471. Broader Than Necessary: A Qualitative Study Exploring Broad-spectrum Antibiotic Prescribing Tendencies Using A Situated Cognition Educational Framework

TL;DR

This study explores why doctors prescribe broad-spectrum antibiotics unnecessarily in hospitals, using a framework that considers the context of decision-making.

Contribution

The study introduces Situated Cognition as a framework to understand and potentially improve broad-spectrum antibiotic prescribing practices.

Findings

24 factors influencing antibiotic selection were identified and grouped into five themes.

Context and patient factors had the most influence on prescribing decisions.

Nighttime and cross-cover situations were highlighted as high-priority areas for intervention.

Abstract

Effective antibiotic choice is imperative to high quality care. However, antibiotics used in the hospital are often unnecessarily broad-spectrum, leading to increased rates of adverse effects and higher costs to the healthcare system. Prior work has explored how clinicians select antibiotics but not why they use agents that are broader than necessary. Using Situated Cognition – an educational theory positing that knowledge acquisition is inseparable from its setting – as a framework, we sought to improve our understanding of how clinicians conceptualize, justify, and manage broad-spectrum antibiotics in the inpatient setting.

We conducted 12 semi-structured interviews with hospitalists and senior Internal Medicine residents who practice at the University of Michigan and Ann Arbor Veterans Affairs hospitals (Table 1). Interviews explored participants’ experiences with antibiotics in different inpatient settings. Employing Situated Cognition as a sensitizing framework, we generated a codebook from interview transcripts through an iterative, inductive process. We consolidated codes into themes using Braun & Clark’s thematic analysis approach.

We identified 24 factors impacting antibiotic selection that coalesced into 5 themes: context, external factors, practice patterns, personal factors, and patient factors (Table 2). Condensing these concepts revealed a framework of influence with context and patient factors having the most effect and external factors the least (Figure 1). Most participants described challenges when selecting antibiotics at night and when cross-covering others’ patients.

Our results build on prior management reasoning research, using the lens of Situated Cognition to better understand broad-spectrum antibiotic use. Situated Cognition effectively describes the interactions between the provider, patient, and the environment as they relate to antibiotic prescribing and illuminates situations with the potential for impactful intervention. Notably, our study identified nighttime and cross-cover as high priority settings with the potential to improve antibiotic decision-making through educational initiatives with the goal of combating unhelpful external pressures.

All Authors: No reported disclosures

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