Focus: Infectious disease

What do parents want when it comes to prescribing antibiotics?

Rita Mangione-Smith, MD, MPH

Feeling pressured to prescribe an antibiotic when you don't believe it's medically necessary? Consider the author's recommendation to offer that parent a contingency plan—described here as a remedy for overprescribing.

The expectations of parents and patients are widely cited as a major cause of antibiotic overprescribing among pediatricians and other primary care providers,^1­7 and prescribing of antibiotics for viral illness is a major continuing problem.^8­10 Continued overprescribing of antibiotics will, ultimately, cause an increase in the rate of antibiotic-resistant infections,^11­13 thereby increasing morbidity and mortality.¹⁴

What happens during the doctor- parent (or doctor-patient) interaction is a key determinant of antibiotic overprescribing. We are beginning to understand how parents influence prescribing choices when they directly or indirectly communicate their desire for an antibiotic to physicians and how physicians can respond appropriately and successfully to such pressure.

In this article, I discuss several areas of this subject:

• what we know about determinants of antibiotic overprescribing

• how strongly parents' expectations influence prescribing practices

• how parents exert pressure to prescribe during the office visit

• how physicians might avoid prescribing antibiotics just because they feel pressured by parents to do so—thereby combating overprescribing in the practice.

Antibiotics for URI: A likely prescription?

The common cold is a leading cause of acute morbidity, visits to physicians, and school absenteeism among children in the United State.¹⁵ Despite a body of evidence that antibiotics have no role in the treatment of most of these infections,^16­21 it is estimated that 38% of children who are given a diagnosis of an upper respiratory infection (URI) leave the physician's office with an antibiotic prescription in their parents' hands.⁹ Approximately $40 million is spent on antibiotics for the common cold annually in the United States.²² We know that frequent antibiotic use is a risk factor for development of drug-resistant strains of bacteria, which are costly to treat when they cause infection and which result in increased mortality.^12,14,23­26

The decision to prescribe an antibiotic is complex and involves multiple factors (see table). Among these are the patient's age, the duration of symptoms and worsening of symptoms, findings on the physical examination, the physician's perception of whether parents expect a prescription for an antibiotic, parents' need to return to work (no so-called sick day care available for their child), the physician's concern about an adverse outcome if treatment is withheld, physician demographics, and specialty.^6,7,27­34

Determinants of antibiotic prescribing

In one study, 71% of family practitioners and 53% of pediatricians surveyed indicated that they would immediately prescribe an antibiotic for an infant who had a one-day history of signs of a URI; fewer respondents treated older children immediately (50% of family practitioners and 24% of pediatricians).³³ Patients who have a clear nasal discharge are less likely to receive an antibiotic,²⁹ whereas those who have had a fever for longer than 48 hours³⁰ or have a fever exceeding 38.5º C, symptoms lasting longer than three days,²⁸ postnasal drainage, yellow or green nasal drainage, rales or rhonchi, or sinus tenderness²⁹ are more likely to receive an antibiotic.

In a study of two private pediatric practices comprising 10 physicians,⁶ we found that the pediatricians prescribed an antibiotic for presumed viral illness 62% of the time when they thought that the parents expected one—compared with 7% of the time when they did not think that parents wanted an antibiotic. It is not surprising, therefore, that, in a recent survey by the Centers for Disease Control and Prevention (CDC), 58% of physicians reported that their decision to prescribe an antibiotic for children who had a URI was influenced by parents' pressure³⁴; 18% of pediatricians and 34% of family physicians surveyed by the CDC reported that avoiding a return visit—particularly when the family was insured by a managed care organization—was an incentive to provide an antibiotic for a child who had a common cold. (In that study, however, physicians who prescribed the fewest antibiotics for the common cold also had a lower rate of office visits for that condition.)

Another group of investigators found that, among children who were given a diagnosis of the common cold in the office, those who did not receive an antibiotic at the initial visit had an unexpected second visit in 29% of cases. On the other hand, those who initially received an antibiotic returned in 44% of cases.³⁵ Physicians who are further away (in years) from medical school graduation and who see more episodes of URI prescribe antibiotics for these illnesses more often. They are less likely, however, to use broad spectrum antibiotics than physicians who graduated from medical school more recently.^31,35

What do parents expect from visits for a cold?

Parents make visits to the pediatrician for their child who has a common cold with several expectations about what the doctor will ask and what he or she will tell them about the child's illness. These expectations include that the physician will:

• ask about the child's symptoms

• tell the parents the name of the child's illness and its cause

• tell them how to make the child feel better

• explain their choice of treatment.^6,27

At least one half of parents who make these visits report that they do not want an antibiotic for their child,^6,36 but physicians are not very successful at determining who among the parents and patients who visit their offices expects an antibiotic.^1­4,6,29 Although physicians often believe that parents will be dissatisfied if they do not receive an expected antibiotic, research has not supported this belief.^3,4,6,37

The key to satisfaction in these visits is high-quality physician-parent communication rather than writing a prescription for antibiotics. Parents often mainly want reassurance that their child who has symptoms of a cold does not have something more serious.²⁷

Some parents do expect to receive a prescription for an antibiotic when their child has a cold.^6,29,36 These parents often report having received antibiotics in the past when their children had a similar illness. Some of what parents expect, therefore, is based on their experience with the child's physician. If a physician gives a parent an antibiotic for the child's cold or bronchitis, it increases the likelihood that the parent will expect the same behavior the next time the child has the same kind of illness.

Communication breakdown

Gaps in communication often occur during the physician-parent encounter.³⁸ Why do we sometimes believe parents expect an antibiotic, when, in reality, they do not? From the findings of a recent in-depth study of more than 250 physician-parent encounters, we have learned why some of these communication breakdowns occur.^37,39

We conducted a survey of parents of children 2 to 10 years of age who came to see the pediatrician because of symptoms of a cold. First, we asked parents about their expectations for their child's visit; next, we recorded the visit on audiotape. After the visit, we asked parents about their level of satisfaction with the care their child had received. We also surveyed the physician after each visit to determine whether he or she thought the parent had expected to receive an antibiotic.

We found that the way parents presented their child's problem to the physician had a strong influence on whether the physician believed that they wanted an antibiotic.³⁹ When parents offered a possible bacterial diagnosis when they presented the child's problem, rather than simply listing the child's symptoms, the physician was much more likely to think that they expected an antibiotic. For example, a parent who proposed a diagnosis might say: "Caitlyn was up all night crying, and she vomited, so we decided we better bring her in to make sure she doesn't have an earache again." In contrast, a parent who only listed the child's symptoms might say: "Brendan was burning up last night with fever and has a really bad cough and runny nose, so we thought you had better check him out."

It is interesting to note that, in our study, the way parents presented the child's problem bore no relationship to their reported expectation about receiving an antibiotic. In other words, parents who expected an antibiotic were no more likely to offer a possible bacterial diagnosis when describing their child's problem than were parents who did not expect an antibiotic. This at least partly explains why physicians' perceptions of parents' expectations for antibiotics often do not match parents' actual expectations. The lesson appears to be that, when parents offer a possible bacterial diagnosis, physicians should not jump to the conclusion that what they want is an antibiotic. In such circumstances, parents may truly want only reassurance that their child does not have an ear infection or other problem that might require an antibiotic.

We also found that parents rarely directly asked for an antibiotic (1% of cases),³⁷ and were slightly more likely (10% of cases) to mention an antibiotic indirectly. For example, a parent might say: "Our neighbor has the same symptoms and he was started on an antibiotic by his doctor. Jesse plays with him just about every day." Any mention of antibiotics by the parent, direct or indirect, made the physician much more likely to believe that the parent expected to receive an antibiotic for the child. Parents who did not expect an antibiotic, however, were as likely to mention them during the visit as were parents who reported that they did expect to receive an antibiotic.

It is possible that physicians in our study misinterpreted the meaning of those statements, or that parents were not completely honest about whether they expected an antibiotic. At any rate, only 11% of parents—whether they expected an antibiotic or not—actually brought up the subject in the discussion during the child's visit with the physician. Because approximately 50% of parents in this study expected that their child's physician would prescribe an antibiotic,⁶ most did not voice their expectations to the physician.

This observation leads us to conclude that most parents probably use indirect methods to communicate their expectations about antibiotics; further research is needed to uncover how parents do this. If physicians can be made familiar with common communication behaviors that parents use when they expect an antibiotic, they will be better able to identify when they need to address antibiotics directly and discuss whether they are appropriate.

What can we conclude?

Antibiotic overprescribing continues to be a major problem despite several high-profile public campaigns to educate the public and to increase awareness of the problem among physicians. We know that physicians are often incorrect about what parents expect regarding antibiotics; those inaccurate perceptions may sometimes result from reaching the wrong conclusion about parents' expectations when they offer a possible bacterial diagnosis during their presentation of their child's problem, or when they bring up antibiotics as a topic of discussion.

Physicians who believe that a parent wants an antibiotic are much more likely to prescribe one for a cold and other probable viral illnesses. When you sense the pressure to prescribe an antibiotic and believe it is medically unnecessary, I recommend that you consider providing the parent with a contingency plan (see "A potent prescription for avoiding overprescribing," below), a simple communication device that we identified in the study just described.³⁷ Good physician-parent communication will result in greater parent satisfaction—and should reduce antibiotic overprescribing.

REFERENCES

1. Britten N, Ukoumunne O: The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: A questionnaire study. Brit Med J 1997;315:1506

2. Cockburn J, Pit S: Prescribing behaviour in clinical practice: Patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study. Brit Med J 1997;315:520

3. Hamm RM, Hicks RJ, Bemben DA: Antibiotics and respiratory infections: Are patients more satisfied when expectations are met? J Fam Pract 1996;43:56

4. Himmel W, Lippert-Urbanke E, Kochen MM: Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Primary Health Care 1997;15:118

5. Macfarlane J, Holmes W, Macfarlane R, et al: Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: Questionnaire study. Brit Med J 1997;315:1211

6. Mangione-Smith R, McGlynn EA, Elliott MN, et al: The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999;103:711

7. Vinson DC, Lutz LJ : The effect of parental expectations on treatment of children with a cough: A report from the ASPN. J Fam Pract 1993;37:23

8. Gonzalez R, Steiner JF, Sande MA : Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901

9. Nyquist A, Gonzales R, Steiner JF, et al: Antibiotics for children with upper respiratory infections. JAMA 1998;280:1301 (letter)

10. Schappert SM: Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1997. Vital Health Stat 13 1999; Nov;(143):i-iv,1­39

11. Deeks SL, Palacio R, Ruvinsky R, et al: Risk factors and course of illness among children with invasive penicillin-resistant Streptococcus pneumoniae. The Streptococcus pneumoniae Working Group. Pediatrics 1999;103:409

12. Nava JM, Bella F, Garau J, et al: Predictive factors for invasive disease due to penicillin-resistant Streptococcus pneumoniae: a population-based study. Clin Infect Dis 1994;19:884

13. Watanabe H, Sato S, Kawakami K, et al: A comparative clinical study of pneumonia by penicillin-resistant and sensitive Streptococcus pneumoniae in a community hospital. Respirology 2000;5:59

14. Feikin DR, Schuchat A, Kolczak M, et al: Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995­1997. Am J Pub Health 2000;90:223

15. Benson V, Marano MA: Current estimates from the National Health Interview Survey, 1995. Vital Health Stat 10 1998;Oct (199):3

16. Todd JK, Todd N, Damato J, Todd W: Bacteriology and treatment of purulent nasopharyngitis: A double blind, placebo- controlled evaluation. Pediatr Infect Dis 1984;3:226

17. Orr PH, Scherer K, MacDonald A, et al: Randomized placebo-controlled trials of antibiotics for acute bronchitis: A critical review of the literature. J Fam Pract 1993;36:507

18. Howie JGR, Clark GA: Double-blind trial of early demethyl-chlortetracycline in minor respiratory illness in general practice. Lancet 1970;2:1099

19. Gordon M, Lovell S, Dugdale A: The value of antibiotics in minor respiratory illness in children. Med J Austral 1974;1:304

20. Stott NCH, West RR: Randomised controlled trial of antibiotics in patients with cough and purulent sputum. Brit Med J 1976;2:556

21. Taylor B, Abbot GD, Kerr MM, Ferguson D: Amoxycillin and cotrimoxazole in presumed viral upper respiratory infections of childhood: Placebo controlled trial. Brit Med J 1977;2:552

22. Mainous AG, Hueston WJ, Clark JR: Antibiotics and upper respiratory infection: Do some folks think there is a cure for the common cold? J Fam Pract 1996;42:357

23. Radetsky MS, Istre GR, Johansen TL, et al: Multiply resistant pneumococcus causing meningitis: Its epidemiology within a day-care center. Lancet 1981;2:771

24. Jackson MA, Shelton S, Nelson JD, et al: Relatively penicillin-resistant pneumococcal infections in pediatric patients. Pediatr Infect Dis 1984;3:129

25. Reichler MR, Allphin AA, Breiman RF, et al: The spread of multiply resistant Streptococcus pneumoniae at a day-care center in Ohio. J Infect Dis 1992;166:1346

26. Tan TQ, Mason EO, Kaplan SL: Penicillin-resistant systemic pneumococcal infections in children: A retrospective case-control study. Pediatrics 1993;92:761

27. Barden LS, Dowell SF, Schwartz B, et al: Current attitudes regarding use of antimicrobial agents: Results from physicians' and parents' focus group discussions. Clin Pediatr 1998;37:665

28. Davy T, Dick PT, Munk P: Self-reported prescribing of antibiotics for children with undifferentiated acute respiratory tract infections with cough. Pediatr Infect Dis J 1998;17:457

29. Dosh SA, Hickner JM, Mainous AG, et al: Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. J Fam Pract 2000;49:407

30. Le Saux N, Pham B, Bjornson C, et al: Antimicrobial use in febrile children diagnosed with respiratory tract illness in an emergency department. Pediatr Infect Dis J 1999; 18:1078

31. Mainous AG, Hueston WJ, Love MM: Antibiotics for colds in children. Who are the high prescribers? Arch Pediatr Adolescent Med 1998;152:349

32. Pennie RA: Prospective study of antibiotic prescribing for children. Canadian Family Physician 1998;44:1850

33. Schwartz RH, Freij BJ, Ziai M, et al: Antimicrobial prescribing for acute purulent rhinitis in children: A survey of pediatricians and family practitioners. Pediatr Infect Dis J 1997;16:185

34. Watson RL, Dowell SF, Jayaraman et al: Antimicrobial use for pediatric upper respiratory infections: Reported practice, actual practice, and parent beliefs. Pediatrics 1999;104:1251

35. Pichichero ME, Green JL, Francis AB, et al: Outcomes after judicious antibiotic use for respiratory tract infections seen in a private pediatric practice. Pediatrics 2000;105:753

36. Braun BL, Fowles JB: Characteristics and experiences of parents and adults who want antibiotics for cold symptoms. Arch Fam Med 2000;9:589

37. Mangione-Smith R, McGlynn EA, Elliott MN, et al: Parent expectations for antibiotics, doctor-parent communication, and satisfaction. Arch Pediatr Adolesc Med 2001;155:800

38. Korsch BM, Gozzi EK, Francis V: Gaps in doctor-patient communication: Doctor patient interaction and patient satisfaction. Pediatrics 1968;42:855

39. Stivers T: Presenting the problem in pediatric encounters: "Symptoms only" versus "candidate diagnosis" presentations. Health Communication 2001 (in press)

THE AUTHOR is an assistant professor in the department of pediatrics, University of California, Los Angeles.

A potent prescription for avoiding overprescribing?

In our recent study of communication between physicians and parents,¹ we identified a simple communication technique that pediatricians can use to avoid overprescribing when the patient has a viral illness, while maintaining parents' satisfaction with the care their child receives. We call this communication technique a contingency plan. What is it?

In our contingency plan, the physician explains to the parents that antibiotics are not indicated at this time, but that they should return if their child does not get better or gets worse over the next one or two days—at which point antibiotics would probably be prescribed. Some physicians may already be using such a plan to communicate with parents; now we have objective data to support its use.

In our study, parents who expected antibiotics but did not receive them were significantly more satisfied when the physicians offered such a plan (see figure). In fact, parents who received a contingency plan tended to be more satisfied than parents who were given a prescription for antibiotics.

We caution physicians to avoid offering a telephone contingency plan, in which they promise to call in a prescription if the parent calls back and reports that their child is not improving. Such a plan clearly puts a physician at legal risk if he or she knowingly chooses not to reevaluate a child who has not improved or is getting worse.

A contingency plan is a simple communication technique that gives a child one or two days to recover spontaneously from a viral illness—the outcome in most cases. This technique also prevents parents from developing the belief that it was the antibiotic that prompted the improvement in their child's condition.

REFERENCE

1. Mangione-Smith R, McGlynn EA, Elliott MN, et al: Parent expectations for antibiotics, doctor-parent communication, and satisfaction. Arch Pediatr Adolesc Med 2001;155:800

Comparing all groups, only A and B are significantly different from each other (P < 0.05).

 

Rita Mangione-Smith. What do parents want when it comes to prescribing antibiotics?. Contemporary Pediatrics 2001;10:63.