Overview
The results outlined below reflect the identified factors and processes of influence of PCNs in promoting a rational use of antibiotics for acute non-complicated self-limiting infections. A socio-demographic questionnaire was analyzed descriptively with regard to participant- and practice-level characteristics. A total of 27 physicians participated in the interviews (9 female, 18 male). Physician interview durations varied between 7:54 minutes and 62:50 minutes, with a mean of 28:14 minutes. MA interview durations ranged between 17:30 and 42:32 minutes (mean 26:53 minutes). All participating MAs were female (n=11). Mean duration of stakeholder interviews was 30:15 minutes (range 16:28 to 44:42 minutes). Stakeholders had between 1 and 10 years of experience in their current position. On average, physician respondents in the survey were 55 years old, had 25 years of working experience and had been members of their PCNs for 10 years (Table 2).
Interview participants
|
N
|
Phys
|
MA
|
Stakeholder
|
Total
|
Sex (f/m) n (%)
|
45
|
9/18 (33/66)
|
11 (100/0)
|
3/4 (43/57)
|
23/22 (59/41)
|
Age years (range) (mean)
|
45
|
43-66 (55.2)
|
20-60 (38.5)
|
31-63 (46.3)
|
31.3-63 (46.6)
|
Experience in current position years (range) (mean)
|
45
|
10-38 (26.07)
|
2-40 (19.3)
|
1-10 (5.85)
|
1-40 (17.09)
|
Working in general practice (%)
|
38
|
66.6
|
81.8
|
-
|
74.2
|
Part-time employment n (%)
|
4
|
1 (2.7)
|
3 (27.3)
|
-
|
4 (8.88)
|
Practice network member years (range) (mean)
|
27
|
2-23 (10.18)
|
-
|
-
|
10.18
|
Additional qualifications n
|
7
|
-
|
7
|
-
|
7
|
Survey respondents (T0)
|
|
|
|
|
|
Sex (f/m) n (%)
|
304
|
229 (148/76)
|
80 (100/0)
|
-
|
228/76 (74/26)
|
Age years (range) (mean)
|
299
|
35-73 (54.4)
|
19-61 (38.7)
|
-
|
19-73 (46.5)
|
Working experience years (range) (mean)
|
306
|
5-48 (25.4)
|
1-40 (19.2)
|
-
|
1-48 (22.3)
|
Working in general practice (%)
|
309
|
75.3
|
76
|
-
|
75.6
|
Resident years (range) (mean)
|
220
|
1-41 (17.7)
|
-
|
-
|
220 (17.7)
|
Network member years (range) (mean)
|
207
|
0-28 (10)
|
-
|
-
|
10
|
Participating in network events times/year (range)
|
217
|
7.3
(0-50)
|
-
|
-
|
7.3 (0-50)
|
Table 2. Characteristics of the interview sample and survey respondents (T0)
Findings from the qualitative data are reported regarding aspects explored within the inductive domain ‘Primary care networks’ and focus on social influence processes [23–25] identified during the analysis: perceived social support, social learning, social-normative pressures and social contagion. For illustration, extracted quotations have been included. All provided quotes were translated with due diligence and are referenced with participant number and transcript position. Additional quotes are provided as supplementary material (Supplementary Table 1). Figure 1 describes the analytical process and points out relevant sub-categories defined during the analysis.
Social support
Being a network member
Generally, physicians and MAs felt their networks to be a strong support factor both for existing daily and implementing new routines. Data generated through surveys T0 and T1 showed that 74% and 59% respectively of physicians experienced support for new routines, 43% and 36% acknowledged network impact on prescribing decisions, guideline-oriented care (70.5% and 60%), and management of patient expectations (61.2% and 51%) and felt supported in pursuing shared-decision making (61% and 59%) (Table 3). Table 3 shows results from physician survey T0 and T1 on network participation.
Participating in the network …
|
Agree
T0/T1 (%)
|
Neutral
T0/T1 (%)
|
Disagree
T0/T1 (%)
|
…motivates guideline-oriented patient care
|
70.5/60
|
18.5/19
|
11/22
|
…supports shared-decision making
|
60.8/59
|
19.8/24
|
19.4/18
|
…supports managing patient expectations
|
61.2/51
|
21.6/30
|
17.2/19
|
…supports implementing new routines
|
74/59
|
16.3/18
|
9.7/24
|
…has an impact on antibiotic prescribing decisions
|
43.3/36
|
22.1/22
|
34.5/43
|
Table 3. Physician perspective on network participation (T0, T1)
When asked about the significance of being a member in a primary care network in the interviews, participants shared clear ideas. Predominantly, cited aspects referred to being part of a group rather than working just as a single practice. Access to collective knowledge through active in person peer exchange was considered to be of high importance with regards to support in situations of uncertainty, complex cases and the synchronization of therapy decisions across disciplines. Physicians stated different reasons for initially joining their network including options for future prospects, further personal development, communicative peer exchange, upskilling and utilization of joint administrative structures.
“Personally, I think that … it is the future, … the single practice, all alone without peer exchange, at least for me, it is definitely not a model I want to work in.”
Phys08, Pos. 56
“We have found a forum where we look at the big picture and that means, I don’t only look at pediatric topics but also at orthopedics, gynecology, dermatology and all other areas, and they, too, learn what is important for us, for life, for our perspective.” Phys02, Pos. 20
MAs felt that the network membership motivated them to support the physician (72% in T0 and 69,9 % in T1), fostered dealing with patient expectations (68% and 71.3%), supported the implementation of new routines (71% and 68.4%) and had an impact on their part in patient care (59% and 60.3 %). During the interviews, they shared physician views regarding future prospects, peer exchange and joint administrative structures. They also added their own perspectives referring to financial aspects and benefits for patient care. Stakeholder substantiated physician and MA perspectives, emphasized the importance of collaboration, communicative peer exchange and collective efforts of upskilling in networks. They also reflected on support of basic human needs.
“Patient care, to begin with, exactly, so that patients are well supported, and I think, I will be honest, it might also be a question of billing.” MA06, Pos. 44
“… makes you somewhat happier, fulfills your own expectations and of course motivates you, when you can enter into dialog and, as a bonus, can present yourself and what you can do really, really well, to the network, and you can collect everybody’s experiences – when this exchange happens.” Sh04, Pos. 84
Impacting care delivery
Regarding care delivery, participants saw network membership as an asset and a decisive factor for quality management, both in the study context and beyond. Continuity of care within the network was seen as supported by more and closer peer contacts, simplified peer exchange, usage of shared electronic patient records, fast appointment scheduling and patient transfers to medical specialists.
“Improved care services for the patients, not only in the ARena study, but in general …” MA03, Pos. 75
“…important to me that I communicate with others and I believe, working in the network contributes to quality management in the long run …” Phys23, Pos. 54
“Mutual communication is top priority, in my opinion, this is underestimated, and through such networks where you are forced to communicate with each other, this is promoted immensely, and all involved benefit and of course not least the patients.” Sh04, Pos. 70
Confirming own perspective
Social support through communicative peer exchange was also seen as affirmative to own perspectives regarding importance of specific topics or course of own action.
“This peer exchange is extremely important and contributes a lot to self-confidence, I presume.” Phys23, Pos. 56
“Exactly these discussions happen in these networks, … What does this mean? How do I accompany patients, take care of them, how can I conduct conversations? To support each other in finding a way and entering into discussion …” Sh02, Pos. 22
Social learning
Upskilling
Participants reported structured approaches of regularly offering upskilling events by their networks and taking part in a range of medical and organizational training programs such as quality and efficiency circles for MAs and physicians, workshops, case studies, and journal clubs. These learning opportunities were considered to be supportive in terms of providing new knowledge and peer exchange opportunities in a protective setting at the same time. Participants also felt supported by provided information components on evidence-based practice and provision of patient information.
“We regularly meet in quality circles, I think that is quite good, and do case reviews … I find this very pleasant in the network, because you know each other and dare to come out of your shell …” Phys14, Pos. 44
Participating in ARena
Physicians reported taking part in ARena-specific quality circles focusing on best practice guideline-oriented use of antibiotics and finding opportunity there for thematically relevant peer exchange within the network. Survey data (T0 and T1) showed that 83.4% and 86% of the participating physicians used the offered trainings on guideline-oriented antibiotics therapy and 71.5% and 72 % acknowledged that peer exchange about antibiotic prescribing for acute non-complicated infections was provided within their network (Table 4). There was indication of a heightened alertness to quality improving mindful antibiotic prescribing as a result of the PCNs’ study participation.
In my primary care network …
|
Agree
T0/T1 (%)
|
Neutral
T0/ T1 (%)
|
Disagree
T0/T1 (%)
|
…antibiotics therapy is discussed
|
89.5/86
|
8.8/10
|
1.7/4
|
…peer exchange about guideline-oriented antibiotics therapy is offered
|
79.9/79
|
14.5/11
|
5.6/10
|
…exchange about antibiotic prescribing routines for non-complicated infections is possible
|
71.5/73
|
18.4/16
|
10.1/11
|
…there are conventions about antibiotics for non-complicated infections
|
65.8/72
|
21.5/16
|
12.7/12
|
…training on guideline-oriented antibiotics therapy is offered
|
89/75
|
6.6/18
|
4.4/7
|
…I participated in training on guideline-oriented antibiotics therapy
|
89/87
|
6.6/9
|
4.4/4
|
Table 4. Results from surveys T0 and T1 referring to training and peer exchange
Social-normative pressures
Shared network attitude
Participants made references that pointed to a shared network attitude which included a common interest in evidence-based guideline-oriented care, mutual support in situations of uncertainty or locum care, long existing memberships, and a general sense of community. Financial aspects and ties to pharmaceutical manufacturers were negated. However, pointing to potential selection processes, it was also mentioned that PCN members needed to be willing to implement changes. This was reflected in survey T0 data, where 90% of the physicians indicated they had implemented changes in their practices during the past two years. Aspects of social integration and in one case a perceived lack of it were contemplated as well as potentially different circumstances in case of not being a network member.
“So, I think, in this context [in the network], you generally mind your prescribing behavior and of course now in particular you mind your antibiotic prescribing, too.” Phys22, Pos. 17 and 50
“Quality circles are obligatory. If one says ‘I can stay as I am’, he is not an adequate network physician, if you like, but this ultimately means change.” Sh05, Pos. 56
“Thinking I would not be in the network and not have the [peer] exchange options, perhaps one would not have participated in the study at all, but overall, we probably would act differently and not attach so much importance to that.” Phys22, Pos. 50
Management
Generally, the management teams of PCNs were seen positive and active in aiming for a strong common appearance, provision of information and training on new developments, evidence-based guideline-oriented care, and opportunities for peer exchange. In some cases, political involvement in contractual negotiations with health insurers were reflected on. One physician explicitly described the network manager as a go-ahead character who promoted digitalization efforts. This was the only mention of someone being considered an opinion leader regarding specific topics. One stakeholder saw network management in this role. Participants who were involved in network or stakeholder management gave their managerial viewpoint.
“I am a network board member … it is important to me to absolutely provide know-how.” Phys24, Pos. 38
“I don’t think physicians join a network and say ‘I want to practice a better medicine’, but this eventually has to be defined by the management, ... it’s an ambitious pledge and I think it only works in certain areas, … and this is where I see ARena.”
Sh05, Pos. 48
“…the network has a very honorable manager, a big IT promoter who … co-developed a very good data security concept that practices can implement quite safely.” Phys09, Pos. 30
Social contagion
Interacting and peer exchange
Participants generally cited positive attributions regarding aspects of interaction and peer exchange and a potential impact that physicians might have on each other within the network. Some physicians expressed that they explicitly wanted to work in a PCN member practice to be able to make use of regular peer exchange. With regards to the role PCNs might play in supporting rational prescribing and use of antibiotics for non-complicated infections, they pointed to coordination of care-related aspects and the importance of regular peer exchange and interaction.
“... I think we are more focused and faster, because I have the same thoughts as the cardiologist or the nephrologist…” Phys27, Pos. 78
“Well, we have seen – as a single physician, there is no point in reading something. When we read as a group and the others say ‘yes, I do this, too’, ‘I will do it this way from now on, too, makes sense’, then I am more likely to implement it in my practice, because I know: OK, my peers do this, too. It’s an important effect.”
Phys17, Pos. 28
"That is why I explicitly looked for a practice where this [peer exchange] is possible." Phys08, Pos.56
Potential influences of interacting in PCNs were also reflected critically with regards to antibiotic prescribing decisions, own attitude and using peer exchange windows of opportunity to exert educative influence. Physicians noted that sometimes networks lost members and it could be difficult to gain new ones. One physician described recruiting all physicians in specialist training in his practice. There was no indication of defined non-admission criteria. While physicians focused more on providing contagion in PCNs, stakeholder and MAs contemplated contagion processes.
“It definitely has an effect for the patients, because we do evidence-based, scientifically sound medicine. But this has not changed because I am a network member, but we founded the network so we could infect others [with ideas].”
Phys17, Pos. 36
“The network in the end does not have any influence on a physician’s decision, I think this remains with the physician.” Sh01, Pos. 46
“We actually always have a team meeting when there is something new everyone should know about, and has been discussed [in a quality circle], and then we discuss it in the meeting and see how we can implement or improve certain things in our routines.” MA01, Pos. 66
Translating to peers and team
Physicians and MAs reflected on exchanging information and translating knowledge within their practices and networks in general as well as in the study context. While physicians again focused on providing information to peers, MAs took a more reciprocal perspective and took pride in translating knowledge back to their place of work.
“On my end, I try to incorporate this ENT specialist view, to do genuine networking, to inform my colleagues, to give food for thoughts, reflect experiences I gain in my practice.” Phys24, Pos. 38
“Sometimes it is very cool, there is this MA circle I joined, and you talk to peers, [about their routines], and then you are back at work and can narrate.”
MA11, Pos. 52
Existing network structures regarding information dissemination and peer exchange were seen as promoting factors for knowledge translation and following up with new ideas. Participants reported using in-person meetings and direct phone calls, printed information media, video conferences and communication applications within their PCNs. There was no mention of fixed or loose subgroups in networks other than in connection to medical specialty or organizational level and related topics. There was little mention of communicative exchange between networks. Regarding ARena, participants emphasized their networks’ support for the implementation of the intervention components, following through with study participation and the potential to reach a larger group.
“… I believe that network structures certainly … promote trying out even more, because both personal and administrative structures are in place.” Sh07, Pos. 84
“Ok, one can easily say that without it [the network], we probably would not have followed through as consistently.” Phys19, Pos. 62