Selection of patients was also a dominant theme for patients. Although they thought delayed prescribing might be acceptable for themselves, a number of patients believed that others might not understand or get confused. One patient was happy to make decisions about her own management, but believed the physician should make decisions about her children. Patients did not venture any opinions regarding conditions for which they thought use of delayed prescribing was warranted.
Discussion
Delayed prescribing is a strategy developed primarily to decrease unnecessary antibiotic use in the management of upper respiratory tract infections. Although physicians emphasized the importance of decreasing antimicrobial resistance, patients did not consider this factor. Continued public health education on this issue, including family physicians providing pertinent information to individual patients, could be helpful. Many patients have relatively fixed ideas that antibiotics are either “good” or “bad” for their health without knowing the personal and public health nuances of antibiotic prescribing.
Patients may pressure their physicians for unnecessary antibiotics either by direct request or indirectly by the way they present their complaint.25 Physicians may also incorrectly perceive that patients want antibiotics.6 This study showed that physicians are likely to use delayed prescription as a technique to decrease antibiotic use in patients they perceive as wanting antibiotics regardless of the medications’ appropriateness.
Empowering patients to have more control over their health care management was more important to physicians than patients. Patients held differing views, and whereas some appreciated the option of controlling the decision whether and when to take antibiotics, others expected “the physician to decide.” Perhaps improved physician–patient communication, as well as delayed prescribing, could help patients better understand about antibiotic use.
Many patients in this study had previously received antibiotics for common colds. Most physicians believed that using delayed prescriptions was a compromise strategy that prevented patients from feeling brushed off and offered reassurance, thus protecting the physician–patient relationship. Some patients reciprocated this view. However, a concern expressed by 1 physician that patients might view delayed prescribing as physician incompetence was substantiated by comments from other patients.
The potential adverse effects identified by some of the physicians, such as a serious disorder being masked or missed and physicians having less medical control, could be largely remedied by establishing criteria for suitable patient selection and improved educational resources as suggested above. Physicians and patients both expressed that some patients might automatically have their prescriptions filled and thus take antibiotics unnecessarily. Given that 2 patients had their “delayed” prescriptions filled immediately, this concern appears justified. No safeguard could entirely prevent inappropriate use by other family members.
Both physicians and patients commented that delayed prescribing is not appropriate for all patients. Patients need to understand the explanation of why antibiotics are not currently indicated and the instructions as to when they might be needed. In our opinion, patient comprehension might be greatly assisted by the use of clear handouts explaining, in patient-friendly terms, the management of upper respiratory tract infections.
The use of delayed prescribing in family practice is becoming more common.14,16-19 Considerable inconsistency and contradictory practices were found regarding its use in children and adults. Such diversity in physicians’ views regarding suitable ages raises questions about the optimal use of delayed prescriptions. Similarly, no consensus was found regarding circumstances and instructions under which physicians would use delayed prescribing. The development of more formalized recommendations regarding patient suitability and criteria for delayed prescribing is needed.
Given the concern that some patients might be confused about when to use a delayed prescription, placing the prescription in an envelope with clearly written instructions (ie, when to use and under what conditions) on the outside might ameliorate this difficulty. This practice might serve to further decrease unnecessary antibiotic use. Alternatively, special patient instructions in written form may be warranted, as was done in a controlled before–after study of delayed prescriptions for otitis media.15
In conclusion, previous research has shown delayed prescribing to be an effective means of decreasing antibiotic consumption for conditions not clinically warranting their use.14,15,19 However, not all physicians or patients demonstrated complete satisfaction with the strategy, and both groups agreed that selectivity is required for issuing a delayed prescription. Unlike interventions such as administering new drugs, physicians have spontaneously and independently generated the practice of delayed prescribing. Consequently, the practice varies considerably with respect to which patients, conditions, and instructions are considered appropriate. Formalizing recommendations for patient suitability and instructions for use may be required to ensure safety and consistency. Long-term safety issues will need to be monitored using longitudinal, large-cohort studies.