Table 2.

Sample Clinician Quotes for ARI Antibiotic Prescribing Themes.

Theme 1: Barriers to appropriate prescribing are multifactorial and include difficulty in changing old practices and patient demand.
Barrier: Belief of difficulty in changing old practices	“I think that it’s always difficult to change people’s minds that are set who kind of have that mentality of this is the way that I’ve always done things.”
Barrier: Lack of testing and resources	“Well if we had you know more rapid tests that we could do right here and find out before we let the patient go, that would help you know, and we could say, “No you know nothing grew here or yes, this grew.”
Barrier: Diagnostic Uncertainty	“Probably the other major driver is the uncertainty. In situations of uncertainty, I think the default is to give antibiotics just in case.”
Barrier: Patient Demand	“There is a mix. Like there are some older patients who have always gotten antibiotics will tell me that, and then some of the younger ones are a bit more demanding but it’s not like all of them.”
Theme 2: Antibiotic prescribing decisions were perceived as highly autonomous and yet, diagnostic uncertainty and perceptions of patient demand were cited as factors that made decisions more difficult:
Decisions: Based on knowledge and experience	“So, in 9 out of the 10 cases, I don’t necessarily have to prescribe anything. It’s just a matter of educating the patient about signs and symptoms of other things and when to return back to clinic if the conservative therapy isn’t working is the key.”
Decisions: Uncertainty influences decisions	“I think that the main reason why most providers prescribe when in doubt is because they don’t want to see the patient again (laughter). […] Because I think that at time providers are overloaded, and they don’t want to have to follow up or see them again in 2 days when they need to follow up because the conservative therapy didn’t work”
Decisions: Patient demand/preferences influence decisions	“Yeah, I don’t feel any pressure from the institution at all to make patients happy in that regard. It’s just more like my own (laughter)…. My own, and I’m not sure how to describe it. My own how pressured that I end up getting from the patient and then making me kind of doubt my judgement in certain scenarios where it’s maybe more ambiguous.”
Theme 3: Clinicians perceived variation in peer prescribing practices and influences:
Belief: Social norms: appropriate prescribing by peers varies	“I would say probably 80% of the providers would do the right thing on a regular basis. And when they do not, often there are other things going on. […] There are a handful that do throw it out like candy. So, I think for the majority, they do the right thing the majority of the time, and those cases that they do end up prescribing antibiotics for, I think there’s usually a reason, and usually a good reason.”
Perception: Knowledge of guidelines exists but not necessarily followed	“It’s the treat them and street them principle. You know. Get them. Get it done. Get them out. Because it’s faster. You do your turnaround, and you go onto the next patient. Because it’s a common mentality. Like I said, it’s something that we as providers I think really have to understand that is the mentality, and the only people who can change that mentality is us.”
Belief: social norms: peers’ practice influences patient demand	“I think that you know it has to be everybody is using the same guidelines and you know. If we’re all saying the same thing. I think where patients get confused is you go to one doctor who says you don’t need an antibiotic and then the next time you go to a provider and they give you an antibiotic. The patient is going to have a sense of mistrust.”
Belief: patient demand can be addressed	“If you’re patients don’t think that you care about them when they walk out the door. I mean they know when I don’t prescribe that antibiotic. They know that I’m invested in their healthcare and so they’ve got to trust that decision you know.”
Theme 4: Clinician-focused interventions were considered valuable particularly if delivered with sensitivity:
Intervention Suggestion: feedback suggestion: compare to peers	” […] I kinda enjoy the competition stuff, so you’ll see a lot good to do things, […] if you kinda post those like anonymous up on a board and kind of see how everyone stacks up against each other.”
Intervention Suggestion: Feedback should be a comprehensive review	“Well I’d like [those who provide feedback] to know what I was thinking when I wrote these antibiotics. I guess you know if we’re talking just standard stuff I’d like them to be aware of how long the patient’s been sick, how severe their symptoms have been, you know what they, you know kind of what they tried at home so they know why I’ve made the decision to write those antibiotics on something that they may think is questionable practice.”
Intervention Suggestion: Feedback needs to be delivered in a positive way	“If it’s presented in the sort of format of this is what you’re doing wrong and this is how you have to do it better, that would not be very successful, but if it’s presented as these are some tools that people have found to be successful and you might want to consider it as something to add to your - you know, in other words, if it’s presented as something for people to add as opposed to an extra tool for them to use, then that would probably be more successful than criticizing people for the way in which they are doing things.”
Intervention Acceptability: Feedback: positive perception	“Well, I would like to get pointers. As a provider, I feel like that we deal with people, and I think that we don’t know everything, and we could always learn, and so the pointers should be helpful, and we all have different styles. But if it’s something that I feel like that I could use or something that I feel like that I’m weak in, I would definitely try to incorporate it so that I could do a better job.”
Theme 5: Educational communication for patients was assessed as superior to a process of shared decisions:
SDM: For Abx this involves patient education and sharing alternate treatments	“ if you take the time to educate the patient and if you take the time to explain the risk, and then kind of make the decision together. Like you know, this isn’t in your best interest, and they kind of agree that, “Yeah, I can see where you’re coming from, and I’m okay with that, and I’m willing to do these other things.” Again, if you educate them, they can make shared decisions”.
SDM: concern sometimes decision for abx should not be shared	“It’s hard to make or to do shared decision making with someone that’s insistent on needing an antibiotic because most of the time they’re not open to listening to reason because they feel that that’s what they need and that’s what they want.”
SDM: Antibiotic prescribing is not a shared decision	“Yes and no. I, I don’t really give them the option to say well yeah, I want an antibiotic […] I usually you know give them the proper education on what’s going on with them and, […] the steps and what to do and you know if you’re not better in so long then we’ll consider an antibiotic, that sort of thing. So, I mean I, in that manner you know with shared decision making in that I provide them the education that they need but I’m not gonna let them tell me yeah, I’m good, go ahead and give me an antibiotic.”
Theme 6: The importance of team standardization of practice and communication were cited as key tools for engaging in future appropriate prescribing:
Future Behavior: Promote wise stewardship through educating subgroups	“I am pretty stingy if you will with antibiotics. I know that my staff here knows that I don’t just write prescriptions for antibiotics. I have patients that call in and say that I have such and such. I need an antibiotic, and they know to say no, you have to come in and be evaluated. She’s not just going to write you a prescription for an antibiotic.”
Future Behavior: Promote wise stewardship through educating subgroups	“[…] spending that time to go over like the decision-making process and what antibiotics are and what they do and don’t treat, what the side effects are, and then you know it’s what I enjoy about teaching, so we have residents in here like 3 or 4 of them a day and we go through that and talk about it and, you know, decisions on which antibiotics to use and what pathogens you’re treating and what are the risks, so I mean just that kind of education environment. I enjoy that, so yeah absolutely.”
Future Behavior: Promote wise stewardship through educating subgroups	“I’m always educating the people on my team as well as encouraging the same kind of, especially with our care managers who are our in-care managers. Talking to them about it because a lot of times they are the first contacts of the patients. So helping them understand what’s going on out there as far as overuse and ways that they can help patients and things like that.”