Table 3 Illustrative quotes: DAP, how and for whom; and DAP-Trial and primary care research barriers

DAP, how and for whom

Context

Yes, because [the DAP] is something we use when it’s not entirely clear to us whether the presentation is going to resolve easily. When you have the slightest suspicion, a medical sixth sense that tells you, “hmm, this could get complicated”, or you’re not sure about a tonsillitis and you say, “well, look, it’s quite likely that, with so much pain, so much fever, in 48 hours, you’ll have an abscess or have terrible pus plaques.“ And you are not very sure. Basically, that’s it. An uncertainty that it may be something viral that will get complicated or that is already a bacterial infection. (P10, DAP-Trial participant, medium-high socioeconomic area)

I have done it before the weekend. If they come in on a Monday, then you know it’s Monday, it’s fine because there is a lot of accessibility. I’ve done it more often on Thursdays, Fridays, thinking “where will they go on Saturday, Sunday?”. Before a public holiday or Easter holidays. When I’ve done it, I’ve done it more often in those situations. (P22, DAP-Trial non-participant, medium-high socioeconomic area)

There are also times you use it as a tool not to prescribe immediately. In other words, you think they shouldn’t take it, the patient, you know they do not agree, so… and then you can use it in such a way, that a possibility, in the long run, maybe, is if they see that they are getting better, they won’t take it, and they don’t take it. (P4, DAP-Trial participant, medium-low socioeconomic area)

… I believe it is more often in a situation of a quick unscheduled visit (…). Because you probably will not see this patient again, another professional will visit them instead, you lose follow-up of them. It’s ‘right here, right now’, another decision of the moment. If this happens with your patient, it’s easier to say “if you are not feeling well, come back in a few days and I will examine you again”. (P4, DAP-Trial participant, medium-low socioeconomic area)

Patient profiles

That they really understand that they understand, or that one knows how to explain it to them, and they understand it (…) (P13, DAP-Trial non-participant, medium-low socioeconomic area)

Those of us who have been working for a long time now, when we know the patient. Because, of course, when you’ve been working for a long time, you know if they are a compliant patient, if they are a multi-frequenter patient, if they are…… You know these things. If you think they are compliant and will do well, then that is also a criterion. If they are multi-frequenters, they’ll still come back after two days if they don’t get better, even with the DAP, that can also influence whether you do it or not. I mean, those are criteria that you can also consider. (P9, DAP-Trial participant, medium-high socioeconomic area)

It is the profile of the people. I think that perhaps the population that could benefit most is the young population, who can understand it. But this population rarely comes to see us. And then, when you have to educate a patient with whom you aren’t too close, because the confidence your patients have in you is different. And then, we often visit with this type of patient profile in the unscheduled visits, where not even the same doctor visits them. So the credibility of the professional here counts a lot. For me, it is much easier to work with my usual patients than when I visit with someone else. (P23, DAP-Trial non-participant, medium-high socioeconomic area)

In short, DAP is probably very suitable for patients who do not want antibiotics. This kind will wait 24 or 48 h. In other words, they are aware of not taking antibiotics. On the other hand, with those convinced of taking them, it doesn’t matter if you ask them to wait. (P26, DAP-Trial non-participant, medium-high socioeconomic area)

The problem is that you still have a doubt, right?, with the patient who doesn’t agree, who’s not sure… or if one thinks or this person is a hypochondriac, that once I give them a DAP, they will accept it, and will surely go directly to buy an antibiotic. Because I don’t leave the prescriptions at the reception desk, I give them in person. And then you doubt, right? (P7, DAP-Trial participant, medium-low socioeconomic area)

DAP advantages and disadvantages

Let’s see, advantages… You could say the number of visits, maybe, but I don’t care. In other words, if the patient is not feeling well, it’s fine that they come back and visit me again. This is the advantage I can think of. (P15, DAP-Trial non-participant, medium-low socioeconomic area)

(…) I think they find this option safer for them, don’t they? [they think,] “OK, you now think it is not necessary, but you let me this second option in case I get worse…” (P4, DAP-Trial participant, medium-low socioeconomic area)

(…) Anyway, I use it and I use it also for that reason (…) they are no longer in distress thinking “I feel terrible”, and it also gives them the chance to say, “well, maybe I don’t need it, the antibiotic, right?“ And therefore, well, I don’t know, it’s useful, it’s useful. And the patient, from what I see, leaves satisfied. (P4, DAP-Trial participant, medium-low socioeconomic area)

(…) what’s most important to me: you give them a little independence and self-management of their own health. And actually the only thing you are doing differently is knowing that they must take the antibiotic if it happens to them or not, I mean, if you explain it to them, they are able to do it themselves. Not everyone, though. (P3: DAP-Trial participant, medium-high socioeconomic area)

The problem is that you still have a doubt, right? With the patient who doesn’t agree, who’s not sure, or if one thinks that this person is a hypochondriac, that once I give them a DAP, they will accept it, and will surely go directly to buy an antibiotic. Because I don’t leave the prescriptions at the reception desk, I give them in person. And then you doubt, right? You don’t know if they’ve taken it or not, if you’re actually making a good…. (P7, DAP-Trial participant, medium-low socioeconomic area)

So, of course, if I don’t know how it is going to progress… without re-examining them, sometimes I’d rather be the one to decide when and how, than giving this to the patient. (P25, DAP-Trial non-participant, medium-high socioeconomic area)

You have to think about it a lot and be really sure what you mustn’t give them [antibiotics], what you can give them, what you have to explain to them well… Putting time aside, it’s the act of thinking, it’s much easier to click, click, click, antibiotic, and goodbye. I mean, a DAP involves extra efforts from the clinician, apart from explaining and so on, even if you have a person on the other side of the desk who understands it perfectly, it implies thinking about it, saying, “Come on, let’s do it” and explaining it to them. I mean, I’m sure there are more DAPs at 3 pm than at 7 pm. (P3, DAP-Trial participant, medium-high socioeconomic area)

Patient-led DAP versus DAP collection

The thing is, both as a professional and user of the system, I don’t think I would like the second option [DAP prescription collection] at all, because actually, if I’m fine, I won’t need it and I wouldn’t go get it; but if I’m ill and I really need to go get the antibiotic, it would mean the fever continues —it hasn’t decreased—, it would probably be a bacterial infection and I’m being forced to leave my house again or have to find someone to come with me . I mean, I find that when people are feeling bad, they are the ones to lose out in this case. (P23, DAP-Trial non-participant, medium-high socioeconomic area)

If you leave it at the reception desk, the patient has to make an effort. Then, “this person may not come to collect it”, but they won’t schedule a visit either. This would be the ideal strategy, because they don’t come to the office, but they also don’t start taking it straight away, right? (P14, DAP-Trial non-participant, medium-low socioeconomic area)

Improvement proposals

There could also be incentives for clinicians. Right? Make it a way to consider prescriptions, just as we have others, well, it could be one more. (P4, DAP-Trial participant, medium-low socioeconomic area)

DAP-Trial and primary care research barriers

DAP-Trial

(…) I found it very rewarding and interesting, partly because of what you see of an

investment in the future, as promoting a rational use of drugs, of antibiotics, and for me it was very rewarding. (P12, DAP-Trial participant, medium-low socioeconomic area)

Yes, because it’s useful. It’s a strategy… well, I didn’t know either, I learned to apply it as a result of the study we did last year. Did you apply it before? (P10, DAP-Trial participant, medium-high socioeconomic area)

Well, for me the field work was very tedious. There were a lot of people who could have been included, but there was very little time, and that limited one a lot to include patients. On the other hand, I think I liked the study, because it was conducted in the primary care setting, in a real-world situation. Everything I was against in reporting the field work, I was in favour of after with the results, how they came out. But anyway, I really thought it was very tedious and that one lost interest in doing it because of what it meant if… (P4, DAP-Trial participant, medium-low socioeconomic area)

Primary care research

“(…) that most of the research is conducted at the hospital level, but at the primary care level or with conditions that we only see in the primary care setting, such as upper RTIs, little has been done (…) (P9, DAP-Trial participant, medium-high socioeconomic area)

“Hmmm, I think, firstly, that if you are working full-time as a healthcare provider, it is very complicated, because with our visiting hours, our timetable is almost full, and we don’t have much time left for anything else (…) (P9, DAP-Trial participant, medium-high socioeconomic area)

It seems to me that perhaps now the only benefit —well, at least in the ICS [Catalan healthcare service]— that you can get is that, as an activity, it is valuable for your professional career. Well, I’m just saying this to try to see some personal benefit. The only thing I can think of right now. But apart from that… (P2, DAP-Trial participant, medium-low socioeconomic area)

I don’t know, if it is an interesting study for primary care and so interesting, then I think that the organization could collaborate with the schedules, or —I don’t know—, somehow saying, “if you do this, you will have fewer patients every day”, because it is harmful for patients who are waiting on you. Because you are feeling bad, thinking “now I will spend half an hour with this person, and I am already running 15 minutes late, or half an hour, add another half an hour and it will be an hour”, and the poor people there who had an appointment, you are also feeling bad about that, and so are they… it is also harming the healthcare service. I mean if the organization committed… (P9, DAP-Trial participant, medium-high socioeconomic area)