Back-up Antibiotic Prescriptions for Common Respiratory Symptoms

Group differences were assessed for significance using the chi-square statistic or Fisher’s exact test for categorical variables and analysis of variance for continuous variables. All tests were 2-tailed and were considered significant at P <.05.

Results

A total of 947 patients were evaluated for common respiratory symptoms by 19 family physicians, 2 physician extenders (a nurse practitioner and a physician assistant), and 9 family medicine residents.

Rates and Correlates of Back-up Antibiotic Prescriptions

From the 947 enrolled patients with common respiratory symptoms, 441 (46.6%) were not given antibiotics: 286 (30.2%) were given back-up antibiotic prescriptions, and 220 (23.2%) were given immediate-fill antibiotic prescriptions. Patients younger than 35 years and those with complaints of cough were twice as likely to be given back-up antibiotic prescriptions. Female sex and health care provider role as a physician extender were the only physician characteristics that were positively associated with the use of back-up prescriptions. Neither the role as primary care physician nor the physician’s number of years in practice were related to the type of prescription given.

Of 286 patients given back-up antibiotic prescriptions, we obtained completed follow-up surveys from 255 (89.2%). There were no significant differences between respondents and nonrespondents regarding demographic variables.

Rate and Correlates of Patient Satisfaction

Of the 255 patients who responded, 245 (96.1%) reported that they were satisfied with the care they received at their visit. The majority of the patients (76.1%) felt that their illness would require an antibiotic when their appointment was scheduled. However, only 36.9% of their physicians felt that their illness warranted the use of antibiotics. There was no significant agreement (P=.08) between patients’ perceived need for antibiotics before the office visit and physicians’ subjective rating of the clinical necessity to prescribe antibiotics (Table 1).

Patient and physicians characteristics were not associated with patient self-reported satisfaction rate with the care they received. Satisfaction rates were, however, significantly associated with patient complaints of sinus congestion (Table 2) and a patient’s requirement for additional care at a later time for the same illness (Table 3). Patients with complaints of sinus congestion and those who required additional care at a later time reported significantly less satisfaction.

Fill Rate and Correlates of Back-up Antibiotic Prescription

The overall back-up antibiotic prescription fill rate was 50.2%. Fill rates did not differ significantly by patient characteristics or their self-reported satisfaction with the care received, physician characteristics, or whether the physician was the patient’s primary care physician.

Additional Care

Additional care (defined as any subsequent contact with a health care provider) was required for 9.0% (n=23) of the patients in our study who received back-up antibiotic prescriptions. Of these, 10 consulted by telephone about their illness. Another 12 made repeat office visits, and 1 made an emergency room visit for an exacerbation of asthma; that patient was subsequently admitted overnight for management of her asthma. Of the 23 patients who sought additional care, 17 (74%) filled their back-up antibiotic prescriptions.

Discussion

Several factors are associated with the overprescription of antimicrobials for common respiratory symptoms, including physician specialty, physician knowledge base of the natural history of viral respiratory infections, clinician and patient experiences, patient expectations, and economic pressures related to time and reimbursement. Mainous and colleagues²⁰ and Nyquist and coworkers²¹ have reported that family physicians and general practitioners have prescribed antibiotics significantly more than pediatricians for children with upper respiratory infections (URIs). Schwartz and colleagues²² also conducted a survey based on a written case scenario that highlighted the significant discrepancy between the prescribing habits of family physicians and pediatricians. Compared with 53% of pediatricians, 71% of family physicians would immediately prescribe an antibiotic for a child who had a single day of scant light green and yellow nasal discharge and low-grade fever (P=.001).

Both clinician and patient experiences may also promote antibiotic overusage. If a patient has received an antibiotic for a URI in the past and had a good outcome, that positive experience creates an impression that antibiotic therapy is required and proper.²³ Similarly when clinicians prescribe antibiotics and patients get better, the clinician may incorrectly assume a cause and effect relationship that reinforces the behavior. The negative experiences that a physician has with patients are also worth considering. Clearly, there are still patients who are adamant about getting an antibiotic for every minor cold they catch. These patient encounters are frequently frustrating and time-consuming for physicians, and the emotions they evoke are very powerful. Studies have shown that strong emotions may actually facilitate the memory process,²⁴ and these emotionally charged encounters are more memorable than the routine office visits. This situation may lead physicians into believing that many more patients will demand antibiotics than really would, and some physicians may be writing these questionable prescriptions to avoid conflict.