Delayed antibiotic prescriptions: what are the experiences and attitudes of physicians and patients? - Original Research

Journal of Family Practice, Nov, 2002 by Bruce Arroll, Felicity Goodyear-Smith, David R. Thomas, Ngaire Kerse

* 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.

* KEY WORDS Antibiotics; family practice; qualitative evaluation; upper respiratory tract infection. (J Fam Pract 2002; 51:954-959)

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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 antibiotic-resistant 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." Couchman et al (14) reported that 50% of patients given "`back-up'" antibiotic prescriptions did not fill them. Cates (15) 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.'" Little et al studied its effectiveness in managing sore throat (17) and otitis media. (18) In our recently published RCT (19) 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.