# Understaffing and overprescribing: a register study on the role of locum physicians in antibiotic prescribing patterns in primary care in Northern Sweden

## TL;DR

This study finds that higher reliance on temporary doctors in understaffed clinics in Sweden leads to more inappropriate antibiotic use for certain infections.

## Contribution

The study demonstrates a novel link between locum staffing levels and antibiotic overprescribing in primary care for respiratory infections.

## Key findings

- Clinics with higher locum staffing had 2.5 times higher odds of antibiotic prescriptions for infections where they are not recommended.
- Inappropriate antibiotic prescribing was higher in Skellefteå compared to Umeå, where locum staffing was lower.
- No difference in antibiotic prescriptions was observed for pneumonia, where antibiotics are typically appropriate.

## Abstract

Understaffing and dependence on temporary physicians known as locums are common in primary healthcare in Sweden. In this study, we investigate the impact of locum staffing on the quality of antibiotic prescribing for respiratory tract infections. We used two neighbouring cities in northern Sweden with large differences in staffing conditions: Skellefteå, with a 10-fold higher reliance on locum physicians compared to Umeå, which has low locum staffing.

We used data extracted from patient records for all visits, from the four largest healthcare centres in each of the cities Umeå and Skellefteå, for respiratory tract infections, including the ICD-10 diagnosis code and whether antibiotic treatment was prescribed or not. Data on the contracted hours of locum staff for each healthcare centre were also obtained. Statistical analyses were performed with Spearman correlation, Chi-square and Poisson tests. Logistic regression was used to investigate whether prescribing patterns were affected by the level of relay physicians.

We analysed antibiotic prescriptions for respiratory tract infections based on data from 11,228 patient visits. Regardless of the statistical method used, we found a statistically significant difference, with higher rates of antibiotic prescribing for diagnoses where antibiotics generally are not recommended or where they should be prescribed restrictively. For pneumonia, where antibiotics should normally be prescribed, no difference was seen. The odds of antibiotic prescription for acute upper respiratory tract infection in Skellefteå were 2.5 times higher than in Umeå, with a positive correlation between locum staffing and antibiotic prescriptions for diagnoses where antibiotics should be used restrictively.

Our findings show that a high level of locum staffing and thus insufficient staffing with permanent General practitioners leads to higher rates of inappropriate antibiotic prescribing. This is shown both at the level of individual primary care healthcare centres and at the community level.