(2021) 22:205
Guo et al. BMC Fam Pract
https://doi.org/10.1186/s12875-021-01556-z
Open Access
RESEARCH
Exploring antibiotic prescribing in public
and private primary care settings in Singapore:
a qualitative analysis informing theory
and evidence-based planning for value-driven
intervention design
Huiling Guo1,2, Zoe Jane-Lara Hildon2*, Victor Weng Keong Loh3, Meena Sundram4,
Muhamad Alif Bin Ibrahim1,5, Wern Ee Tang6,7 and Angela Chow1,2,7
Abstract
Background: Singapore’s healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems.
Aim: To explore processes underpinning decision-making for antibiotic prescribing, by considering doctors’ experiences in different primary care settings.
Methods: Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary
care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data
were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model,
informing solutions to appropriate antibiotic prescribing.
Results: Given Singapore’s lack of national guidelines for antibiotic prescribing in primary care, practices are currently
non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining
such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by
reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling
optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding
interventions to improve antibiotic prescribing practices.
These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions
should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions,
or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is
*Correspondence: Zhildon@nus.edu.sg
2
Saw Swee Hock School of Public Health, National University
of Singapore and National University Health Systems, Singapore,
Singapore
Full list of author information is available at the end of the article
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
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Guo et al. BMC Fam Pract
(2021) 22:205
Page 2 of 14
crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared
decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change.
Conclusions: These VALUE dimensions are recommended as potentially transferable to diverse contexts, and the
model as implementation tool to be tested empirically and updated accordingly.
Keywords: Antimicrobial stewardship, Antibiotic prescribing, Primary health care doctors, Qualitative research, VALUE
model for appropriate antibiotic prescribing in primary care
Introduction
Antimicrobial resistance (AMR) is a rising global health
threat. It has been projected that 10 million annual deaths
would be attributable to AMR by 2050, with nearly half
of these occurring in Asia [1]. Traditionally, antibiotic
stewardship guidelines have primarily focused on tertiary
hospitals, while such recommendations remain lacking
in outpatient settings [2–4]. In 2016, the US Centers for
Disease Control and Prevention (CDC) released a guiding framework for antibiotic stewardship in outpatient
settings, which included primary care clinics, to extend
monitoring and improvement of antibiotics use in such
contexts [5].
Antibiotic prescribing itself has been described as an
adaptive expertise, which requires the incorporation of
clinical knowledge, experience and cognitive styles, but
which is also framed by the characteristics of the patient
[6]. Prescribing decisions have been found to be made
under varying levels of support, cognitive loading as
well as consideration of patient expectations, demands
and self-presentation [6]. As such, the interplay between
patient and doctor can be conceived as each adhering to
practical considerations as well as social roles that influence their interaction. On the primary care doctor’s side,
antibiotic prescribing has been shown to be dependent
on their presentation of ‘expert self ’, ‘benevolent self ’ and
‘practical self ’ during the clinical consultation [7].
Furthermore, the concept of value-based practice recognises the contribution of diverse values, from both
patients and doctors, emphasizing the need to negotiate and align these to achieve shared decision-making
in clinical practice [8, 9]. Patients’ values refer to what
patients expect from their clinical experience while for
doctors’, this includes the beliefs, both professional and
personal, that determine priorities in clinical practice
and related decision-making [10]. Organisational culture is also value-laden, driven by leadership and agreed
standards of practice, that may override individual priorities and further influence doctors’ clinical decisions
[11]. For example, it can be argued that doctors practising in an environment which shares, promotes and
even monitors/evaluates against standardised bestpractice guidance and information are more likely to
learn to react in accordance to these.
Existing literature has emphasized procedural factors driving the doctor’s antibiotic prescribing, such as
the lack of decision aids to support clinical judgment,
diagnostic uncertainties and so forth [12–17]. Effects
of clinical environment have been less considered [18–
21], as have ways of consolidating the environmental
aspects and procedural ones into a coherent synthesis or narrative. More evidence-based theory-driven
approaches are needed to guide antibiotic intervention
development that accounts for systemic differences
that allows practitioners to judge how best to promote
change in their own environments [22, 23]. Realist principles are applied to the current analysis [24]. Realist
thinking seeks to account for diversity in Context while
identifying Mechanisms, or aspects of practice which
can be used to explain leverage positive Outcomes
(CMO), in our case appropriate antibiotic prescribing.
Inappropriate prescribing is primarily defined herein,
as that which is unnecessarily prescribed, meaning
that no antibiotic was needed whatsoever unless otherwise specified. According to US CDC, this accounts
for upward of 30% of prescribing rising to 50% when
coupled with inappropriate selection, dosing and duration [25]. Social and behaviour change interventions to
affect these outcomes have long been observed to occur
at several social ecological levels which connect individuals to their institutional environments and wider
communities or social norms [26]. In the current study,
we have adapted this approach to frame our analysis
starting with the intrapersonal, and drilling down to
organisational, interpersonal levels, as housed in wider
national and systems contexts.
This multi-level approach coupled with a focus on
contrasting public and private primary care sectors,
and filling the gap in understanding of systems where
doctor both prescribes and dispenses medications in
the clinic [12–21, 27–32] is seen to add to our knowledge gaps on complexity of antibiotic prescribing
processes.
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Primary care structures in Singapore
Material and methods
In Singapore, 20% of primary care attendances occur in
publicly funded polyclinics, with the remainder in private general practitioner (GP) clinics [33]. GP clinics
include 1) Solo practices, which are single clinics that
operate under a registered clinic name, 2) Small group
practices, which refer to group practices that operate 2
to 8 clinics, and 3) Large group practices, which operate more than 8 clinics. On average, 20 to 30 doctors
practise concurrently at each polyclinic on each clinic
day, compared to one to two doctors at each private GP
clinic. In most solo and some small group GP practices,
diagnostic tests are outsourced to third-party service
providers incurring additional operating costs whilst
medications are dispensed by the doctor with no or
minimal pharmacist involvement [34].
Doctors working in these practices are often the key
decision-makers on how to operate their clinics. Large
group GP practices, on the other hand, have a central
operating structure that governs how clinics within the
practice are run. This centralisation structure allows for
operating cost-savings through successful negotiations
of lower rental fees, and bulk purchases of diagnostic
services and medications. In addition, GP clinics can
also engage with varying third-party administrators
(TPAs) or managed care organisations (MCOs) acting
as middlemen to provide affordable care to employees
of subscribing companies and sustainable patient referrals to participating GP clinics with different contract
terms [35]. On the other hand, polyclinics are simply
walk-in clinics accessible to all [34], but given their size
and composition, they provide a wider range of multidisciplinary healthcare services than GP clinics. This
includes outpatient services ranging from nursing care
to pharmacy, radiology and laboratory services. Outof-pocket payments by patients are much lower at polyclinics than GP clinics, due to government subsidies
and economies of scale [36].
Given the complexity of how primary care practices
are organised in Singapore, this study’s objectives are to
explore the contexts, and related mechanisms behind
decision-making processes for antibiotic prescribing by
primary care doctors in Singapore by contrasting experiences across public and private sectors. In addition,
we seek to summarise these findings into a conceptual
model that accounts for the multiple socio-ecological
levels that affect antibiotic prescribing across these settings using realist principles. In tandem, we relate the
model to potential strategies for changes targeting primary care service improvement pertaining to appropriate antibiotic prescribing.
Study design and study population
Semi-structured interviews were conducted with primary care doctors in publicly funded polyclinics and
private GP clinics between June 2018 and January 2020.
In Singapore, there are 20 polyclinics and up to 2222 private GP clinics, serving a population of 5.7 million people
[37]. To achieve maximum variation, the study participants were purposively recruited from four different
settings: polyclinics, solo GP practices, small group GP
practices and large group GP practices, with a good mix
of age and years of practice in their current practice setting [38]. Locum doctors were excluded from the study.
In addition to this maximum variation sampling strategy,
the sample size required for this study was also grounded
in the principles of data saturation [39]. The study was
conducted and reported according to the Consolidated
Criteria for Reporting Qualitative Research (COREQ)
guidelines [40].
Semi‑structured interviews
A semi-structured topic guide was developed by HG
(Female, MPH, Research Fellow) based on current literature and thereafter used to explore the factors influencing
antibiotic prescribing practices among polyclinic and GP
doctors in the primary care clinics. The topics and related
questions explored the clinical and non-clinical factors
that influenced participants’ prescribing practices at the
intrapersonal, organisational, interpersonal and national
or community levels (refer to the Topic Guide in Supplementary file (Additional file 1) for further details). Two
sub-sections, one pertaining to specific decision-aids, the
other a ranking exercise on community awareness interventions were not included in the current dataset. These
have been removed from the appended topic guide.
Pilot interviews were conducted by HG with three
primary care doctors to ensure content validity and
the proper phrasing of questions in the guide. HG and
another study team member (Female, MPH, Research
Assistant), who were public health researchers trained
in qualitative fieldwork, conducted the interviews. Interviews were also cross-audited by both study team members by observing three interviews respectively. The audit
was undertaken to minimise interviewer bias, provide
feedback on interview techniques as well as to ensure
adequate probing and rapport building throughout the
interview process.
Invitations letters were sent out to a number of primary
care clinics and primary care doctors to invite them to
the study. Interested clinicians were asked to contact the
study team via email or text messages. The study team
sought to ensure a good representation of age and years
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of practice before recruiting the participants. Recruited
participants were provided with the participant information sheet and informed consent was taken onsite on
the day of the interview. Each interview lasted for 45 to
60 minutes. Interviews were conducted at a preferred
time and location specified by the participant to provide
the greatest convenience and ease for the interview. Confidentiality was ensured by conducting the interviews
behind closed doors at the respective doctors’ clinics or
in a quiet corner in a public location. Interviews were
conducted after consultation hours and in the absence of
clinic staff from their respective clinics.
Moreover, no personal identifiers were collected, and
participants were assigned a study identification number that was used throughout the study duration. Before
the commencement of each interview, the interviewers
would introduce themselves as researchers with no prior
medical knowledge to ensure that participants could be
candid and forthcoming with their responses. Every session was audio-recorded and transcribed verbatim.
Data analysis
Data were analysed using an applied thematic approach
[41], underpinned by realist principles [24, 42]. Two coders (HG and MABI) first read through all the transcripts
to become familiar with the data and embarked on the
process of organising it in Microsoft Word. Specifically,
the coders compared the narratives driving the outcomes pertaining to in/appropriate antibiotic prescribing as shared by doctors across the publicly and privately
funded primary care settings at different socio-ecological levels. This in-depth process informed the development of a preliminary codebook designed to help collate
the data into broad areas for analysis according to our
objectives. This task was based on a review of five transcripts from which saturation of the initial organising
codes was achieved. The coders subsequently analysed
the organised data independently, coding these manually
(using comment boxes in Microsoft Word) for ongoing
discussion.
Thematic codes were then derived iteratively as analyses continued. Discrepancies were discussed and resolved
in the presence of a third study team member. Both intercoder agreement and saturation on emergent themes
were systematically sought and achieved [41]. Saturation
of themes was achieved faster on coding of polyclinic
doctors’ data compared to GP data. This was judged to
have occurred at about one-third way through polyclinic
doctors interviews and more than halfway through for
the GPs’ interviews. Agreed codes were applied to the full
dataset by both coders before data reduction and summarisation were undertaken by one analyst (HG), who
further refined the findings and supporting subthemes
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by grouping these and relevant illustrative quotes in
Microsoft Excel. The relationships between the themes
were then mapped out according to the levels that they
targeted and summarised in a descriptive model (HG and
ZH). Major themes are reported in bold as section headers while supporting subthemes are in italics.
Basic descriptive data of the participants was computed using STATA/SE 15.0 (StataCorp LLC, College Station, TX).
Results
Study participants
Thirty primary care doctors were interviewed. Their
median age was 40 (range 27 – 69) years (Table 1). The
majority were Singapore citizens and of Chinese ethnicity. There were more female participants represented in
the polyclinics than GP clinics. In contrast, more participants from GP clinics had more than 10 years of clinical
experience, and more had post-graduate training in Family Medicine than those from the polyclinics.
Objective I: Exploring decision‑making contexts
for antibiotic prescribing across primary care settings
National level
Lack of standardised national antibiotic prescribing guidelines for primary care settings In relation
to the broader Singapore context, polyclinic doctors
shared that they could refer to the paediatric dosing and
Table 1 Basic characteristics of participants
Demographics
Polyclinics GP Clinics Total
Number of Participants
17
13
Median Age
35
47
40
Age Range
27 - 69
31 - 60
27 - 69
13 (76)
5 (38)
18 (60)
14 (82)
11 (85)
25 (83)
Singapore Citizen
15 (88)
13 (100)
28 (93)
Singapore Permanent Resident
2 (12)
0
2 (7)
10 (59)
5 (38)
15 (50)
7 (41)
8 (62)
15 (50)
9 (69)
16 (53)
7 (54)
14 (47)
30
Age, in years
Gender, N (%)
Female
Ethnic Group, N (%)
Chinese
Resident Status, N (%)
Highest Education Level, N (%)
Basic Medical Degree
Post-Graduate Degree in Family
Medicine
Total Duration in Medical Practice, in counts (%)
More than 10 years
7 (41)
Total Duration in Current Practice, in counts (%)
More than 10 years
7 (41)
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disease-specific treatment guidelines made available to
them by the polyclinics for antibiotic prescribing while
these were generally absent in the GP settings, regardless
of practice size. While it was unanimous amongst polyclinic and GP doctors that guidelines had to be twinned
with clinical judgment, the need for guidance was concurrently emphasized. Since no national, standardised primary care ones existed, this meant that doctors often had
to rely on multiple out-of-context sources (such as hospital and/or non-local guidelines) to inform their prescribing decisions:
“… [while] Guidelines are only meant to guide us in
a certain way but we still need our clinical discretion
to decide whether truly the patient needs antibiotics
or not.” (P5)
“In Singapore, I don’t think we have such a guideline. There’s a need for this [emphasis our own], but
we don’t have [it]…Every single hospital, they have
guidelines for antibiotics…we can follow [that].”
(GP23)
“I rely more on Up-To-Date [referring to an international online clinical decision support resource]
actually.” (P5)
In sum, it was conveyed that a common set of nationally endorsed guidelines, tailored to primary care, was
lacking and considered useful. Data suggested that consistency in use of these would provide a concrete starting
point for aligning appropriate prescribing across primary
care settings.
Page 5 of 14
in giving into demands rather than supporting clinical
judgment:
“Healthcare has unfortunately become very customer service-oriented…after thoroughly counselling
the patient…for indication, as opposed to having the
patient scream at you…I may give Amoxicillin…it’s
a fine line to tread between getting a complaint and
exercising your best clinical judgment.” (P1)
“We still partially belong to the service sector you
know, so a lot of times I do have to admit that if
patients ask for antibiotics and they are insistent,
our threshold to reject them is very low.” (GP22)
Thus, we were alerted to the danger that primary care
doctors, particularly in the private sector, may cave under
insistent patient demands, rather than take the time
to persuade them otherwise. Operational models and
related factors shaped and perpetuated practice cultures
that did not see the need to cave into patient demands;
mechanisms that resulted in shared decision-making
in particular helped to drive appropriate prescribing,
related themes and subthemes are detailed below.
Organisational level
Role of operational models, practice size and shaping of
organisational values Primary care doctors are vulnerable to medical liabilities, yet our data revealed that publicly funded operational model gave the doctors a sense of
security due to perceived organisational backing. This was
said to contribute to relieving the pressure of having to
satisfy patient demands:
Intrapersonal level
Perceptions of types of care delivery and provider
roles Our data reflected a tension between a desire to
practise holistic healthcare provision and an expectation
of customer service-oriented care delivery:
“For family practice to be able to continue and
grow, acute care is not the main thing they have to
focus on. Actually many times we actually look at
the complete care…not just disease management…
we are actually moving towards health prevention
and disease prevention and…the next stage…health
preservation, means how to actually make them
healthier and better as a whole family, [and] not just
the patient [alone].” (GP12)
The latter occurred when patients presented more
as clients than patients, and was more likely to result
“When you are working in polyclinic[s], you have
[the] government on your back…but in the private
sector, the issue is when…medical legal [issues arise]
…or patient come after you with a lawyer letter…
when things happen, their backs are not covered.”
(GP30)
“Practising here in the polyclinic gives me the liberty
of not giving antibiotics unless its evidence-based
and that, to a certain extent, gives me empowerment…not forced to give anything just to make the
patient happy. So it’s easier to practise that way…
you don’t have to bow to the wishes of the patient
but you practise the way you are supposed to.” (P9)
Furthermore, in larger organisations - like polyclinics or even large group GP clinics - practice norms were
established via shared protocols, and these were key to
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establishing shared values and continuity of preferred
practices:
“A lot of times, it’s a legacy effect as well because
for us, we belong to an organisation. So the clinic
changes hands very frequently and usually when we
come in, we inherit what was given to us. We make
minor changes along the way but a lot of times we
keep to what was given to us.” (GP22)
“We are more resource-strapped and we have more
protocols, I feel that we are a bit more restricted
when it comes to giving antibiotics.” (P20)
Conversely, standards of practice while tending to be
less documented, shared institutional values were established by the leadership, and deviations were especially
noticeable:
“In a place like us…you stick out…whatever thing
you do will stick out…another doctor will pick up
and…instant reporting…so that helps [to] keep us on
our toe[s]…Whereas…if you are [in] solo [practice],
it’s different. There’s nobody to police you…at least
here…we will think…how would your peer[s] think…
[and] what repercussion.” (P11)
As such, size of the organisation and the legacy of values, or those of the current leadership, being placed
either on shared protocols or undocumented yet ‘known’
practices formed the backdrop to antibiotic prescribing
behaviours.
Effects of financing models on operations and related
organisational values The financing of clinics also
helped to determine how clinics operated and these
effects could trickle down to patient care. In polyclinics, the financing model is unified across all clinics and
consultation fees are subsidised by the government for
all local residents. Polyclinic doctors shared that patient
health financing schemes, insurance and claiming considerations had little or no influence on antibiotic prescribing
habits since government-subsidy is provided to the majority of their patients:
“It doesn’t really matter for me because I feel that
everyone is [given] subsidised care [by the government] … if I feel that antibiotic is really needed
[rather than under prescribing], I will give the antibiotic. It doesn’t matter.” (P20)
However, the situation in the GP clinics was much
more complex due to potential third-party financing (TPAs) model for the patients. The opinions of solo
and small group GPs towards TPAs or Managed Care
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Organisations (MCOs) acting as middlemen were mixed.
Some GPs welcomed third-party financing structures
because it sustained the patient pool. Others pointed out
that TPA and MCO arrangements came with contract
restrictions that impacted clinical prescribing, e.g. it was
described how with limitations on the per capita funding
provided for each patient and the types of drugs claimable under the contract, doctors might resort to shortening
the recommended antibiotic course and to prescribe only
approved types of antibiotics to the patients:
“I don’t do company contracts [referring to TPA and
MCO contracts] but I [have] work[ed] in company
contract clinics before. So for example, you get antibiotics right, you give 5 days or 7 days. At the counter, the staff will cut down to 2 or 3 days because to
cut costs…That’s why I don’t do contracts…they only
give you this amount. So you either hit it or you bust
it.” (GP14)
“We used to take up some of the third party insurance companies [referring to TPA and MCO contracts] and they will restrict you to prescribing
generic rather than patented. But not the decision to
prescribe or not to prescribe…For those who accept
the insurance payments, the insurance company’s
terms and conditions can be very restrictive…I think
it affects one’s prescribing habits.” (GP25)
Furthermore, GP doctors also felt that TPA and MCO
contracts disrupted the patient-doctor relationship. This
was especially problematic when the patient-doctor relationship was highly valued by GP doctors (to be illustrated below). In particular, TPA and MCO contracts
were perceived to turn the patient-doctor relationship into
transactional cost-based one which lacked mutual trust
or respect, and loyalty, creating a backdrop where antibiotics were more likely to be prescribed to satisfy patients’
demand:
“For those [under TPA/MCO] contract…there is no
loyalty, there is no trust…there is no mutual trust or
respect…So sometimes if you just want to get rid of
the patient, you just give [antibiotics].” (GP14)
“Because the relationship you have with patients
with managed healthcare [refers to TPA/MCO]…
the patients already have a conception that you’re
not going to treat them well…because they have the
card. They can just go to another GP the next day
[and] just pay 5 dollars.” (GP24)
As compared to polyclinics, financial models encouraging transaction-based relationships were more likely to
occur in GP settings, in particular participation in TPA
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and MCO administration disrupted the relationship
between doctors and patients.
Drug formulary management and organisational prescribing know-how Primary care clinics in Singapore
both prescribe and dispense medications to patients at a
single location and their operational models also determine the way drug formulary is managed in each clinic.
The pharmacies within the polyclinics are managed by
outpatient pharmacists and the drug formulary is controlled by the organisation. Polyclinic doctors mentioned
that they hardly made decisions on antibiotic procurement, which saved a lot of administrative load. Patients
were given scripts to collect antibiotic prescriptions from
community or hospital pharmacies if the drug was not
stocked up in the polyclinics:
“There were some cases whereby a patient…[has]
multiple allergies to different antibiotics and then
the one that I wanted to give wasn’t available. Levofloxacin. So in that case I give him an external prescription that he can buy…in the other pharmacies.”
(P6)
On the other hand, in GP settings, drug formulary management forms a large proportion of the GP doctors’ role
in clinical practice, taking up time and effort, potentially
distracting from time that could be given to patient care
and relationship building. As described by a couple of
solo GP doctors:
“We’re more than happy to lose the pharmacy actually…we have to manage the dispensary, to manage
all these medications, [but] to us, this is not our core
job right? Our core job is a doctor…to provide consultation and just charge the consultation…we can
actually focus what is important to us.” (GP23)
“I have no problems with [abolishing dispensing
role]. It reduces my headaches. I just put a consult
fee and that’s it. I don’t need to buy drugs, and think
about what tier I have, how many shall I stock, can I
dispense it before the drug expires.” (GP24)
On the other hand, some GPs expressed that having control over customising their formulary and choosing antibiotic stock allowed them to improve knowledge
of what was being dispensed and better ability to monitor and prescribe according to their clinical expertise and
preferences:
“I own my practice…I can put very fanciful stuff…I
mean we can order in. Private practice is very simple. You want something, it comes in 2 days. You
Page 7 of 14
don’t need a process of [procurement]. So it’s actually extremely minimal and efficient [when orders
are placed].” (GP15)
“I have, over the years, kind of narrowed down my
antibiotics to those that I most likely would use…I
think I have almost never written a prescription outside for antibiotics.” (GP24)
“Before I start work anywhere, I will look at the
stocks and see whether my favourite medicines are
available or not. If they are not, I will ask for the
medications to be brought in.” (GP27)
Therefore, providing that drug formulary management
was administrated such that it did not impinge on patient
consultation times, there were benefits described by having control over this process. Though on the whole, outsourcing such processes were seen to help keep valuable
patient consult time where it was most needed - with
patients rather than procurement order sheets.
Objective II: Exploring mechanisms that give rise
to appropriate antibiotic prescribing across primary care
settings
Mechanisms influencing practice
High patient loads, lack of continuity in care and the
importance of trust building Trust between patients and
doctors, and ability to leverage this to adequately communicate whether there was a real need for antibiotics
was viewed as central to appropriate prescribing. Relatedly, high patient loads were said to impede this and the
process of shared decision-making. The lack of time, and
likelihood of being able to see the same doctor and take
time to counsel were traded-off to deal with the volume
of patients:
“Yeah, that…does play a factor. So let’s say if there
[are] time constraints, sometimes I don’t have the
luxury of time to explain in detail…So definitely…it
will lead to more antibiotic prescription[s]…because
we don’t have the time to explain in detail…so we
end[ed] up giving more to those who insist[ed].” (P6)
“On days whereby I am superbly busy…sometimes
you have to see like 80, 90 patients in a day, and if
the patients request for antibiotics and you don’t
have time…I guess if it’s so clear-cut that he needs it,
I would just prescribe.” (GP13)
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(2021) 22:205
In contrast, due to greater autonomy to control their
patient flow, GPs in particular talked about ensuring that
they spent sufficient consultation time to counsel each
patient:
“Another thing that we build in our practice [is that]
we give time [to our patients]…[for] every patient,
we schedule 10 minutes. So now we are quite happy
that we have an appointment system.” (GP23)
Page 8 of 14
patient[s] who say “Because you don’t give me antibiotics, you’re a lousy doctor, I’m not seeing you
anymore, I go elsewhere”. So I actually do not have
this problem…I would explain to the patients. And
I do ask them, I don’t think you need antibiotics
right now. You may later but you do not know. But
if you can, it’s always better to avoid it, are you ok
with it?...So usually [we are] able to come to a consensus.” (GP13)
In certain settings, discontinuity of attending doctors
with regular patients, for example the registration system
randomly assigning patients to an attending doctor, made
trust building difficult. In addition, regular rotation of
doctors between the different care sections, such as acute
walk-in, chronic care and paediatric sections impeded
the doctors from delivering continuity of care to regular
patients:
“My patients are very well-selected…because over
the years, you sort of train[ed] them not to use
antibiotics…because we do have a reputation that
we don’t give antibiotics, so generally after a while,
all those in the neighbourhood [who] wants antibiotic…will not turn up in our clinic…it’s the training.” (GP14)
“I mean usually [in the] polyclinic, there are a lot
of patients. So our rapport is not as easy, I think.
And we don’t usually see our own patients back. So
maybe it’s not as easy for them to trust us.” (P4)
In summary, practices that were able to emphasize
trust building, manageable patient loads and continuity of care were able to catalyse optimal antibiotic prescribing practices.
This experience was different for many GPs. Due to the
organisation’s valuing of autonomy and flexibility in shaping their practices in accordance to their personal values,
solo and small group GP doctors expressed that they
were able to structure their model of care to be conducive
for the establishment of a trusting patient-doctor relationship. This happened, in part, through patient referrals as a basis for building a client base, and easy-to-use
appointment systems ensuring continuity of care:
“We have been around for a while and also our
model of care is very different. So we go by appointment system. We do very little walk-in and a lot of
people know us. They are referred by friends and
all that. So after a while, the trust level is very high.”
(GP14)
“We will keep out these doctor hoppers, because we
have an appointment system... So those patients
that are used to seeing us, they will book online and
they have to pay five dollars to actually see us…once
patients know that we practice in this way, and is
very clinically based…they are very happy to come
and…they are willing to pay.” (GP23)
Overall, it was emphasized that with continuity of
care, which was enabled in more mature practices, came
greater ease and opportunity to counsel patients on prudent antibiotics use:
“I do have a very matured practice, so I do understand where you’re coming from, whereby some
Values and alignment of organisational culture with
appropriate antibiotic prescribing In addition, it was
notable that doctors who were able to align their personal
values for patient-centred care over “service” provision
with organisational culture, and vice versa, optimised
appropriate antibiotic prescribing. Such alignment was
often complex and multi-factorial. For example, while
solo and small group GP doctors bore more responsibilities to ensure business sustainability of their clinics, their
clinics were also described as able to achieve greater individual autonomy and flexibility in aligning their practices
in accordance to the personal values of their doctors.
These GP doctors could often strike a balance between
business concerns and freedom to practice their personal
values on care delivery, and this included decisions on
prudent use of antibiotics:
“We charge very high for consultations…I do not
need to sell antibiotics to earn money. I do not
need to sell medicine to earn money…I can talk
the whole half an hour with you and I charge 100
bucks. I don’t even need to…sell you anything. So
that is the beauty of it. I am not pressured to give
you antibiotics or for that matter, any medicine.”
(GP14)
“In our practice we have a lot of control because
basically we run our own practice…so basically
we’re not obliged to follow what the patient wants.
We are quite happy to lose the patient because we
Guo et al. BMC Fam Pract
(2021) 22:205
are so busy anyway. So we are not obliged to give
whatever the patient requests for.” (GP23)
Nonetheless, a couple of GP doctors shared how this
context could enable other scenarios, depending on
what was being prioritised and by whom. Sometimes
the need to sustain business and the related value to
optimise revenue could drive GP doctors towards
prescribing antibiotics in order to increase earnings,
e.g. prescribing either unnecessary or expensive nongeneric brands to increase profit:
“The principle behind every GP’s prescribing practice is different. I know that there are some more
profit-driven GPs, whom I think would give antibiotics because of higher profit margins.” (GP28)
“I am sure there is financial pressure for doctors
to add antibiotics…they may not disclose this.
Because who will say that, “Oh I give medicine
because it’s additional revenue but not because it’s
indicated?” (GP29)
Alignment of organisational and personal values that
prioritise healthcare provision overriding businesscentred models was clearly positioned as pathway to
appropriate antibiotic prescribing outcomes.
Emphasis on liaison with patients and shared decision-making That said, an important interim outcome was also identified. Successful patient liaison was
expressed as resulting from valuing and enabling shared
decision-making:
“It is always important in family medicine that we
establish a very close and long relationship with
your patient. And a correct relationship is always
a partnership. So when you have established a
partnership, that means there is a great degree of
trust and communication channels are naturally
opened. So once that happens, it is very easy to
be able to come up with a management plan that
both agree on. And usually the patients would listen to the doctor.” (GP13)
“A good patient-doctor rapport will solve a lot of
issues. One is trust, two is the willingness to work
out problems together and solve it versus one who
have no rapport where you are just there to ‘service’ the patients…[The patients] will treat you like
a technician…but then again, rapport takes two
hands to clap. So it is not just willing doctors but
also the patient has to be willing to establish that.
So overall, if there is cooperation, a lot of things
Page 9 of 14
tend to work out better, of course.” (GP30)
The emphasis on cooperative patient liaison was positioned as driven by both organisational culture creating opportunity for this and a personal commitment for
such exchanges which with the ultimate goal of allowing clinical judgment to prevail. Shared decision-making
emerged as a clear interim outcome to enabling those
related to appropriate prescribing.
Using data to monitor and evaluate appropriate antibiotic prescribing behaviours and related outcomes While
audits were thought to be useful to improve antibiotic prescribing habits, primary care doctors expressed that more
could be done. In the polyclinics, regular audits were at
times described as part of the organisational process for
monitoring antibiotic prescribing, although these procedures were not often notable in practice:
“So for us in the polyclinic…we do have check and
balances on how we order our antibiotics.” (P19)
“I think polyclinics do audits on the antibiotics prescribing right? I think, I’m not that sure.” (P3)
Similarly, in GP clinics, while random audits by the
Ministry of Health were said to take place, antibiotic prescribing volumes were not queried during this process
meaning that little external pressure to reduce antibiotic
prescribing was being routinely applied and tracked:
“We have audits…I mean MOH does come down
and audit our medical records…They do look
through medical records but they don’t go and count
how many antibiotics you have used.” (GP30)
To enable successful antibiotic stewardship in the primary care setting, applied research needs to be conducted
to provide a transparent platform for the formal use of
monitoring and evaluation data to inform evidence-based
guidelines:
“There should be an audit in every healthcare system whether it is a polyclinic, or a GP…Because we
cannot be in every consult room every single time,
so the only way to do is…to retrospectively audit the
amount of cases where doctors are in a controlled
environment like ours. In the polyclinic, it is very
easy to do. I don’t know how feasible it is to do in
the private practice but there should be some form of
monitoring of this…you want to see whether in those
situations, it was warranted for; and then the other
thing is you can get patient’s feedback. I mean if
there are more studies or surveys tracking patients in
the private and polyclinic healthcare then we have a
Guo et al. BMC Fam Pract
(2021) 22:205
better idea of whether [antibiotic use] is really effective…or not in our population.” (P20)
By having better transparency and agreed indicators
that capture outcomes such as the core practice of shared
decision-making known to influence appropriate prescribing, improvement on antibiotic prescribing in the
primary care setting can be meaningfully driven forward.
Objectives III: Building a conceptual model to inform
planning and related strategies for targeting primary care
service improvement for appropriate antibiotic prescribing
Taking a bird’s eye view, the operational models of primary care were tied to financing and ability to prioritise a
more patient-centric approach reflected in deeply-rooted
organisational structures and cultures that inform primary care provision. Primary care settings in the current
study were demonstrably very heterogeneous environments, where doctors could be inspired to play either
the role of service or healthcare providers. Thus, primary care doctors were observed to be driven in part by
operational models. Those with stable government funding and centralized pharmacy for drug procurement and
dispensing in publicly-funded polyclinics in Singapore,
emphasized the importance of clinical consultations,
keeping the focus on the patient as opposed to additional
responsibilities.
Models which can avoid having to bear with the consequences of not being able to build a mature practice/
Fig. 1 VALUE model for improving appropriate antibiotic prescribing
Page 10 of 14
returning patient base, e.g. due to TPAs or MCOs, or
be distracted from applying consistent antibiotic guidance and stewardship, or clear messages and consultation
given to patients, will better allow inappropriate antibiotic prescribing to be avoided. In view of the above findings and known literature, we have proposed the VALUE
model to conceptualise the key components of appropriate antibiotic prescribing and stewardship in the primary
care (Fig. 1).
Across contexts, the following mechanisms were seen
to leverage appropriate antibiotic prescribing, starting
with encouraging holding Values consistent with prioritising AMR reduction, and Aligning organisational
culture to these, for instance by leveraging standardised
guidelines and interpersonal intervention tools. Such
interventions should account for the wider systemic
constraints experienced in publicly funded, high patient
turnover institutions, or private clinics with transactional
models of care. Ultimately, a focus on Liaison between
patient and doctor will drive better antibiotic prescribing
outcomes.
For instance, building in adequate consultation time
and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable
shared decision-making. Lastly, Use of monitoring data
to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change. Exemplar
Guo et al. BMC Fam Pract
(2021) 22:205
Page 11 of 14
Table 2 Exemplar organisational and behavioural change strategies corresponding to the VALUE model for improving appropriate
antibiotic prescribing
Mechanisms
Organisational and behavioural change strategies
Values and Aligning
Message consistency:
• Standardised guidelines and agreed protocols in use across primary care sectors
Alignment between organisation and doctors:
• Organisational-led email circulars leveraging these, sent in the name of established and valued institutional bodies
• Reminders of the risks and impact of AMR in primary care practice, while also promote the need to make time or build in
micro-strategies, especially in clinics with high patient load, for discussion on appropriate antibiotic prescribing, and the risks of
inappropriate prescribing
• Promoting shared decision-making through incorporation into clinics’ mission statements and inculcating such values to
newly employed doctors during orientation, and utilise trigger videos which use patients’ experiences as discussion points,
especially in larger clinics
• Informal training to promote role modelling of appropriate patient counselling using mentorship programming for junior
doctors
Alignment between doctors and patients:
• Organisational promotion of continuity of care, encouraging patient ‘loyalty’, and delivering care through a fixed team of
doctors such that understanding of antibiotic prescribing decisions can be shared and sustained over time
Liaison with patients Communication aids:
• To improve dealing with high patient loads through fast turnover communication tools (micro-strategies) such as decision
aids with consistent messaging
• Gamification strategies to empower public to make shared decision-making through gaming interventions aimed at engaging both patients (playing the game) and doctors in discussion about the takeaway messages from the game together
Use of monitorAudit and feedback:
ing data to track and
• Use of routine monitoring data for audit and feedback on prescribing behaviours at the individual doctor level (closed feedEvaluate
back) and to benchmark organisations against one another (open feedback) shared at regular meetings or in email circulars
• Distil research findings on AMR and inappropriate antibiotic prescribing into short, accessible briefs posted and disseminated
in clinical settings (knowledge management practices)
Developing meaningful indicators
• Incorporate shared decision-making as a key indicator measuring appropriate antibiotic prescribing
• Measure and evolve elements of the VALUE model based on empirical evidence
intervention types and related change strategies aligning to the VALUE model are presented in Table 2. The
VALUE model is recommended to guide intervention
planning and it is not intended to be static reflection of
optimal antibiotic prescribing, but as a summary of findings, reflecting a description of what is currently known
[43]. It is proposed as an implementation too, components of which can be tested empirically and updated
accordingly.
Discussion
Our study has identified themes that lend critical
insights on antibiotic prescribing by primary care doctors and shed light on the underlying mechanisms driving antibiotic prescribing across primary care settings.
Themes relating to the operational models used in clinics,
financial considerations, drug formulary management,
patient load, and a trusting patient-doctor relationship,
were demonstrated as central to appropriate antibiotic
prescribing.
The importance of such elements have been highlighted elsewhere [7]. For example, both the importance of established and up-to-date national antibiotics
guidelines [31] and that of valuing patient-centred care
have been demonstrated to contribute to reducing
antibiotic prescribing [8]. In addition, the role of the
interpersonal level is known to affect antibiotic prescribing, in particular when doctors do not take time
to accurately assess patients’ expectations of antibiotic
prescribing [44]. Further to which, it is notable that
being given antibiotics does not always correlate with
satisfaction of the clinical encounter anyway [44, 45].
As for use of monitoring and evaluation data, this has
long been recommended for practice improvement by
the US CDC guidelines and recently, by Arieti et al. [5,
46].
Nevertheless, there remains a powerful need to ‘connect the dots’ by providing a realist [42], applied and
evidence-based conceptual model that maps the social
ecology and potential areas for intervention to improve
appropriate antibiotic prescribing. A recent study conducted in Sweden found that doctors in private practice
were 6% more likely to prescribe antibiotics as compared
to doctors in public practice [47], with a similar trend
observed from another cross-sectional study conducted
in Malaysia [48]. Instead of dissecting and addressing the
issue of inappropriate antibiotic prescribing by different primary care funding structures, the current study
offers a comprehensive exploration across private and
public sectors. Outlining not simply the elements driving
Guo et al. BMC Fam Pract
(2021) 22:205
appropriate and inappropriate practice but how these
interrelate.
Collective and coordinated antibiotic stewardship
efforts in primary care (both public and private practice) would improve appropriate antibiotic prescribing
in primary care clinics at a national level [49]. Our study
highlighted opportunities for national interventions
to improve antibiotic prescribing in primary care, particularly in private practices which manages the bulk of
primary care acute conditions in Singapore. It has been
observed that primary care doctors desired national
guidelines on antibiotic prescribing to standardise best
practices [31]. Guidelines based on local epidemiological
data and antibiotic susceptibility patterns would be crucial for supporting primary care antibiotic stewardship
and overcoming variations in context- and value-based
prescribing practices. Clinical decision support tools can
also play a role in guiding primary care doctors in evidence-based antibiotic prescribing decisions by developing risk prediction models to guide antibiotic prescribing
decisions, as demonstrated in a local outpatient emergency department setting [50].
The primary strength of the current study lies in the
construction of the VALUE model and its transferability
to other primary care contexts. The conceptual model
can be cohesively applied to evaluate each level of the
ecosystem to address inappropriate antibiotic prescribing. For instance, the VALUE model can be used to assess
organisational culture, personal motivations, to critique
and overhaul operations while accounting for funding
structures, and helping to refocus where and how time
is spent when battling high patient loads. The study
also undertook one-on-one semi-structured interviews
with doctors in primary care settings which allowed an
in-depth exploration of antibiotic prescribing practices
among this unique group of healthcare workers. Moreover, the researchers were careful in building rapport with
study participants, which enabled them to be forthcoming and open in sharing their practices and experiences.
Additionally, the use of a maximum variation purposive
sampling strategy enabled the study to elicit the broadest
range of experiences within our sample of interest. The
study also utilised principles of data saturation and intercoder agreement to ensure the rigour and trustworthiness of the study findings.
We acknowledge that our data is however limited
to a context and primary care practice that were preCOVID-19. Rapid shifts may be on their way to influence
the ecology of acute respiratory tract infections in the last
12 months.
Page 12 of 14
Conclusion
Multiple factors influence antibiotic prescribing in primary care. The ability to make shared decisions with
patients on antibiotic prescribing is dependent on the
balance between managing patient load, continuity
of care or ‘loyalty’ of returning patients, and building
trusting patient-doctor relationships. Systemic constraints and factors hindering interpersonal interactions with patients can be overcome by aligning
values on reducing AMR and promoting patient liaison
through consistent messaging and tailored intervention
tools improving patient liaison. Antibiotic stewardship
interventions will be rendered more effective if monitoring and evaluation data are used to capture indicators that are known to effect change, and these shared
meaningfully and transparently to both inform audit
and feedback strategies and to updated theory and evidence base of intervention initiatives.
Abbreviations
AMR: Antimicrobial resistance; CDC: Centers for Disease Control and Prevention; GP: General practitioner; MCO: Managed care organisations; TPA: Thirdparty administrator.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12875-021-01556-z.
Additional file 1. Topic Guide: Understanding antibiotic prescribing
through a multilevel approach.
Acknowledgements
The study team would like to thank all the primary care doctors who participated in our study, polyclinic heads and administrative staff for their kind
permission to allow us to conduct the study in their clinics, and Nur Azzriyani
Binte Roslan for assisting in the facilitation of the interviews.
Authors’ contributions
AC conceived the study, provided overall direction and planning for the
study, and critically revised the manuscript. HG designed the interview guide,
arranged and conducted the interviews, coded and analysed the data, and
drafted the manuscript. ZH provided guidance on data analysis and critically
revised the manuscript contributing to the refining of the thematic analysis
and the formulation of the VALUE model. VWKL, MS and WET provided guidance on the design of the interview guide, assisted the study team in inviting
primary care doctors to participate in the study, and provided inputs for the
manuscript. MABI assisted in the coding and analysis of the data, and provided
inputs for the manuscript. All authors read and approved the final manuscript.
Funding
This work was supported by the National Medical Research Council Singapore,
Health Services Research Grant (NMRC/HSRG/0083/2017).
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Guo et al. BMC Fam Pract
(2021) 22:205
Declarations
Ethics approval and consent to participate
Ethical approval for this study was obtained (reference number: 2017/01179)
and all methods in this study were performed in accordance with the relevant
guidelines and regulations from the National Healthcare Group Domain Specific Review Board, Singapore. All participants had provided informed consent
to participate in the study.
Consent for publication
Not applicable.
Competing interests
All the authors declare no competing interests.
Author details
1
Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore. 2 Saw Swee
Hock School of Public Health, National University of Singapore and National
University Health Systems, Singapore, Singapore. 3 Division of Family Medicine,
Yong Loo Lin School of Medicine, National University of Singapore, Singapore,
Singapore. 4 National University Polyclinics, Singapore, Singapore. 5 School
of Social and Health Sciences, James Cook University, Singapore Campus,
Singapore, Singapore. 6 National Healthcare Group Polyclinics, Singapore,
Singapore. 7 Lee Kong Chian School of Medicine, Nanyang Technological
University, Singapore, Singapore.
Received: 23 February 2021 Accepted: 7 October 2021
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