51 Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers 3 extracted where provided. Study quality was assessed using the National Heart and Lung Institute (NHLI) study quality assessment tool for quantitative studies and the Critical Appraisal Skills Programme (CASP) for qualitative studies (22, 23). Framework Determinants were placed in a framework by a reviewer (MS) which was thereafter reviewed by the research group and adapted based on consensus in the groups’ discussion. We used a practical framework set-up as described by Morgan et al. (17). This framework is specifically designed for understanding and reducing medical overuse in primary care and takes all relevant domains of influence into account, including the culture of healthcare consumption, patient factors and experiences, the culture of professional medicine, clinician attitudes and beliefs, practice environments and patient–clinician interactions. The domain ‘government’ was left out of the framework as it was found to be redundant owing to our selection of studies from developed countries in which GPs play a gatekeeper role. If the definition of determinants showed large similarity, we choose to combine the determinants to prevent overlap in our framework. Determinants were eligible to be added to the framework if they had a positive or negative impact on inappropriate antibiotic prescribing. The determinants were classified as having either a positive or negative influence on inappropriate antibiotic prescription according to the findings and description in their study. Subsequently, each determinant was noted in the framework with a plus or minus sign. The identified determinants were categorised and attributed to the framework domains specified by a method described by Morgan et al. (17). Determinants specific to one country, as well as those on which studies reported conflicting results, were included to create a complete framework appropriate to various settings. Determinants on which studies returned conflicting results were noted in the framework with a plus or minus sign (±). Patient and public involvement Patients were not involved in designing the review, data collection, interpretation or write-up of this review.
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