Back-up Antibiotic Prescriptions for Common Respiratory Symptoms

We performed an observational study on the current prescribing habits of our physicians. The study included prospective data collection on the use of a back-up antibiotic prescription strategy among patients presenting with complaints of common respiratory symptoms to 28 physicians and 2 physician extenders in 3 family practice clinics between January and April 1999. These clinics are part of the Scott & White Healthcare System and are located in Temple (Santa Fe Clinic), Waco, and Killeen, Texas.

The practice of providing back-up antibiotic prescriptions was regularly used by many of the physicians as part of their routine management options, while others were unfamiliar with the concept or used it only rarely. All physicians were advised of the study objectives and were encouraged to enroll patients who received back-up antibiotic prescriptions. However, the physicians were not asked to change their usual prescribing habits. The study protocol was approved by the Institutional Review Board of the Scott & White Memorial Hospital and Clinic.

Study Participants and Data Collection

A concerted effort was made to enroll all patients who presented with complaints of a head cold or respiratory symptoms during this 4-month period. Our inclusion criteria were strict but broad. Patients were enrolled in the study if they had head congestion, sinus congestion, fever, headache, cough, chest congestion, or sore throat. Patients were only excluded if they had one dominant symptom and physical finding, such as earache. In addition to the front desk personnel, physicians and nurses could also enroll patients in the study if the patient brought up the need for treatment of respiratory complaints that were not mentioned to the appointment clerks (eg, “Oh, by the way, while I am here for my blood pressure follow-up, would you check out my head cold. I think I may be coming down with something and thought maybe I should get some antibiotics.”).

When patients reported for their appointments, a physician survey was attached to the front of their chart by front desk office personnel. This survey could also be added to the chart when the patient was put into an examination room if the nurse was made aware of the patient’s expectation for evaluation of respiratory symptoms. The physician survey which was filled out at the conclusion of the office visit elicited information regarding: (1) physician and patient demographic information; (2) the patient’s primary complaints; (3) whether the physician was the patient’s primary care physician; (4) type of prescription given to the patient (an immediate-fill antibiotic prescription, a back-up antibiotic prescription, or no antibiotic prescription); and (5) physician subjective rating, on a 5-point scale, of the clinical necessity for prescribing antibiotics for the patient.

The patients who were given back-up antibiotic prescriptions were each given a patient survey to complete with instructions to return the form in a provided preaddressed envelope 7 days after their initial appointment. Patients who did not return their surveys were called by the research coordinator, and the surveys were completed over the phone.

The patient survey included questions about: (1) patient satisfaction with the care received; (2) their perceived need before the office visit for an antibiotic prescription; (3) whether they received a written back-up antibiotic prescription; (4) whether they filled the back-up prescription; and (5) whether they required any subsequent medical care for the same illness.

Definition of the Back-up Strategy

A back-up antibiotic prescription strategy was defined in our study as a prescription given to a patient along with instructions to fill the prescription only if the condition deteriorated or failed to improve within a predefined number of days. The exact number of days was not standardized by the study protocol, allowing each physician to customize this aspect of care.

Statistical Analysis

Data management and analysis were performed using SAS¹⁸ on a mainframe and the Statistical Package for the Social Sciences¹⁹ on a personal computer. We determined physicians’ use of the back-up antibiotic prescription strategy using selected variables by comparing study subjects who received back-up antibiotic prescriptions with those given immediate-fill prescriptions. We computed crude odds ratios (ORs) and 95% confidence intervals (CIs) for use of the back-up prescription strategy. Variables that were statistically significant in their bivariate relationship with use of the back-up antibiotic prescription strategy and those with some biological plausibility (eg, patient age) were entered into a multivariate logistic regression modeling to compute adjusted ORs.

We also computed patient satisfaction and fill rates of back-up antibiotic prescriptions. Agreement between patients’ perceived need for antibiotics before the office visit and physicians’ subjective rating of the clinical necessity to prescribe antibiotics for patients was assessed using the k statistic. To determine correlates of patient satisfaction with the back-up prescription strategy, we compared satisfaction rates of study subjects by patient and physician characteristics, the presenting respiratory complaints, and several selected characteristics. Finally, correlates of back-up prescription filling were similarly determined by comparing filling rates by the same characteristics.