Back-up Antibiotic Prescriptions for Common Respiratory Symptoms

The expectations of patients also play a large role in perpetuating the overprescription of antibiotics. Vinson and Lutz²⁵ have shown that parental expectations have a large impact on decisions of physicians to prescribe antibiotics for children with cough. There is no doubt that many patients expect antibiotics for URIs. In our study 76% of the patients felt their illness would require an antibiotic before the office visit. Not meeting that expectation makes clinicians uncomfortable and fearful that patients will be dissatisfied, despite studies that show differently.¹⁷

In our study, half of the patients given a back-up antibiotic prescription filled it by the seventh day. What is the significance of this? Critics would say that we enabled many patients to get unnecessary antibiotics. We prefer to interpret the 50% fill rate as an overall reduction from the usual practice. We know from unpublished chart reviews of our physicians in acute care clinics that patients presenting with URIs receive antibiotics approximately 60% of the time. This rate is similar to what is quoted in the literature for antibiotic usage for URIs.²⁶ In our study, we found that approximately 23% of patients got an immediate-fill antibiotic, 30% got a back-up prescription, and the rest received advice on symptomatic management but no antibiotic treatment. The finding that only half of the back-up group filled their prescriptions is a significant reduction (approximately 15%) in overall antibiotic usage. Such a reduction has an immediate positive effect on all the problems caused by the overusage of antibiotics, and may have an impact on the expectations and behavior of these patients with future URIs.

We found that patients were generally very satisfied when a back-up antibiotic prescription strategy was used. Although 96% of respondents reported that they were satisfied with their care, we believe that there are multiple factors involved in patient satisfaction, but our study methodology did not allow us to isolate those that were attributed to the back-up antibiotic prescription strategy. However, in general, using this approach did not appear to affect overall satisfaction with the physician-patient encounter.

Limitations

There are many limitations to our study. First, during the study period there may have been an artificially high use of the back-up strategy compared with what normally occurs in our physician practices. All of the physicians involved were advised of the objectives of our study. The concept of a back-up prescription was not new to them, but those who were not familiar were encouraged to be open to the opportunity to use it. Other physicians who routinely used this strategy discussed their success with it and may have influenced some of their peers to use it more frequently. We suspect that the 30% rate of the back-up concept with URI patients may be an overestimate from the usual practice of these physicians. Also, the data were collected during the peak of the influenza season, and we suspect many of the physicians were more confident that much of what they were treating in the office was of viral etiology. Consequently, they would be more likely to use a back-up than an immediate-fill prescription. Also, simply knowing that the data were being collected may have changed some of the prescribing habits of the physicians in terms of their overall use of antibiotics (Hawthorne effect). Although no precise baseline use of antibiotics was established in this group of patients with these physicians, chart reviews of patients with similar complaints before the study indicated an antibiotic usage rate of 55%. (National figures derived from Medicare claims data indicate a rough estimate as high as 60%). Future studies should consider randomizing groups of physicians into users and nonusers of the back-up prescription strategy to more accurately measure the effects of this practice.

Another limitation to our study was that physicians were allowed to enroll patients even if they were not identified by the front office personnel as meeting the enrollment criteria. This may have introduced a selection bias in the study, although we know that the actual number of patients enrolled by physicians was only a fraction of the total. The use of a uniform standard protocol should be adhered to in future studies.

Finally, satisfaction rates were based on self-reported data. Because these patients were seen in their usual site of medical outpatient care they may have given socially desirable responses and been reluctant to report negative experiences fearing that the information would influence their future care.

Conclusions

The back-up antibiotic prescription strategy appears to be a reasonable option for treating patients with common respiratory symptoms in the ambulatory setting. It was associated with a high degree of patient satisfaction and may be useful as a method of re-educating patients and decreasing the use of antibiotics. The finding that half of the patients chose not to fill these prescriptions also suggests a potential health care cost savings opportunity.