156 Chapter 6 time per consultation is available, which is independently associated with more antimicrobial overprescribing (45, 46). In our study, we interpret practice size also as a proxy for continuity of care in daily practice by the same provider. Larger primary care practices generally make use of locums, more GPs staffing the practice, and we know that a higher number of GPs involved with the same population is related to weaker continuity of care in practice. In transition there is a risk of loss of information essential to adequate follow-up and thus overprescribing due to medical uncertainty (47). The second GP confronted with the same problem may also view prescription of an antimicrobial as an appropriate decision simply on the basis of knowing that it is the second encounter with the same patient (33). Our results also identified the Friday as the weekday prone for (over-)prescribing, in contrast to a UK study that found no differences per weekday (21). In our case, annex to workload effects, a possible additional explanation might be that GPs use a delayed antimicrobial prescription strategy. In this strategy patients are prescribed antimicrobials before they are actually needed and instructed to collect it, or use it only when specific symptoms worsen. However, this additional supposition would need verification in pharmacy records which we were unable to arrange. In an analysis comparing associations of determinants of appropriate antimicrobial prescribing for all infections to those for RTIs only, some differences were noted. It now emerged that a higher household income was associated with more appropriate antimicrobial prescribing for RTIs, whereas an association of single-parent-households with appropriateness of antimicrobial prescribing was no longer present. Comorbidity showed a stronger association with antimicrobial overprescribing for RTIs compared to antimicrobial overprescribing for all disease groups. A possible explanation for these differences is that antimicrobial prescriptions for RTIs are more likely not needed, simply because most RTIs are caused by viruses that do not respond to antimicrobials. By contrast, UTIs, sexually transmitted diseases and skin infections can usually be appropriately treated with an antimicrobial. Evaluating various findings, the overarching theme, as well as an entry for further improvement of primary care antimicrobial prescription, seems to be the availability of time for consultation and shared decision making. Some specific misunderstandings due to cultural differences when encountering patients with a migrant background, practice size as a measure for providing continuity of care and the availability of extended consultation time, Friday as a day of over prescription, the choice for macrolides thus prevailing convenience over rational arguments, all point in the direction of physicians presumably trying to cope with workload.
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