Value judgment of antibiotics
The theme of “value judgment of antibiotics” was evident only among patients. Several expressed the opinion that antibiotics were the necessary treatment to take every time they became ill. Conversely, other patients considered antibiotics bad for them and preferred to use alternatives such as naturopathic medications.
Decreased antibiotic use
The primary motivation for delayed prescribing by physicians was to decrease unnecessary antibiotic use. Benefits include avoiding patient side effects; decreasing the drug bill for taxpayers; and, especially, decreasing the occurrence of antibiotic resistance. Several patients made comments relevant to this theme. None identified decreasing resistance as an important goal, but 3 patients said the strategy could help avoid unwarranted antibiotic use.
Patient-centered factors
“Patient-centered factors” was a strong theme to emerge—especially from high-prescriber physicians. The physicians indicated that delayed prescribing helped them practice more patient-centered medicine—educating patients to take more responsibility for their own health care management and being more receptive to patient needs. Some physicians took into account pending weekends or patients’ travel or work commitments when offering delayed prescriptions. Although some patients mentioned their involvement in decision making, this aspect generally was not a key factor for many of them. Some liked to make the decision for themselves, which included using their “delayed” prescription immediately. Most patients did not wish to have an active role in decision making and preferred their physicians to decide for them. No patients commented on the role of the physician in providing them with education on their health matters.
Effects on the physician–patient relationship
The theme of “effects on the physician–patient relationship” delineated an associated factor for physicians: the strategy of delayed prescribing strengthened physician–patient relationships by helping physicians cope with the pressure they experienced from patients expecting antibiotics for common colds; by reassuring patients; by giving patients something to take home; and by preventing patients from going to a different physician to obtain antibiotics. An alternative view, expressed by one low-prescriber physician, was that delayed prescribing might damage the physician–patient relationship because the patient might consider the physician incompetent.
For a few patients, use of delayed prescriptions was reassuring. Several patients’ expectations that antibiotics were required persisted at the end of the consultation, and they chose to have their prescriptions filled immediately. Presumably, they would have gone elsewhere had they left the consultation empty-handed. Use of delayed prescribing had a potential negative effect on the physician–patient relationship for at least 2 patients. They perceived delayed prescribing as an indication of physician indecisiveness and incompetence or that the physician was trying to hold down costs to the patient at the risk of the patient’s being ill.
Patient convenience
The theme of “patient convenience” and cost savings was a strong theme among physicians and less so among patients. Several patients identified that delayed prescriptions could save them trouble and expense. For 3 patients this was not an issue, but they acknowledged it could be of value to busy working people or low-income patients.
Adverse effects of delayed prescribing
Regarding the theme of “adverse effects of delayed prescribing,” some physicians saw little or no disadvantage if delayed prescriptions were given to the right patients with correct instructions. However, low-prescribers identified a number of possible adverse effects of delayed prescriptions, such as leading to missing or masking serious illness, with possible medicolegal ramifications. Physicians were concerned about being perceived by patients as losing control of the situation and being less able to monitor outcomes. Even using delayed prescribing, some patients might still take antibiotics unnecessarily. The possibility also exists that the antibiotic might be saved and later used inappropriately by another family member.
Patients identified several potential problems, often for people other than themselves. Not only could delayed prescriptions have the potential to be confusing, especially for less-educated people, but 1 patient thought the practice might lead to patients taking antibiotics unnecessarily.
Selectivity for use
Physicians generally were selective about patients for whom they considered delayed prescribing appropriate. Patients who were poorly educated, who had a bad command of English, or who were transient to the practice were identified as poor candidates for receiving delayed prescriptions. Most physicians restricted delayed prescriptions to a particular age range. However, within this category there was considerable variability and inconsistency. Many used delayed prescriptions only for children, with children younger than 6 years being the most suitable group; others used delayed prescribing only for children older than 6 to 8 years. One physician would not use the strategy in very young children, ie, younger than 3 years. There was no consensus regarding circumstances or specific instructions for use. Some used delayed prescribing only with clearly viral illnesses; others employed the strategy in patients with chronic illnesses during which secondary infection was more likely. Instructions varied regarding symptoms to watch out for and how long to wait before filling the prescription.