The influence of social relationships on clinician interpretation of performance data in an outpatient antibiotic stewardship intervention.

backgroundAudit and feedback (A&F) of performance is a common strategy to improve antibiotic prescribing, yet it is variably successful. Little is known about the impact of social relationships on the implementation of A&F interventions in antibiotic stewardship. Our objective was to identify how social context influences primary care clinicians' perceptions of A&F received as part of a stewardship intervention.

methodsWe conducted semi-structured interviews with primary care clinicians who participated in a stewardship intervention in the Eastern United States. Interviews were conducted in the year following the intervention and respondents were purposively sampled by their performance: (1) sustained high performance, (2) improved performance, and (3) no improvement. Snowball sampling was used to deepen our understanding of practice context. Interviews were analyzed using the framework method.

resultsInterviews were conducted with 32 clinicians from 15 practices. Two clinicians were recruited via snowball. Thirty respondents were exposed to the intervention (of 183 clinicians in the intervention). Of these 30 respondents, 13 sustained high performance, 7 improved, and 10 did not improve. The content of responses by group varied in descriptions of the influence of social relationships on clinician understanding of feedback. Three relationships were identified as important: 1) with the health system, 2) with the practice, and 3) with patients. Clinicians with consistently high or improved performance described being understanding of and responsive to the demands of the health system and having a unified approach to judicious prescribing in their practice. They also expressed confidence in navigating patient demand for antibiotics. Clinicians whose performance did not improve were either annoyed by, anxious about, or dismissive of the health system's expectations, had low levels of interactions with colleagues in their practice surrounding antibiotics and prescribing norms at the practice that catered to patient expectations for antibiotics. They also reported difficulty in negotiating patient demand for antibiotics.

conclusionsThis study examines clinician reactions to the implementation of a feedback intervention to improve antibiotic prescribing in primary care. Our study demonstrates that clinicians use social relationships to make sense of performance feedback, which may influence the formation and execution of behavioral intentions in response to feedback.