Antibiotic Use in Acute Respiratory Infections and the Ways Patients Pressure Physicians for a Prescription
STUDY DESIGN: A multimethod comparative case study was performed including descriptive field notes of outpatient visits.
POPULATION: We included patients (children and adults) and clinicians in 18 purposefully selected family practices in a midwestern state. A total of 298 outpatient visits for acute respiratory tract (ART) infections were selected for analysis from more than 1600 encounters observed.
OUTCOMES MEASURED: Unnecessary antibiotic use and patterns of physician-patient communication were measured.
RESULTS: Antibiotics were prescribed in 68% of the ART infection visits, and of those, 80% were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines. Patients were observed to pressure physicians for medication. The types of patterns identified were direct request, candidate diagnosis (a diagnosis suggested by the patient), implied candidate diagnosis (a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness, appealing to life-world circumstances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptable reasons and diagnoses to patients.
CONCLUSIONS: Patients strongly influence the antibiotic prescribing of physicians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limited benefits of such use, and clinicians should consider appropriate responses to these different patient pressures to prescribe antibiotics.
Acute respiratory tract (ART) infections, such as common cold, bronchitis, pharyngitis, sinusitis, and otitis media, are among the most common problems seen in primary care practice.1 Unnecessary use of antibiotics for these infections is a major worldwide problem both in terms of cost2 and as a contributor to the development of antibiotic-resistant bacteria.3
Although there is some evidence that physicians misdiagnose many viral infections as bacterial,4,5 recent studies suggest that the reasons for unnecessary antibiotic prescribing are more complex, having as much or more to do with patient and physician expectations as with physicians’ diagnostic skills.6-8 These studies are limited to describing perceptions of behavior rather than actual behavior, because of their use of interview and focus group data. Consequently, we do not know what actually happens during outpatient visits for ART infections that leads to antibiotic prescribing.
Two studies by Stivers9,10 underscore the importance of directly observing what transpires during encounters with pediatric ART infection patients. Stivers’ examination of videotaped visits found that, in some cases, parental pressure for antibiotics influenced the physician’s decision to prescribe. This finding has not been replicated, however, in family practice settings, where both adults and children are seen. We used direct observation of outpatient visits to family physicians for ART infections to analyze the effects of physician-patient communication on unnecessary antibiotic prescribing. By understanding the ways these communication patterns influence prescribing behavior, practicing family physicians can develop strategies to deliver more appropriate care for ART infections.
Methods
These data were collected as part of the Prevention & Competing Demands in Primary Care Study, which was an in-depth observational study begun in October 1996 and completed in August 1999 that examined the organizational and clinical structures and process of community-based family practices. Each of 18 purposefully selected practices was studied using a multimethod comparative case study design that involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. Field researchers directly observed and dictated descriptions of approximately 30 patient encounters with each of the more than 50 clinicians. Details of the sampling and data collection are available elsewhere in this issue.11
Data Analysis and Interpretation
Encounters related to ART infection were identified in the database using search terms for symptoms and diagnoses including: sore throat, runny nose, congestion, cough, drainage, postnasal drainage, earache, cold, upper respiratory infection, pharyngitis, sinusitis, bronchitis, and otitis. ART infection was identified as the principal or associated diagnosis in 316 outpatient visits of a total of 1637 observed encounters; 298 had sufficiently rich data for analysis. The encounters were first coded for antibiotic use or nonuse.
Before any qualitative analysis began, visits during which antibiotics were prescribed were further characterized as appropriate or unnecessary according to guidelines by the Centers for Disease Control and Prevention (CDC) for judicious use of antibiotics for children12 and adults.Table W113* Two family physicians assigned appropriate/unnecessary codes independently. Inter-rater reliability was good (k=0.71). All disagreements were resolved by discussion.
Subsequently, the text for each outpatient visit was read independently by 2 family physicians, a medical anthropologist, a nurse, and a communication specialist. This research team discussed individual encounters as a group to identify emerging patterns of physician-patient interaction.
