grape M, Song Y, Yan L, Lunborg CS. Overuse of antibiotics for the common cold–attitudes and behaviors among doctors in rural areas of Shandong Province, China. BMC Pharmacol Toxicol. 2015; 16: 6.
5. Institute of Medicine. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Board on Health Care Services. Clinical Practice Guidelines We Can Trust. Washington DC: National Academies Press. 2011. p. 53-56.
6. Panagakou SG, Spyridis Ν, Papaevangelou V, heodoridou KM, Goutziana GP, Theodoridou MN, Syrogiannopoulos GA, Hadjichristodoulou CS. Antibiotic use for upper respiratory tract infections in children: a cross-sectional survey of knowledge, attitudes, and practices (KAP) of parents in Greece. BMC Pediatr. 2011; 11: 60.
7. Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, Fu Y, Chen X, Cals J, Zhang F. Knowledge, attitude and practice of antibiotics: a questionnaire study among 2500 Chinese students. BMC Med Edu. 2013; 13: 163.
8. Salsgiver E, Bernstein D, Simon MS, Eiras DP, Greendyke W, Kubin CJ, Mehta M, Nelson B, Loo A, Ramos LG, Jia H, Saiman L, Furuya EY, Calfee DP. Knowledge, attitudes, and practices regarding antimicrobial use and stewardship among prescribers at acute-care hospitals. Infect Control Hosp Epidemiol. 2018; 39: 316-322.
9. Liu C, Liu, C, Wang D, Zhang X. Knowledge, Attitudes and Intentions to Prescribe Antibiotics: A Structural Equation Modeling Study of Primary Care Institutions in Hubei, China. Int J Environ Research Public Health. 2019; 16: 2385.
10. Firouzabadi D, Mahmoudi L. Knowledge, attitude, and practice of health care workers towards antibiotic resistance and antimicrobial stewardship programmes: A cross‐sectional study. J Eval Clin Pract. 2019; 1-7.
11. Ajzen I, Fishbein M. A Bayesian analysis of attribution processes. Psychol bull. 1975; 82: 261.
12. Ajzen I. The theory of planned behavior. Organiz Behav Human Decs Proc. 1991, 50, 179-211.
13. Venkatesh V, Davis FD. A theoretical extension of the technology acceptance model: Four longitudinal field studies. Manage Sci. 2000; 46: 186-204.
14. Baker J. The technology–organization–environment framework. Information systems theory. New York: Springer. 2012. p. 231-245.
15. Chung A, Rimal RN. Social norms: A review. Rev Comm Res. 2016; 4: 1-28.
16. Liu CF, Tsai YC, Jang FL. Patients’ Acceptance towards a Web-Based Personal Health Record System: An Empirical Study in Taiwan. Int. J. Environ. Res. Public Health. 2013; 10: 5191-5208.
17. Hsieh PJ. Physicians’ acceptance of electronic medical records exchange: An extension of the decomposed TPB model with institutional trust and perceived risk. Int J Med Inform. 2015; 84: 1-14.
18. Low C, Chen Y, Wu M. Understanding the determinants of cloud computing adoption. Indu Manage Data System. 2011; 111: 1006-1023.
19. Ahmadi H, Nilashi M, Ibrahim O. Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals. Int J Med Inform. 2015; 84: 166-188.
20. Shahzad K, Jianqiu Z, Zia MA, Shaheen A, Sardar T. Essential factors for adopting hospital information system: a case study from Pakistan. Int J Compu App. 2018; 58: 1-12.
21. Handayani PW, Hidayanto AN, Pinem AA, Hapsari IC, Sandhyaduhita PI, Budi I. Acceptance model of a hospital information system. Int J Med Inform. 2017; 99: 11-28.
22. Soliman KS, Mosbeh R. An exploratory analysis of factors affecting users' adoption of corporate intranet: A Tunisian study. Manage Res News. 2008; 31: 375-385.
23. Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implement Sci. 2009; 4: 1-13.
24. Mccormack B, Mccarthy G, Wright J, Coffey A. Development and testing of the Context Assessment Index (CAI). Hon Soc Nurs. 2009; 6: 27.
25. Nunnally JC. Psychometric Theory. New York: McGraw-Hill. 1978.
26. Muthén BO. Multilevel covariance structure analysis. Soc Metho Res. 1994; 22: 376-398.
27. Ahmed RR, Veinhardt J, Streimikiene D, Awais M. Mediating and Marketing factors influence the prescription behavior of Physicians: An Empirical Investigation. Amfiteatru Econ J. 2016; 18: 153-167.
28. Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother. 2017; 72: 2418-2430.
29. Tong Y, Tan CH, Teo HH. Direct and Indirect Information System Use: A Multimethod Exploration of Social Power Antecedents in Healthcare. Inform System Res. 2017; 28: 690-710.
30. Huang HT, Tsai CH, Wang CF. A Model for Promoting Occupational Safety and Health in Taiwan’s Hospitals: An Integrative Approach. Int J Environ Res Public Health. 2019; 16: 882.
31. Hsiao JL, Chen RF. Critical factors influencing physicians’ intention to use computerized clinical practice guidelines: an integrative model of activity theory and the technology acceptance model. BMC Med Inform Decis Mak. 2015; 16: 3.
32. Wolff M, Bower DJ, Marbella AM, Casanova JE. US family physicians' experiences with practice guidelines. Fam Med. 1998; 30: 117-121.
33. Taba P, Rosenthal M, Habicht J, Tarien H, Mathiesen M, Hill S, Bero L. Barriers and facilitators to the implementation of clinical practice guidelines: a cross-sectional survey among physicians in Estonia. BMC Health Serv Res. 2012; 12: 455.
34. Charpentier S, Sagnes-Raffy C, Cournot M, Cambou JP, Ducassé JL, Lauque D, Puel J, ESTIM Midi-Pyrénées Investigators. Determinants and prognostic impact of compliance with guidelines in reperfusion therapy for ST-segment elevation myocardial infarction: results from the ESTIM Midi-Pyrenees Area. Arch Cardiovasc Dis. 2009; 102: 387-396.
35. Hasegawa K, Shinohara C, Broadbent JP. The effects of ‘social expectation’ on the development of civil society in Japan. J Civ Soc. 2007; 3: 179-203.

Tables

Table 1   Characteristics of the sample physicians and hospitals

Table 2  Scores for each dimension

Table 3  Factors correlated to utilization of CPG on antimicrobial

Table 4  Multilevel linear regression of the utilization of CPG on antimicrobial