Delayed antibiotic prescriptions: What are the experiences and attitudes of physicians and patients?
The Journal of Family Practice. 2002 November;51(11):954-959
November 1, 2002|The Journal of Family Practice
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- 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.
A general inductive approach, similar to grounded theory, was used. Individual written interview responses were initially analyzed to identify subthemes. Interviews were then collated and analyzed for emerging categories. These were combined into major themes through ongoing discussions with an experienced qualitative researcher (D.T.) and rereading of the transcripts by the first 3 authors until consensus was reached regarding the main themes being expressed. The data were double-coded by an independent researcher (N.K.) as a consistency check, and discrepancies were resolved by negotiation between 2 of the researchers (N.K., F.G.). Patient and physician data sets were coded separately.
Results
A picture emerged of both advantages and disadvantages of delayed prescription use. An associated scenario was the variability of criteria used to decide whether delayed prescribing was considered appropriate or inappropriate. Seven primary themes were identified (Table 1): value judgment of antibiotics, decreased antibiotic use, patient-centered factors, effects on the physician–patient relationship, patient convenience, adverse effects of delayed prescribing, and selectivity for use. Many themes were common to both groups of subjects. Examples of their responses illustrating the primary themes are shown in Table 2.
TABLE 1
Descriptions of themes
| Theme | Description |
|---|---|
| Value judgment of antibiotics | The perception that antibiotics are either “good and necessary” for people or “bad” for people |
| Decreased antibiotic use | The desire to decrease unnecessary antibiotic use to avoid patient side-effects, to decrease the drug bill for taxpayers, and to decrease the development of resistance to antibiotics |
| Patient-centered factors | The ability of physicians to educate patients and empower them to be more involved in decision making about their health care management |
| Effects on the physician–patient relationship | The perception that delayed prescribing might have ither positive effects (eg, reassuring patients and meeting their expectations for antibiotics) or negative effects (eg, negative patient perception of physician competence or increased patient concerns about entitlement from the health system) |
| Patient convenience | The time and money patients save |
| Adverse effects of delayed prescribing | The possible adverse effects, with potential medicolegal ramifications: the missing or masking of serious illness; the physician losing control of the patient’s medical situation; the physician becoming less able to monitor outcomes; the possibility that some patients might still take antibiotic unnecessarily; and/or the possibility that antibiotics might be saved and later used inappropriately by another family member |
| Selectivity for use | The factors determining who might get a delayed prescription: patient age, education, ability to understand English, transiency to the practice, and other varying criteria for use regarding specific conditions |
Answers from physicians and patients interviewed about their use of delayed prescriptions
| Theme | Quotes from physicians | Quotes from patients |
|---|---|---|
| Value judgment of antibiotics | “I wanted to prove to myself I could get better without antibiotics.” | |
| “I expect to get antibiotics if I go to the physician with the flu.” | ||
| Decreased antibiotic use | “Using a delayed prescription means you don’t give unnecessary antibiotics.” | “I don’t like putting unnecessary drugs intomy body.” |
| Patient-centered factors | “[Use of delayed prescribing provides] “an opportunity to educate and empower patients, allows them to make decisions for themselves, and offers them convenience of both access and cost. Otherwise they would have to return [to the physician’s office] if they [their condition] deteriorated.” | “I like to decide for myself; I know when I need antibiotics.” |
| “I prefer the physician to make the decision.” | ||
| Effects on the physician–patient relationship | “The patient goes out the door with something. It does not damage the physician–patient relationship; the patient does not feel short-changed.” | “Some parents panic; it helps to ease their “minds.” |
| “The patient might think you don’t know “ what you are doing, that you are sitting on the fence … the patient has decided to come to physician for advice and wants to be told what to do, not [be] given more options.” | “If I go to the physician, it is because I know I need antibiotics.” | |
| “Younger physicians these days don’t have the experience; they are too busy to know when something is really wrong.” | ||
| Patient convenience | “Patient convenience: preventing afterhours office visits saves the patient time and money.” | “It saved [me] time and money.” |
| Adverse effects of delayed prescribing | “Some patients will start right away anyway and use antibiotic when they really don’t need it. … [the physician has] no way of knowing whether they take it or not… [patients] may not seek medial attention if they get sicker because they have started the antibiotic and assume that’s all that can be done.” | “Some people might take it [antibiotics] unnecessarily.” |
| “There could be medicolegal problems with a litigious patient.” | “Maybe some people need to be told what to do and would get confused.” | |
| Selectivity for use | “I would never give [a delayed prescription] to very small children, infants, or even children younger than 3 or 4 [years].” | “[Delayed prescribing is] good for me but not necessarily for everybody. Many people … have a very poor understanding of medicines.” |
| “I mostly use it [delayed prescribing] in children younger than 6 years. | “I want the physician to make the decision when it’s my children; I’d rather take them back [to the office if necessary].” | |
| “I don’t use [delayed prescribing with] patients, especially elderly ones, having a past history of chronic illness—such as bronchitis, excessive smoking, sinusitis— that has required antibiotics.” |
