Gemeinwohl versus wohl des einzelnen "... habe ich noch nie drüber nachgedacht" Qualitative ergebnisse einer mixed-methods-studie zur verordnung von antibiotika bei harnwegsinfekten

Background: Individual therapeutic decisions are a contentious point in the context of medical quality work and guideline implementation. In the course of a mixed-methods study on antibiotic prescribing for uncomplicated urinary tract infections (UTI) a sustained change in prescribing could be demonstrated. The complex intervention comprised a self-conducted practice test of trimethoprim (TMP). The aim of the qualitative part was to evaluate the attitudes of the family physicians (FP) towards guidelines, the making of their therapeutic decisions and the effect of the practice test on their opinions. Methods: The study was conducted in a before-after design with qualitative elements. The qualitative part consisted of focus-groups and single interviews, semi-structured by discussion guides that had been developed by an interdisciplinary team of researchers. Evaluation of the transcribed discussions and interviews was done according to the method of qualitative content analysis by Mayring. Results: Guidelines first were widely perceived as out of touch with reality and rejected as a whole. Antibiotic choice was seen as reflex like, mainly driven by former hospital training. The interest of the single patient was clearly paramount to the common good of preventing antibiotic resistance. Concerning this task the FPs missed any solidarity within the health care system. In the three months practice test TMP had a success rate of 94%. This strongly changed opinions towards the use of TMP. Peer group opinion, self-reflection and personal experience in the practice test were predominantly seen as the change inducing agents. Conclusions: The choice between broad- and small-spectrum antibiotics mirrors the conflict of the FP's responsibility for individual and collective at the same time. The good of the individual patient stood clearly in front of the public health goal of avoiding bacterial resistance. Prescribing of broad-spectrum antibiotics appears thus to be logical and reasonable from this perspective. The practice test and ownership of the process of knowledge acquisition convinced the participants that with TMP both goals are achievable. Possibly it is the public-health perspective of guidelines that sometimes blocks their translation into practice.