scholarly journals 2071. A Survey of Antibiotic Prescribing Practices Among Adult Primary Care Physicians in Idaho

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S698-S698
Author(s):  
Anubhav Kanwar ◽  
Susan Heppler ◽  
Karl Madaras-Kelly ◽  
Martha Jaworski ◽  
Curtis Donskey
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Primary Care Physicians ◽  
Healthcare Facility ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Prescription Data ◽  
Prescribing Practices ◽  
Diagnostic Uncertainty ◽  
Test Ordering

Abstract Background Prescribing an antibiotic is a complex process involving an interplay of prescriber’s knowledge, diagnostic acumen and patient factors. Understanding the prescriber rationale is key to provide feedback which might improve appropriateness of antibiotic prescribing. Currently, there are limited data on prescribing and test ordering practices among primary care physicians. Methods We surveyed primary care physicians taking care of adults (age 18 years and above). Physicians were contacted through the Idaho State Medical Board by a one-time email containing the survey link. The survey consisted of 25 questions under 2 major themes of diagnostic and antimicrobial stewardship (AS). It assessed physicians’ practice setting, ordering of diagnostic tests and antibiotics for common infections, delivery of patient education regarding antibiotics, availability of antibiogram and antimicrobial stewardship services, and assessment of penicillin allergy. Two infectious diseases physicians independently reviewed the results for appropriateness of testing and antibiotic prescribing per IDSA guidelines. Results Of 929 physicians surveyed, 157 (17%) responded. Of the respondents, 95 (61%) were male, the mean age was 50 years, and 72% worked in outpatient settings and were family medicine specialists. Only 55% of physicians reported having an AS program at their healthcare facility. Test-of-cure for C. difficile infection (24%) and UTI (13%) and use of superficial culture data to guide the treatment of osteomyelitis (27%) were the most common reasons for inappropriate testing. Longer than recommended duration, antibiotic combinations with overlap of spectrum, and guideline-discordant indications for prescribing antibiotics were the main reasons for inappropriate antibiotic use. The main factors influencing the decision to prescribe an antibiotic were diagnostic uncertainty (42%), being unsure of patient follow-up (23%) and cost of testing (21%). Conclusion The survey results highlight the need for prescriber education for decreasing inappropriate test ordering and antibiotic prescribing. Additional studies involving a review of patient records, lab and prescription data are needed to confirm these practices. Disclosures All authors: No reported disclosures.

scholarly journals Knowledge, Attitudes and Intentions to Prescribe Antibiotics: A Structural Equation Modeling Study of Primary Care Institutions in Hubei, China

2019 ◽  
Vol 16 (13) ◽  
pp. 2385 ◽  
Author(s):  
Chenxi Liu ◽  
Chaojie Liu ◽  
Dan Wang ◽  
Xinping Zhang
Keyword(s):  
Primary Care ◽  
Antibiotic Resistance ◽  
Primary Care Physicians ◽  
Structural Equation ◽  
Antibiotic Use ◽  
Equation Modeling ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Motivation To Change ◽  
Attitudes And Practices

The aim of this paper is to measure the knowledge and attitudes of primary care physicians toward antibiotic prescriptions and their impacts on antibiotic prescribing. A questionnaire survey was conducted on 625 physicians from 67 primary care facilities in Hubei, China. Structural equation modelling (SEM) was applied to test the theoretical framework derived from the Knowledge, Attitudes, and Practices (KAP) theory. Physicians’ knowledge, five sub-types of attitudes, and three sub-types of behavioral intentions towards antibiotic use were measured. Physicians had limited knowledge about antibiotic prescriptions (average 54.55% correct answers to 11 questions). Although they were generally concerned about antibiotic resistance (mean = 1.28, SD = 0.43), and were reluctant to be submissive to pressures from consumer demands for antibiotics (mean = 1.29, SD = 0.65) and the requirements of defensive practice (mean = 1.11, SD = 0.63), there was a lack of motivation to change prescribing practices (mean = −0.29, SD = 0.70) and strong agreement that other stakeholders should take the responsibility (mean = −1.15, SD = 0.45). The SEM results showed that poor knowledge, unawareness of antibiotic resistance, and limited motivation to change contributed to physicians’ high antibiotics prescriptions (p < 0.001). To curb antibiotic over-prescriptions, improving knowledge itself is not enough. The lack of motivation of physicians to change needs to be addressed through a systematic approach.

scholarly journals Coping With Diagnostic Uncertainty in Antibiotic Prescribing: A Latent Class Study of Primary Care Physicians in Hubei China

2021 ◽  
Vol 9 ◽  
Author(s):  
Chaojie Liu ◽  
Dan Wang ◽  
Lixia Duan ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Broad Spectrum ◽  
Primary Care Physicians ◽  
Latent Class ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Behavioral Patterns ◽  
Diagnostic Uncertainty ◽  
Logistic Regression Models ◽  
Broad Spectrum Antibiotics

Background: Misuse of antibiotics is prevalent worldwide and primary care is a major contributor. Although a clear diagnosis is fundamental for rational antibiotic use, primary care physicians often struggle with diagnostic uncertainty. However, we know little about how physicians cope with this situation and its association with antibiotic prescribing.Methods: A total of 583 primary care physicians were surveyed using the Dealing with Uncertainty Questionnaire. Their prescriptions (n = 949,181) over the year 2018 were retrieved retrospectively. Two categories of behavioral patterns of participants were identified based on latent class analyses (high vs. low openness and collaborativeness) in responding to diagnostic uncertainty. Multi-level logistic regression models were established to determine the associations between these behavioral patterns and antibiotic prescribing (overall and broad-spectrum antibiotics) for illness without an indication for antibiotics and those with a conditional indication for antibiotics, respectively, after adjustment for variations of patient (level one) and physician (level two) characteristics.Results: Most physicians reported open communications with their patients (80.96%), collected further information (85.08%), and referred patients to specialists (68.95%) in dealing with diagnostic uncertainly. More than half (56.95%) sought help from colleagues. Less than 20% acted on intuition or adopted a “wait and see” strategy. About 40% participants (n = 238) were classified into the group of low openness and collaborativeness in coping with diagnostic uncertainty. They were more likely to prescribe antibiotics for the recorded illness without an indication for antibiotics (AOR = 1.013 for all antibiotics, p = 0.024; AOR = 1.047 for broad-spectrum antibiotics, p &lt; 0.001), as well as for the recorded illness with a conditional indication for antibiotics (AOR = 1.226 for all antibiotic, p &lt; 0.001; AOR = 1.257 for broad-spectrum antibiotics, p &lt; 0.001).Conclusion: Low tolerance with diagnostic uncertainty is evident in primary care. Inappropriate and over antibiotic prescribing is shaped by physicians' coping methods of diagnostic uncertainty. Physicians' openness and collaborativeness in responding to diagnostic uncertainty is associated with lower antibiotic prescribing in primary care. Interventions targeting on better management of diagnostic uncertainty may offer a promising approach in reducing antibiotic use in primary care.

scholarly journals Identifying antibiotic prescribing patterns through multi-level latent profile analyses: a cross-sectional survey of primary care physicians in Hubei of China

2020 ◽  
Author(s):  
Dan Wang ◽  
Chaojie Liu ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Broad Spectrum ◽  
Primary Care Physicians ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Latent Profile Analyses ◽  
Broad Spectrum Antibiotics

Abstract Background Overuse of antibiotics significantly fuels the development of AMR, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n=501,072) made by the participants from 1 January to 31 March 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO “Watch and Reserve” list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results On average, each primary care physician issued 909 (ranging from 100 to 11941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD=17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD=15.83%) contained broad-spectrum antibiotics; 71.92% (SD=21.42%) contained parenteral administered antibiotics; 23.52% (SD=19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD=20.98%) contained antibiotics listed in the WHO “Watch and Reserve” list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

scholarly journals Perceptions, Current Practices and Interventions of Community Pharmacists Regarding Antimicrobial Stewardship: A Qualitative Study in France

2021 ◽  
Author(s):  
Claire Durand ◽  
Aude Chappuis ◽  
Eric Douriez ◽  
Frédérique Poulain ◽  
Raheelah Ahmad ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Antimicrobial Resistance ◽  
Community Health ◽  
Antimicrobial Stewardship ◽  
Thematic Analysis ◽  
Community Pharmacists ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Community Health Care

Abstract Background: Community health care accounts for the vast majority of antibiotic use in Europe. Given the threat of antimicrobial resistance (AMR), there is an urgent need to develop new antimicrobial stewardship (AMS) interventions in primary care that could involve different health care providers including community pharmacists. This study aimed to explore the perceptions, currents practices and interventions of community pharmacists regarding antimicrobial stewardship.Methods: Semi-structured qualitative interviews were conducted with community pharmacists in France. Participants were recruited through a professional organization of community pharmacists combined with a snowballing technique. Interviews were audio recorded, transcribed and analyzed using thematic analysis. The Consolidated Framework for Implementation Research was used while developing the interview guide and carrying out thematic analysis.Results: Sixteen community pharmacists participated. All the respondents had good awareness about antimicrobial resistance and believed community pharmacists had an important role in tackling AMR. Some barriers to community pharmacists’ participation in AMS were identified such as difficult interactions with prescribers, lack of time and lack of access to patient medical records and diagnosis. Increased patient education, audits and feedback of antibiotic prescribing, increased point-of-care testing and delayed prescribing were interventions suggested by the pharmacists to improve antibiotic use in primary care. Strategies cited by participants to facilitate the implementation of such interventions are increased pharmacist-general practitioner collaboration, specialized training, clinical decision support tools as well as financial incentives. Conclusions: This study suggests that community pharmacists could play a greater role in infection management and AMS interventions. Further interprofessional collaboration is needed to optimize antibiotic prescribing and utilization in community health care.

scholarly journals Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection

2015 ◽  
Vol 2 (3) ◽  
Author(s):  
Raymund Dantes ◽  
Yi Mu ◽  
Lauri A. Hicks ◽  
Jessica Cohen ◽  
Wendy Bamberg ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Healthcare Providers ◽  
Population Level ◽  
Healthcare Facility ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Oral Antibiotic ◽  
Prescribing Practices ◽  
Active Population ◽  
Prescription Rates

Abstract Background.  Antibiotic use predisposes patients to Clostridium difficile infections (CDI), and approximately 32% of these infections are community-associated (CA) CDI. The population-level impact of antibiotic use on adult CA-CDI rates is not well described. Methods.  We used 2011 active population- and laboratory-based surveillance data from 9 US geographic locations to identify adult CA-CDI cases, defined as C difficile-positive stool specimens (by toxin or molecular assay) collected from outpatients or from patients ≤3 days after hospital admission. All patients were surveillance area residents and aged ≥20 years with no positive test ≤8 weeks prior and no overnight stay in a healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions dispensed in 2010 were obtained from the IMS Health Xponent database. Regression models examined the association between outpatient antibiotic prescribing and adult CA-CDI rates. Methods.  Healthcare providers prescribed 5.2 million courses of antibiotics among adults in the surveillance population in 2010, for an average of 0.73 per person. Across surveillance sites, antibiotic prescription rates (0.50–0.88 prescriptions per capita) and unadjusted CA-CDI rates (40.7–139.3 cases per 100 000 persons) varied. In regression modeling, reducing antibiotic prescribing rates by 10% among persons ≥20 years old was associated with a 17% (95% confidence interval, 6.0%–26.3%; P = .032) decrease in CA-CDI rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions in prescribing penicillins and amoxicillin/clavulanic acid were associated with the greatest decreases in CA-CDI rates. Conclusions and Relevance.  Community-associated CDI prevention should include reducing unnecessary outpatient antibiotic use. A modest reduction of 10% in outpatient antibiotic prescribing can have a disproportionate impact on reducing CA-CDI rates.

scholarly journals Management of Common Infections in German Primary Care: A Cross-Sectional Survey of Knowledge and Confidence among General Practitioners and Outpatient Pediatricians

Antibiotics ◽  
2021 ◽  
Vol 10 (9) ◽  
pp. 1131
Author(s):  
Peter Konstantin Kurotschka ◽  
Elena Tiedemann ◽  
Dominik Wolf ◽  
Nicola Thier ◽  
Johannes Forster ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practitioners ◽  
Primary Care Physicians ◽  
Antibiotic Use ◽  
Educational Interventions ◽  
Treatment Decisions ◽  
Antimicrobial Treatment ◽  
Antibiotic Prescribing ◽  
Cross Sectional Survey ◽  
Cross Sectional

Outpatient antibiotic use is closely related to antimicrobial resistance and in Germany, almost 70% of antibiotic prescriptions in human health are issued by primary care physicians (PCPs). The aim of this study was to explore PCPs, namely General Practitioners’ (GPs) and outpatient pediatricians’ (PDs) knowledge of guideline recommendations on rational antimicrobial treatment, the determinants of confidence in treatment decisions and the perceived need for training in this topic in a large sample of PCPs from southern Germany. Out of 3753 reachable PCPs, 1311 completed the survey (overall response rate = 34.9%). Knowledge of guideline recommendations and perceived confidence in making treatment decisions were high in both GPs and PDs. The two highest rated influencing factors on prescribing decisions were reported to be guideline recommendations and own clinical experiences, hence patients’ demands and expectations were judged as not influencing treatment decisions. The majority of physicians declared to have attended at least one specific training course on antibiotic use, yet almost all the participating PCPs declared to need more training on this topic. More studies are needed to explore how consultation-related and context-specific factors could influence antibiotic prescriptions in general and pediatric primary care in Germany beyond knowledge. Moreover, efforts should be undertaken to explore the training needs of PCPs in Germany, as this would serve the development of evidence-based educational interventions targeted to the improvement of antibiotic prescribing decisions rather than being focused solely on knowledge of guidelines.

scholarly journals A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Warren McIsaac ◽  
Sahana Kukan ◽  
Ella Huszti ◽  
Leah Szadkowski ◽  
Braden O’Neill ◽  
...  
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Care Provider ◽  
Primary Care Provider ◽  
Antibiotic Use ◽  
Primary Care Providers ◽  
Audit And Feedback ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Tract Infections

Abstract Background More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. Methods Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. Results There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). Conclusions A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. Trial registration clinicaltrials.gov (NCT03517215).

Stewardship in the primary care and long-term care settings

2016 ◽  
Author(s):  
Naomi Fleming
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Long Term Care ◽  
Diagnostic Tools ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Term Care ◽  
Care Facilities ◽  
Tract Infections

This chapter focuses on stewardship in the primary care and long-term care settings. Antibiotic prescribing in the community accounts for 80% total antibiotic prescribing and approximately 75% of this is for acute respiratory tract infections, many of which are viral. There is also significant variation in prescribing practices that is not explained by differences in presenting patients. These factors suggest that antimicrobial stewardship programmes are necessary. This chapter identifies the components of stewardship that have been successful in influencing antibiotic prescribing in primary care and shares local experiences with practical examples. The lack of UK evidence about antimicrobial stewardship in long-term care facilities is discussed, along with successful interventions from overseas. Challenges within these settings are highlighted, including patient demand, lack of access to microbiological and diagnostic tools, competing targets, time pressures, and clinical uncertainty.

scholarly journals Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians

2020 ◽  
Vol 11 ◽  
Author(s):  
Dan Wang ◽  
Chaojie Liu ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Broad Spectrum ◽  
Primary Care Physicians ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Latent Profile Analyses ◽  
Broad Spectrum Antibiotics

Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants.Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO “Watch and Reserve” list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns.Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO “Watch and Reserve” list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers.Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

scholarly journals Practice-Level Association between Antibiotic Prescribing and Resistance: An Observational Study in Primary Care

Antibiotics ◽  
2020 ◽  
Vol 9 (8) ◽  
pp. 470
Author(s):  
Dylan Batenburg ◽  
Theo Verheij ◽  
Annemarie van’t Veen ◽  
Alike van der Velden
Keyword(s):  
Primary Care ◽  
Urine Culture ◽  
Antibiotic Use ◽  
Urine Samples ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Susceptibility Data ◽  
Country Level ◽  
Practice Population ◽  
Primary Care Practices

A direct relation between antibiotic use and resistance has been shown at country level. We aim to investigate the association between antibiotic prescribing for patients from individual Dutch primary care practices and antibiotic resistance of bacterial isolates from routinely submitted urine samples from their patient populations. Practices’ antibiotic prescribing data were obtained from the Julius Network and related to numbers of registered patients. Practices were classified as low-, middle- or high-prescribers and from each group size-matching practices were chosen. Culture and susceptibility data from submitted urine samples were obtained from the microbiology laboratory. Percentages of resistant isolates, and resistant isolates per 1000 registered patients per year (population resistance) were calculated and compared between the groups. The percentages of resistant Escherichia coli varied considerably between individual practices, but the three prescribing groups’ means were very similar. However, as the higher-prescribing practices requested more urine cultures per 1000 registered patients, population resistance was markedly higher in the higher-prescribing groups. This study showed that the highly variable resistance percentages for individual practices were unrelated to antibiotic prescribing levels. However, population resistance (resistant strains per practice population) was related to antibiotic prescribing levels, which was shown to coincide with numbers of urine culture requests. Whether more urine culture requests in the higher-prescribing groups were related to treatment failures, more complex patient populations, or to general practitioners’ testing behaviour needs further investigation.

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