Delayed antibiotic prescriptions: What are the experiences and attitudes of physicians and patients?

,

Original Research

Delayed antibiotic prescriptions: What are the experiences and attitudes of physicians and patients?

J Fam Pract. 2002 November;51(11):954-959

By

Bruce Arroll, MB, ChB, PhD

OBJECTIVE: To explore the experiences and opinions of family physicians and patients regarding the delay of antibiotic prescriptions, to be dispensed if symptoms persist or worsen over time, in treating upper respiratory tract infections.
STUDY DESIGN: Qualitative study using semistructured interviews conducted in family practice in Auckland, New Zealand.
POPULATION: Thirteen physicians recruited from a study of family physicians’ reported antibiotic prescribing and 13 patients recruited from the intervention arm of a randomized controlled trial on delayed antibiotic prescribing.
OUTCOMES MEASURED: Patients’ and physicians’ experiences of delayed antibiotic prescriptions for upper respiratory tract infections.
RESULTS: The primary themes identified were value judgments of antibiotics, decreased antibiotic use, patient-centered factors, effects on the physician–patient relationship, patient convenience, adverse effects of delaying prescription, and selectivity for use of antibiotics. Many themes were common to both patients and physicians. Physicians valued empowering patients’ decision making about their health care management more highly than did patients. Decreasing antibiotic use was not a key factor for most patients. Both groups acknowledged the value in saving patients time and money. Physicians viewed the strategy as giving patients reassurance and meeting their expectations for antibiotics. Negative implications included perception of physician incompetence and physician loss of management control. Opinions were mixed regarding which patients, under which conditions, were suitable for delayed antibiotic prescriptions.
CONCLUSIONS: Although delayed antibiotic prescriptions are effective in decreasing antibiotic use for conditions not clinically warranting antibiotics, neither patients nor physicians universally endorsed this strategy. Research to establish formalized recommendations for patient suitability and instructions for use would be of value.

PDF Download

References

1. Arroll B, Goodyear-Smith F. General practitioner management of upper respiratory tract infections: when are antibiotics prescribed? N Z Med J 2000;13:493-6.

2. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. Br Med J 1998;317:637-42.

3. Arroll B, Everts N. The common cold: what does the public think and want? N Z Fam Physician 1999;26:51-6.

4. Macfarlane J, Holmes W. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. Br Med J 1997;315:1211-4.

5. Palmer DA, Bauchner H. Parents’ and physicians’ views on antibiotics. Pediatrics 1997;99:E6.-

6. Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and physicians’ perceptions of patients’ expectations—a questionnaire study. Br Med J 1997;315:520-3.

7. Britten N. Patients demands for prescriptions in primary care. Br Med J 1995;310:1084-5.

8. Arason VA, Kristinsson KG, Sigurdsson JA, Stefansdottir G, Molstad S, Gudmundsson S. Do antimicrobials increase the carriage rate of penicillin resistant pneumococci in children? Cross sectional prevalence study. Br Med J 1996;313:387-91.

9. Verkatesum P, Innes JA. Antibiotic resistance in common acute respiratory pathogens. Thorax 1995;50:481-3.

10. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA 1995;273:214-9.

11. Hueston WJ, Mainous AG, 3rd, Ornstein S, Pan Q, Jenkins R. Antibiotics for upper respiratory tract infections. Follow-up utilization and antibiotic use. Arch Fam Med 1999;8:426-30.

12. Mainous AG, 3rd, Hueston WJ. The cost of antibiotics in treating upper respiratory tract infections in a Medicaid population. Arch Fam Med 1998;7:45-9.

13. Thomas MG, Arroll B. “Just say no”—reducing the use of antibiotics for colds, bronchitis and sinusitis. N Z Med J 2000;113:287-9.

14. Couchman GR, Rascoe TG, Forjuoh SN. Back-up antibiotic prescriptions for common respiratory symptoms. Patient satisfaction and fill rates. J Fam Pract 2000;49:907-13.

15. Cates C. An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. Br Med J 1999;318:715-6.

16. Dowell J, Pitkethly M, Bain J, Martin S. A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care. Br J Gen Pract 2001;51:200-5.

17. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. Open randomised trial of prescribing strategies in managing sore throat. Br Med J 1997;314:722-7.

18. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. Br Med J 2001;322:336-42.

19. Arroll B, Kenealy T, Kerse N. Does a delayed prescription reduce unnecessary antibiotic use? A randomized controlled trial. J Fam Pract 2002;51:324-8.

20. Curtis S, Gesler W, Smith G, Washburn S. Approaches to sampling and case selection in qualitative research: examples in the geography of health. Soc Sci Med 2000;50:1001-4.

21. Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? Br Med J 2001;322:1115-7.

22. Guba EG, Lincoln YS. Competing paradigms in qualitative research. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, Calif: Sage Publications Inc; 1994;105-117.

23. Kuzel AJ, Engel JD, Addison RB, Bogdewic SP. Desirable features of qualitative research. Fam Pract Res J 1994;14:369-78.

24. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1998.

25. Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract 2001;50:853-8.

KEY POINTS FOR CLINICIANS

Delayed antibiotic prescriptions are effective in decreasing antibiotic use for conditions not clinically warranting antibiotics.
Family practitioners valued empowering patients to be more involved in decision making about their health care management more highly than did patients.
Family practitioners generally viewed the strategy as giving patients reassurance and meeting their expectations for antibiotics.
Both patients and physicians agreed that delayed prescribing is not appropriate for all patients, but currently no consistent criteria have been established.

Family physicians often prescribe antibiotics for common colds despite being aware of their marginal effectiveness for such.^1,2 Major contributing factors are overt patient expectation or demand for antibiotics^3-5 and the physician’s perception that the patient expects antibiotics.^6,7 Detrimental effects of antibiotic overuse include adverse effects on patients, development of antibioti-cresistant bacteria,^8,9 and increased health care costs.^10-12

Although it is possible to “just say no” to patients’ demands for antibiotics,¹³ family physicians may be under considerable pressure to prescribe. A strategy to decrease prescribing unnecessary antibiotics without damaging the physician–patient relationship involves giving a delayed (or deferred) prescription, which is a prescription to be filled at a later time if the patient’s condition fails to improve or deteriorates.¹⁴ Couchman et al¹⁴ reported that 50% of patients given “‘back-up”’ antibiotic prescriptions did not fill them. Cates¹⁵ found that delayed prescribing significantly decreased antibiotic use in children with acute otitis media. Results of a randomized controlled trial (RCT) found that 55% of patients with uncomplicated cough did not fill their delayed prescription, although patients demonstrated some dissatisfaction with the strategy.¹⁶ Little et al studied its effectiveness in managing sore throat¹⁷ and otitis media.¹⁸ In our recently published RCT¹⁹ we reported that delayed prescribing significantly decreased the filling of antibiotic prescriptions for the common cold.

The use and effectiveness of a new medical intervention is influenced by how the intervention is viewed by both physicians and patients. Delayed prescription use for the common cold has not been assessed in any qualitative study, although the topic of 1 qualitative study was antibiotic prescribing for sore throats.² The researchers found that although making the diagnosis was not difficult, treatment was a problem because one third of patients expected to be prescribed antibiotics. Our aim was to explore issues and attitudes regarding delayed prescription use from the perspectives of family physicians and patients.

Methods

We used a qualitative approach (1) to explore the complexity of, and relations between, issues identified in delayed prescription use, and (2) to describe the experiences and attitudes of both physicians and patients regarding delayed prescription use. The physicians were recruited from a list of high-prescribers (20 or more delayed prescriptions per month) or low prescribers (1 or fewer delayed prescriptions per month). This list had been prepared for a previous study in which 100 random family physicians had reported their use of delayed prescribing.¹ Patients were recruited from the intervention arm of an RCT on delayed prescribing that examined the hypothesis that delayed prescriptions would result in decreased use of antibiotics for the common cold.¹⁹ Inclusion criteria comprised both patients receiving delayed prescriptions and parents of children receiving delayed prescriptions. Patients in the RCT had given written consent to subsequent interview for the qualitative study. Approval for our study was granted by the Auckland Ethics Committee.

Thirteen physicians and 13 patients were interviewed by telephone (F.G.-S. served as the interviewer). Purposive sampling was used to deliberately include “outliers”’ with respect to characteristics such as sex, socioeconomic level, and geographic location.^20,21 This built sample diversity with respect to different subjects and themes along the main topics of interest (eg, the advantages and disadvantages of delayed prescribing) to improve data robustness. The physicians comprised men and women ranging in age from their 30s to 60s, including both New Zealand–trained physicians and immigrants (from Asia and South Africa) with practice locations ranging from lower to upper middle-class suburbs. Both male and female patients were interviewed, ranging in age from adolescent to elderly (specific ages unavailable). Parents of children receiving delayed prescriptions were included in the patient population. Ethnicity and socioeconomic level included those of European, Moori, and Asian extraction from family backgrounds of differing socioeconomic districts.

The interview data were collected in an iterative process in which themes from the early interviews were specifically checked in later interviews. Interviewing ceased once data saturation had occurred, ie, when no new themes emerged.^22-24 Family physicians were paid for their time. Semistructured, open-ended questions were progressively focused into more structured questions. Questions for physicians included their views on delayed prescribing; the duration, frequency, and circumstances of their use of delayed prescribing; and their perceived advantages and disadvantages of delayed prescribing. Questions for patients included their experiences of receiving delayed prescriptions; their preferences for decision making regarding antibiotic use; and their views about delayed prescribing. The interviews were audiotaped, and although the hand-written interview notes were not transcribed, they were checked against the audio recordings. Recording ceased once it was established that concurrent hand-written notes were similar (nearly verbatim) to the recorded versions. Interviews typically lasted between 10 and 20 minutes.