RESEARCH ARTICLE Diagnosing infections: a qualitative view on prescription decisions in general practice over time Ingunn Bjo ¨rnsdo ´ttir • Karl G. Kristinsson • Ebba Holme Hansen Received: 27 January 2010 / Accepted: 13 September 2010 / Published online: 8 October 2010 Ó Springer Science+Business Media B.V. 2010 Abstract Objective Antibiotics may frequently be pre- scribed on the basis of vague diagnoses, possibly resulting in unnecessary antimicrobial resistance. Our aim is to map general practitioners’ (GPs’) decision-making for common infections, exploring their diagnostic basis for antibiotic prescriptions. Setting General practice in Iceland. Method Ten in-depth qualitative interviews with, and three obser- vations of, GPs in 1995. Diagnostic issues extracted and analysed. In 2006, eight GPs commented on analysis and updated (email/telephone). Main outcome measure Diag- nostic variability and reasons for prescribing antibiotics, consistency or changes over time. Results Wide variations were uncovered in diagnostic procedures, although each GP remained consistent through time. Some GPs had developed ‘‘rules-of-thumb’’. They often balanced risks against issues like money, time, need for the workforce (perceived importance of the patient’s job), client’s need for job/earnings (perceived ability to afford a sick day) and doctor-patient relationship (risk of refusal adversely affecting the relationship). Perceptions of risk varied from focusing on resistance development to focusing on possible harm from untreated infections, also ranging between considering both to worrying about neither. Changes over time were not prominent but included increased point-of- care testing and the perception by GPs that patients were increasingly willing to ‘‘wait and see’’. Conclusions Large variability and individuality characterized the GPs’ diag- nostic procedures, contrasted by consistency through time. If modification of diagnostic routines is needed, provision of ‘‘scientific facts’’ and technological aids is insufficient. A prerequisite for changing practice is GPs’ acceptance of accuracy of information and of reliability, applicability, and relevance of technology, for physician and/or patient. Keywords Anti-bacterial agents Á Diagnosis Á Evidence- based medicine Á Iceland Á Infection Á Physician’s practice patterns Impact of findings on practice • GPs’ diagnostic procedures vary between individuals and between infections. • GPs’ diagnostic procedures are relatively resistant to changes over time. • GPs only change diagnostic procedures if they consider themselves to have adequate information, indicating that change is beneficial. Introduction Liberal prescribing of antibiotics poses a threat to public health due to its link with increasing antimicrobial resis- tance [1]. Antibiotic prescriptions are frequently less I. Bjo ¨rnsdo ´ttir Á E. H. Hansen Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, University of Copenhagen, Copenhagen, Denmark I. Bjo ¨rnsdo ´ttir (&) Á K. G. Kristinsson Research Institute for Pharmaceutical Outcomes and Policy, University of Iceland, Reykjavı ´k, Iceland e-mail: ingunnb@hi.is E. H. Hansen FKL—Research Centre for Quality in Medicine Use, Copenhagen, Denmark K. G. Kristinsson Clinical Microbiology, Landspitali University Hospital, Reykjavı ´k, Iceland 123 Pharm World Sci (2010) 32:805–814 DOI 10.1007/s11096-010-9441-6