Why do physicians think parents expect antibiotics? What parents report vs what physicians believe

OBJECTIVE: To examine the relation between parent expectations for antibiotics, parent communication behaviors, and physicians' perceptions of parent expectations for antibiotics. STUDY DESIGN: A nested cross-sectional study with parallel measures of parents presenting children for acute respiratory infections (previsit) and physicians (postvisit) and audiotaping of the encounters. POPULATION: Ten physicians in 2 private pediatric practices (1 community-based and 1 university-based) and a consecutive sample of 306 eligible parents (response rate, 86%) who were attending sick visits for their children between October 1996 and March 1997. OUTCOMES MEASURED: Communication behaviors used by parents expecting antibiotics and physicians' perceptions of parents' expectations. RESULTS: Parents' use of "candidate diagnoses" during problem presentation increased the likelihood that physicians would perceive parents as expecting antibiotics (from 29% to 47%; P=.04), as did parents' use of "resistance to the diagnosis" (an increase from 7% to 20%). In the multivariate model, parents' use of candidate diagnoses increased the odds that a doctor would perceive a parental expectation for antibiotics by more than 5 times (odds ratio, 5.23; 95% confidence interval, 3.74-7.31; Plt.001), and parents' use of resistance to a viral diagnosis increased these odds by nearly 3 times (odds ratio, 2.73; 95% confidence interval, 1.97-3.79; Plt.001). CONCLUSIONS: Parents perceived as expecting antibiotics may be seeking reassurance that their child is not seriously ill or that they were correct to obtain medical care. Physicians were significantly more likely to perceive parents as expecting antibiotics if they used certain communication behaviors. This study revealed an incongruity between parents' reported expectations, their communication behaviors, and physicians' perceptions of parents' expectations.     

Antibiotics for upper respiratory tract infections. Follow-up utilization and antibiotic use.

OBJECTIVES: To examine the effects of antibiotic prescribing during an initial visit for viral respiratory tract infections on future care seeking and the cost of care. MATERIALS AND METHODS: Retrospective analysis of recorded visits for viral respiratory tract infections (N = 49,862) between January 1, 1995, and December 31, 1997, to practices in a large network of affiliated practices that use the same electronic medical record. RESULTS: Patients receiving antibiotics at the initial visit were less likely to return for a second visit, but this difference was small (15.4% vs 17.4%, P < .001). When returning for the second visit, those who received an antibiotic on the initial visit were prescribed more expensive antibiotics than those who had not received an antibiotic on the initial consultation. Overall, cost from initial antibiotic use outweighed any benefit from reduced utilization in adults and children. CONCLUSIONS: Antibiotic prescribing at an initial contact for a viral respiratory tract illness may reduce the likelihood that an individual will return for a subsequent visit, but adds substantial costs to care for the initial antibiotic and for more expensive antibiotics used on subsequent visits.     

Debiasing effects of education about appropriate antibiotic use on consumers' preferences for physicians

A major goal of this research was to identify an antibiotic education intervention that would increase young adult consumers' preference for physicians who do not unnecessarily prescribe antibiotics for simple acute upper respiratory infections (URIs). Results clearly showed that consumers who read the CDC brochure entitled, "A New Threat to Your Health: Antibiotic Resistance" significantly preferred the physician who would not prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability than the physician who would prescribe antibiotics. In contrast, consumers who did not read the CDC brochure significantly preferred the physician who would prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability and greater concern for patients than the physician who would not prescribe antibiotics. Thus, consumers with low knowledge exhibited a treatment bias and preferred physicians who provided more treatment, and consumer education successfully reversed the treatment bias.     

Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing?

A previously identified communication behavior, online commentary, is physician talk that describes what he/she is seeing, feeling, or hearing during the physical examination of the patient. The investigators who identified this communication behavior hypothesized that its use may be associated with successful physician resistance to perceived or actual patient expectations for inappropriate antibiotic medication. This paper examines the relationship between actual and perceived parental expectations for antibiotics and physician use of online commentary as well as the relationship between online commentary use and the physician's prescribing decision. We conducted a prospective observational study in two private pediatric practices. Study procedures included a pre-visit parent survey, audiotaping of study consultations, and post-visit surveys of the participating physicians. Ten pediatricians participated (participation rate=77%) and 306 eligible parents participated (participation rate=86%) who were attending sick visits for their children with upper respiratory tract infections between October 1996 and March 1997. The main outcomes measured were the proportion of consultations with online commentary and the proportion of consultations where antibiotics were prescribed. Two primary types of online commentaries were observed: (1) online commentary suggestive of a problematic finding on physical examination that might require antibiotic treatment ('problem' online commentary), e.g., "That cough sounds very chesty"; and (2) online commentary that indicated the physical examination findings were not problematic and antibiotics were probably not necessary ('no problem' online commentary), e.g., "Her throat is only slightly red". For presumed viral cases where the physician thought the parent expected to receive antibiotics, if the physician used at least some 'problem' online commentary, he/she prescribed antibiotics in 91% (10/11) of cases. Conversely, when the physician exclusively employed 'no problem' online commentary, antibiotics were prescribed 27% (4/15) of the time (p = 0.07). Use of 'no problem' online commentary did not add significantly to visit length. 'No problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived expectations to prescribe antibiotics.     

Annals Journal Club: Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study

PURPOSE

Communication experts have suggested that it is good practice to ask patients’ directly whether they expect to receive antibiotics as part of asking about the triad of ideas, concerns, and expectations for health care. Our aim was to explore the views and experiences of family physicians about using this strategy with their patients, focusing the interview on the problem of eliciting expectations of antibiotics as a possible treatment for upper respiratory tract infections.

METHODS

We conducted a qualitative study using semistructured interviews with 20 family physicians in South Wales, United Kingdom, and performing thematic analysis.

RESULTS

Family physicians assumed most patients or parents wanted antibiotics, as well as wanting to be “checked out” to make sure the illness was “nothing serious.” Physicians said they did not ask direct questions about expectations, as that might lead to confrontation. They preferred to elicit expectations for antibiotics in an indirect manner, before performing a physical examination. The majority described reporting their findings of the examination as a “running commentary” so as to influence expectations and help avoid generating resistance to a soon-to-be-made-explicit plan not to prescribe antibiotics. The physicians used the running commentary to preserve and enhance the physician-patient relationship.

CONCLUSIONS

Real-world family physicians use indirect methods to explore expectations for treatment and, on the basis of their physical examination, build an argument for reassuring the patient or parent. In contrast to proposed models in the communication literature, interventions to promote appropriate antibiotic prescribing might include a focus on training in communication skills that (1) integrates these indirect methods as part of building collaborative physician-patient relationships and (2) uses the running commentary of examination findings to facilitate participation in clinical decisions.     

Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic use

BACKGROUND: Overuse of antibiotics for acute respiratory infections is an important public health problem and occurs in part because of pressure on physicians by patients to prescribe them. We hypothesized that if acute respiratory infections are called "chest colds" or "viral infections" rather than "bronchitis," patients will be satisfied with the diagnosis and more satisfied with not receiving antibiotics. METHODS: Family medicine patients were presented with a written scenario describing a typical acute respiratory infection where they were given one of 3 different diagnostic labels: chest cold, viral upper respiratory infection, and bronchitis, followed by a treatment plan that excluded antibiotic treatment. Data was analyzed for satisfaction with the diagnosis and treatment plan based on the diagnostic label. A total of 459 questionnaires were collected. RESULTS: Satisfaction (70%, 63%, and 68%) and dissatisfaction (11% 13%, and 13%) with the diagnostic labels of cold, viral upper respiratory infection, and bronchitis, respectively, showed no difference (chi(2) = 0.368, P = .832). However, more patients were dissatisfied with not receiving an antibiotic when the diagnosis label was bronchitis. A total of 26% of those that were told they had bronchitis were dissatisfied with their treatment, compared with 13% and 17% for colds and viral illness, respectively, (chi(2) = 9.380, P = .009). Binary logistic regression showed no difference in satisfaction with diagnosis for educational attainment, age, and sex (odds ratio (OR) = 1.09, 1.00, 0.98, respectively), or for satisfaction with treatment (OR = 1.1, 1.02, 1.00, respectively). CONCLUSIONS: Provider use of benign-sounding labels such as chest cold when a patient presents for care for an acute respiratory infection may not affect patient satisfaction but may improve satisfaction with not being prescribed an antibiotic.     

Why are antibiotics prescribed for patients with acute bronchitis? A postintervention analysis

BACKGROUND: Despite the findings in controlled trials that antibiotics provide limited benefit in the treatment of acute bronchitis, physicians frequently prescribe antibiotics for acute bronchitis. The aim of this study was to determine whether certain patient or provider characteristics could predict antibiotic use for acute bronchitis in a system where antibiotic use had already been substantially reduced through quality-improvement efforts. METHODS: A retrospective chart review was performed in an academic family medicine training center that had previously instituted a quality-improvement project to reduce antibiotic prescribing for acute bronchitis. Patients who had acute bronchitis diagnosed during an 18-month period and who had no other secondary diagnosis for respiratory distress or a condition that would justify antibiotics were selected from a computerized-record database and included in the study (n = 135). Charts were reviewed to document patient symptoms, physical findings, provider and patient characteristics, and treatment. RESULTS: Thirty-five (26%) patients received antibiotics for their acute bronchitis. Adults were more likely to receive antibiotics than children (34% vs 3%, P < .001). Analysis of 20 different symptoms and physical findings showed that symptoms and signs were poor predictors of antibiotic use. Likewise, no significant differences were found based on prescribing habits of individual providers or provider level of training. CONCLUSION: In a setting where antibiotic use for acute bronchitis had been decreased through an ongoing quality-improvement effort, it did not appear that providers selectively used antibiotics for patients with certain symptoms or signs. Other factors, such as nonclinical cues, might drive antibiotic prescribing even after clinical variation is suppressed.     

Association between health insurance and antibiotics prescribing in four counties in rural China.

A cross-sectional study was carried out at county, township and village health care facilities in four counties in rural China in order to describe and compare the effects of health financing systems on antibiotic prescribing in outpatient care. A total of 1232 outpatients at the health care facilities was selected by multi-stage random sampling and were interviewed over 2 weeks. The results showed that health financing systems appeared to influence antibiotic prescribing in outpatient care, both in terms of frequency and of the types prescribed. The insured group had lower prescribing of antibiotics at township and village health care facilities, and for respiratory tract infections, but had higher prescribing of newer antibiotics at county and village health care facilities, for respiratory tract and g-i infections. Because there was a high patient compliance rate (94.3%) in this study the prescribing of antibiotics (supply side behavior) reflected the use of antibiotics (demand side behavior) to a great extent. Thus the results imply that antibiotics prescribing and using might be biased by the patient's health financing systems and antibiotic prescribing was the result of the interaction between physicians and patients.     

The relationship between treatment objectives and practice patterns in the management of urinary tract infections.

OBJECTIVE: To describe physicians' goals when treating uncomplicated urinary tract infections (UTIs) and the relationship between goals and practice patterns. STUDY DESIGN: Analysis of survey results. POPULATION: Primary care physicians. OUTCOMES MEASURED: Self-reported treatment objectives and practice patterns. RESULTS: Most physicians reported their UTI management was convenient for the patient (81.3%). Fewer stated they minimized patients' costs (53.4%), made an accurate diagnosis (56.7%), or avoided unnecessary antibiotics (40.9%). Physicians who stressed convenience or minimizing patient expenses were less likely to use many resources (urine culture, microscopic urinalysis, followup visits and tests, and prolonged antibiotic treatment) and more likely to use telephone treatment. Physicians who stressed accurate diagnoses or avoiding unnecessary antibiotics were more likely to use the same resources and less likely to use telephone treatment. CONCLUSION: UTI management goals vary across physicians and are associated with different clinical approaches. Differences in treatment objectives may help explain variations in practice patterns.     

The physician's role in educating patients. A comparison of mailed versus physician-delivered patient education

BACKGROUND: Patients value receiving educational information during office visits, but physicians often lack the time or training to satisfy this need. We examined whether an increased physician role in educating patients is an effective means of improving patient satisfaction. METHODS: Using a nonrandomized controlled research design, we compared patient satisfaction with self-care information provided by traditional direct-mail approaches and by physicians during routine office visits. We also studied a control group of patients receiving usual care. RESULTS: Patients who received a medical self-care book from a physician were significantly more likely to be satisfied with their office visit than those who received the book in the mail or those who experienced usual care. The intervention group reported greater satisfaction with 11 out of 13 variables related to physician-patient communication and quality of care. There were no significant differences between the control group and the direct-mail group. CONCLUSIONS: The patients who received self-care information from their physicians were significantly more satisfied with their care and their physician-patient communication experience than those in either the direct-mail group or the control group. Our findings lend support to the growing evidence that patients informed by their physicians are more satisfied with their care.