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E-mail Communications in Family Practice What Do Patients Expect?
STUDY DESIGN: A cross-sectional, in-person prevalence survey.
POPULATION: Patients (n=950) with scheduled appointments to see a primary care provider in 6 of 18 family practice clinics in a large health care delivery system in central Texas.
OUTCOMES MEASURED: The proportion of patients with E-mail access, their willingness to use it, and their expectations regarding the timeliness of responses to their E-mail queries about selected clinical services.
RESULTS: Overall, 54.3% of the patients reported having E-mail access, with significant variation among the 6 clinics (33%-75%). Reported areas of strongest desire for using E-mail were to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Patients’ expectations regarding the timeliness of responses to their E-mail queries varied by clinical service. For laboratory results, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26%.
CONCLUSIONS: Most patients attending family practice clinics in central Texas have E-mail access and indicate they would use it to request prescription refills, for nonurgent consultations, and to obtain routine laboratory results or test reports. Regardless of sex or race, patients have high expectations that these tasks can be completed within a relatively short time.
E-mail use has been reported in a variety of broad areas, including biomedical communication, general patient surveys2,3 and medical practice4-8; it is also used by several institutions.9 Approximately half of all US adults report that they currently use E-mail at home or at work, and as many as 40% of patients would use E-mail to communicate with their physicians.10 Experts estimate that 5% to 10% of physicians are already communicating with their patients by E-mail.11
There are many potential benefits to E-mail in medical practice.10,12 It allows for efficient asynchronous communication. It eliminates phone tag, and the caller does not incur long-distance phone charges. E-mail is also a good marketing tool and lends itself well to linkage with patient education Web sites. Another advantage is improved documentation. By simply printing and including or copying all E-mail communications in the medical record, excellent documentation of the provider-patient discourse is obtained. This form of provider-patient communication may be very beneficial financially in capitated environments, where simple medical problems can be addressed without an office visit.
Along with these benefits, however, come significant potential disadvantages.3,12,13 Many physicians are afraid that E-mail would allow patients too much access, and consequently they are reluctant to embrace this innovative communication tool. There are related concerns that patients will barrage their physicians with excessive E-mails on trivial matters. It could become another physician hassle factor of practice and create one more thing to do at the end of the day. Also, there are genuine fears that patients will think of E-mail as a hot line to the physician’s office and inappropriately use it for emergent situations, creating additional liabilities for the physician and staff. There are also very real concerns about privacy and security: How can this exchange of information between providers and patients be protected and kept confidential if it is on the Internet?
Although it is generally agreed that some guidelines are required to manage and regulate E-mail communication between patients and their health care providers,14,15 it is equally important to assess the actual desire for this technology in specific practices. We conducted a needs assessment for E-mail communication between family physicians, other health care providers, and their patients attending 6 family practice clinics in central Texas.
Methods
Study Design and Setting
We performed a cross-sectional, in-person prevalence survey using patients with scheduled appointments to see a primary care physician in 6 of the 18 clinics of the Scott & White Healthcare System in central Texas: Northside Clinic and Santa Fe Clinic in Temple, Belton Clinic, Killeen Clinic, Bryan/College Station Clinic, and Waco Clinic. Temple, Belton, and Killeen are all located in Bell County, while Bryan/College Station is located in Brazos County, the site of the main campus of Texas A&M University. The Scott & White Institutional Review Board reviewed the study protocol.
Study Participants and Data Collection
A concerted effort was made to enroll all patients who presented to each of the 6 clinics on preselected days for the surveys. The days differed by clinic and were selected to enroll a specified number of patients according to clinic size for a total of approximately 1000 subjects. The newly opened Northside Clinic was an exception.
The survey included questions about: (1) current Internet and E-mail access; (2) how likely it was that patients would use E-mail for selected clinical services, if available, scored on a 5-point Likert scale; (3) what in their opinion was a reasonable response time to their E-mail communication about routine laboratory results, prescription refills, and medical questions; and (4) demographic information including sex, age, race/ethnicity, education, and annual family income.
Statistical Analysis
Data management and analysis were performed using SPSS software16 on a personal computer. We determined the proportion of patients with access to the Internet and E-mail by clinic. Overall, reported desired areas for using E-mail for selected clinical services were computed as the combined responses of 3 to 5 on the 5-point Likert scale. Reported desired areas for using E-mail were also computed as mean responses on the scale. We determined patient expectations regarding the timeliness of their E-mail queries. Group differences were assessed for significance using the c2 statistic or Fisher exact test for categorical data and the nonparametric Kruskal-Wallis analysis of variance test for ordinal (Likert-style) data. Finally, multivariate logistic regression modeling was used to control for measured covariates on the 5 main outcome variables. All tests were 2-tailed and considered significant at P less than .05.
Results
E-mail Access
Overall, 54.3% of the patients reported having E-mail access, with a significant wide variation (33%-75%) among the 6 clinics Table 1. Internet access rates mirrored those of E-mail access rates.
Desired Areas for Using E-mail
On the basis of the combined responses of 3 to 5 on the 5-point Likert scale, we found that patients most wanted to use E-mail to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Using E-mail to make or cancel appointments (78%) was the area of least interest reported by all patients Figure 1.
The reported desire to use E-mail for selected clinical services varied by patient demographic characteristics, using mean responses on the 5-point Likert scale. However, after multivariate adjustment for other measured variables, we only found 2 significant associations. African Americans were somewhat less likely than other groups to want to use E-mail to get laboratory results or test reports, and older patients were significantly less interested in using E-mail to consult a nurse on nonurgent simple medical questions.
Timeliness of Responses to E-mail Queries
Patients’ expectations of the timeliness of responses to their E-mail queries varied significantly by selected clinical services but not by clinic. For routine laboratory results, for example, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26% Table 2.
No sex or racial/ethnic differences were found regarding the timeliness of responses to E-mail queries for the 3 selected clinical services. Additionally, there were no demographic differences for the timeliness of responses to E-mail queries about prescription refills. However, there were significant age group and income differences in the timeliness of responses to patients’ E-mail queries on laboratory results or test reports. Although the majority of patients in each age group expected a response to their E-mail queries on laboratory results or test reports within 24 hours, only 6% of patients aged 65 years and older expected a response later than 24 hours compared with 20% to 29% of patients in other age groups. Surprisingly, patients with annual family incomes at both extremes had significantly higher expectations for the timeliness of responses to E-mail queries on laboratory results or test reports than their counterparts in the middle income brackets. Also, patients with educational levels at both extremes, particularly those with less than a high school education, had significantly higher expectations regarding the timeliness of responses to queries on medical questions Table 3.
Discussion
Our findings confirmed some of our suppositions and brought new information to light. We were not surprised to find that slightly more than 50% of our patients had E-mail and Internet access. This statistic is similar to those reported in other published literature.2,3 However, we could not completely explain the large variation from site to site within our own health care system. One plausible explanation for the relatively high rate of E-mail access observed at the Bryan/College Station Clinic is its location in a university town, where the clinic clientele is more likely to have an overall higher level of education than that in some of our other sites.
Recently it was reported in the Dallas Business Journal17 that nearly half of 1000 adult patients interviewed during a Laurus Health.com telephone survey said they would like to have E-mail access to their physician’s appointment scheduling system. In our study, we found a very strong desire for this service (78%) among our patient population. The Laurus Health.com survey also reported that 37% of all patients wanted electronic access to their test results. Our study found that 84% of our patients with E-mail access desired this capability. In fact, our study found a degree of interest in electronic communication with their health care provider that was very similar to that of a University of Michigan study of patients in a general medicine clinic. In the University of Michigan study, 70% of patients surveyed indicated their willingness to communicate with their health care provider using E-mail.18
Although it has been reported that consumers are 35% more likely to choose a physician who offers to communicate with patients using E-mail,17 this is not a marketing strategy that physicians should take lightly. From our study, one could assume that patients have very high expectations regarding response times for this form of provider-patient communication. One of the more disconcerting findings of our study was the exceptionally rapid turnaround time patients expected for obtaining laboratory results or test reports, prescription refills, and answers to their medical questions. Knowing that patients would expect these results within 24 hours at least 70% of the time may be unsettling to many physicians who would feel that this time frame is not attainable with the current system of laboratory processing and handling patient requests. Meeting those expectations may require major changes for physician practices.
The Health Institution Portability and Accountability Act of 1996 places comprehensive new security requirements on the US health care industry.19,20 The standards for privacy and protection of all health information that can be linked directly to an individual mandate that all patient E-mail communication be as secure as possible. Physicians using E-mail with their patients must be familiar and be compliant with these federal regulations.* The Journal of the American Medical Informatics Association also recently published “guidelines for the clinical use of electronic mail with patients.”14 This is an excellent reference for any physician considering E-mail communication and is available at their Web site (www.amia.org).
Limitations
Our study has several limitations. The surveys involved patients who were being seen in 6 clinics in central Texas; therefore, this sample may not truly represent the population at large. Also, all patients were scheduled to see family physicians, limiting the ability to generalize our findings to other disciplines. Future studies should expand beyond one discipline to include other primary care and specialty care departments. Also, the survey results reflect patients’ self-reported anticipated behavior if services were available and do not reflect actual usage. Another limitation is the small number of racial/ethnic minority groups.
The survey instrument we used lacked specificity on some questions. For example, we do not know whether patient expectations vary by test (ie, Do patients expect a faster response to a blood test than to an x-ray or a Papanicolaou test?) Future studies should use more specific survey instruments. Our study did not include an assessment of urban versus rural differences in E-mail communication, although it would seem that factors such as access, time, and lack of knowledge about this new technology may make a difference.21 Additionally, many previous studies have unveiled disparities in health care access between urban and rural populations, defined as places with fewer than 2500 residents. For example, the 25% of Americans who live in rural areas are less likely to use preventive screening services and wear seat belts. Also, in 1996, 20% of the rural population was uninsured, compared with 16% of the urban population.22 Future studies should incorporate this variable in the data collection process.
Conclusions
In central Texas the majority of patients attending6 family practice clinics reported having access to E-mail and indicated they would use it to request prescription refills, obtain routine laboratory results or test reports, and for nonurgent consultations independent of their age group, sex, education, or income. Also, there was a wide variability of E-mail access from practice to practice. Independent of sex or race, patients have high expectations that these tasks can be completed in a relatively short time.
Acknowledgments
We wish to acknowledge the contributions made by all the family physicians, operations managers, and supervisors at the 6 participating clinics during the data collection. We are also grateful to Pat Kirkpatrick for her initial ideas, Saundra Mason for data management, and Marcine Chambers, Linda Teer, and Virginia Gray for secretarial support.
Related resources
- American Medical Informatics Association—nonprofit organization of individuals, institutions and corporations dedicated to developing and using information technologies to improve health care. http://www.amia.org
- California Academy Of Family Physicians—offers monograph on “Making the Most of Physician-Patient E-mail.” http://www.familydocs.org
1. Costello R, Shaw A, Cheetham R, Moots RJ. The use of electronic mail in biomedical communication. JAMIA 2000;7:103-05.
2. Fridsma DB, Ford P, Altman R. A survey of patient access to electronic mail: attitudes, barriers and opportunities. Proc Annu Symp Comput Appl Med Care 1994;15-19
3. Mold JW, Cacy JR, Barton ED. Patient-physician e-mail communication. J Okla State Med Assoc 1998;91:331-34.
4. Sands DZ, Safran C, Slack WV, Bleich HL. Use of electronic mail in a teaching hospital. Proc Annu Symp Comput Appl Med Care 1993;306-10.
5. Nettelman MD, Olcahnski V, Perlin JB. E-mail medicine: dawn of a new era in physician-patient communication. Clin Perform Qual Health Care 1998;6:138-41.
6. Neill RA, Mainous AG, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
7. Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998;129:495-500.
8. Kuppersmith RB. Is e-mail an effective medium for physician-patient interaction? Arch Otolaryngol Head Neck Surg 1999;125:468-70.
9. Singarella T, Baxter J, Sandefur RR, Emery CC. The effects of electronic mail on communication in two health science institutions. J Med Syst 1993;17:69-86.
10. Badal P. Email contact between doctor and patient. BMJ 1999;318:1428.-
11. Provider-patient e-mail could transform medicine. Healthc Benchmarks 1999;6:53-55.
12. The Net. Medical email has benefits, risks. Available at:news.cnet.com/news/. Accessed January 20, 2000.
13. E-mail contact between doctor and patient. Med Pract Communicator 1999;6:5.-
14. Kane B, Sands DZ. for the AMIA Internet Working Group. Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. Guidelines for the clinical use of electronic mail with patients. JAMIA 1998;5:104-11.
15. Taylor K. The clinical e-mail explosion. Physician Exec 2000;26:40-45.
16. SPSS Inc. Statistical package for the social sciences for Windows. Version 8. Chicago, Ill: SPSS Inc; 1996.
17. Dallas Business Journal, August 28, 2000. [Author: Please provide author and title of article]
18. University of Michigan. University of Michigan study finds patients and physicians encourage E-mail use. Available at:www.med.umich.edu/choices/intel.html. Accessed November 27, 1999.
19. Braithwaite W. HIPAA and the administration simplification law. MD Comput 1999;16:13-16.
20. Amatayakul M. HIPAA update: achieving compliance with the new standards. MD Comput 2000;17:54-56.
21. Kalsman MW, Acosta DA. Use of the Internet as a medical resource by rural physicians. J Am Board Fam Pract 2000;13:349-52.
22. US Department of Health and Human Service. Healthy people 2010. Washington, DC: US Department of Health and Human Service; 2000.
STUDY DESIGN: A cross-sectional, in-person prevalence survey.
POPULATION: Patients (n=950) with scheduled appointments to see a primary care provider in 6 of 18 family practice clinics in a large health care delivery system in central Texas.
OUTCOMES MEASURED: The proportion of patients with E-mail access, their willingness to use it, and their expectations regarding the timeliness of responses to their E-mail queries about selected clinical services.
RESULTS: Overall, 54.3% of the patients reported having E-mail access, with significant variation among the 6 clinics (33%-75%). Reported areas of strongest desire for using E-mail were to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Patients’ expectations regarding the timeliness of responses to their E-mail queries varied by clinical service. For laboratory results, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26%.
CONCLUSIONS: Most patients attending family practice clinics in central Texas have E-mail access and indicate they would use it to request prescription refills, for nonurgent consultations, and to obtain routine laboratory results or test reports. Regardless of sex or race, patients have high expectations that these tasks can be completed within a relatively short time.
E-mail use has been reported in a variety of broad areas, including biomedical communication, general patient surveys2,3 and medical practice4-8; it is also used by several institutions.9 Approximately half of all US adults report that they currently use E-mail at home or at work, and as many as 40% of patients would use E-mail to communicate with their physicians.10 Experts estimate that 5% to 10% of physicians are already communicating with their patients by E-mail.11
There are many potential benefits to E-mail in medical practice.10,12 It allows for efficient asynchronous communication. It eliminates phone tag, and the caller does not incur long-distance phone charges. E-mail is also a good marketing tool and lends itself well to linkage with patient education Web sites. Another advantage is improved documentation. By simply printing and including or copying all E-mail communications in the medical record, excellent documentation of the provider-patient discourse is obtained. This form of provider-patient communication may be very beneficial financially in capitated environments, where simple medical problems can be addressed without an office visit.
Along with these benefits, however, come significant potential disadvantages.3,12,13 Many physicians are afraid that E-mail would allow patients too much access, and consequently they are reluctant to embrace this innovative communication tool. There are related concerns that patients will barrage their physicians with excessive E-mails on trivial matters. It could become another physician hassle factor of practice and create one more thing to do at the end of the day. Also, there are genuine fears that patients will think of E-mail as a hot line to the physician’s office and inappropriately use it for emergent situations, creating additional liabilities for the physician and staff. There are also very real concerns about privacy and security: How can this exchange of information between providers and patients be protected and kept confidential if it is on the Internet?
Although it is generally agreed that some guidelines are required to manage and regulate E-mail communication between patients and their health care providers,14,15 it is equally important to assess the actual desire for this technology in specific practices. We conducted a needs assessment for E-mail communication between family physicians, other health care providers, and their patients attending 6 family practice clinics in central Texas.
Methods
Study Design and Setting
We performed a cross-sectional, in-person prevalence survey using patients with scheduled appointments to see a primary care physician in 6 of the 18 clinics of the Scott & White Healthcare System in central Texas: Northside Clinic and Santa Fe Clinic in Temple, Belton Clinic, Killeen Clinic, Bryan/College Station Clinic, and Waco Clinic. Temple, Belton, and Killeen are all located in Bell County, while Bryan/College Station is located in Brazos County, the site of the main campus of Texas A&M University. The Scott & White Institutional Review Board reviewed the study protocol.
Study Participants and Data Collection
A concerted effort was made to enroll all patients who presented to each of the 6 clinics on preselected days for the surveys. The days differed by clinic and were selected to enroll a specified number of patients according to clinic size for a total of approximately 1000 subjects. The newly opened Northside Clinic was an exception.
The survey included questions about: (1) current Internet and E-mail access; (2) how likely it was that patients would use E-mail for selected clinical services, if available, scored on a 5-point Likert scale; (3) what in their opinion was a reasonable response time to their E-mail communication about routine laboratory results, prescription refills, and medical questions; and (4) demographic information including sex, age, race/ethnicity, education, and annual family income.
Statistical Analysis
Data management and analysis were performed using SPSS software16 on a personal computer. We determined the proportion of patients with access to the Internet and E-mail by clinic. Overall, reported desired areas for using E-mail for selected clinical services were computed as the combined responses of 3 to 5 on the 5-point Likert scale. Reported desired areas for using E-mail were also computed as mean responses on the scale. We determined patient expectations regarding the timeliness of their E-mail queries. Group differences were assessed for significance using the c2 statistic or Fisher exact test for categorical data and the nonparametric Kruskal-Wallis analysis of variance test for ordinal (Likert-style) data. Finally, multivariate logistic regression modeling was used to control for measured covariates on the 5 main outcome variables. All tests were 2-tailed and considered significant at P less than .05.
Results
E-mail Access
Overall, 54.3% of the patients reported having E-mail access, with a significant wide variation (33%-75%) among the 6 clinics Table 1. Internet access rates mirrored those of E-mail access rates.
Desired Areas for Using E-mail
On the basis of the combined responses of 3 to 5 on the 5-point Likert scale, we found that patients most wanted to use E-mail to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Using E-mail to make or cancel appointments (78%) was the area of least interest reported by all patients Figure 1.
The reported desire to use E-mail for selected clinical services varied by patient demographic characteristics, using mean responses on the 5-point Likert scale. However, after multivariate adjustment for other measured variables, we only found 2 significant associations. African Americans were somewhat less likely than other groups to want to use E-mail to get laboratory results or test reports, and older patients were significantly less interested in using E-mail to consult a nurse on nonurgent simple medical questions.
Timeliness of Responses to E-mail Queries
Patients’ expectations of the timeliness of responses to their E-mail queries varied significantly by selected clinical services but not by clinic. For routine laboratory results, for example, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26% Table 2.
No sex or racial/ethnic differences were found regarding the timeliness of responses to E-mail queries for the 3 selected clinical services. Additionally, there were no demographic differences for the timeliness of responses to E-mail queries about prescription refills. However, there were significant age group and income differences in the timeliness of responses to patients’ E-mail queries on laboratory results or test reports. Although the majority of patients in each age group expected a response to their E-mail queries on laboratory results or test reports within 24 hours, only 6% of patients aged 65 years and older expected a response later than 24 hours compared with 20% to 29% of patients in other age groups. Surprisingly, patients with annual family incomes at both extremes had significantly higher expectations for the timeliness of responses to E-mail queries on laboratory results or test reports than their counterparts in the middle income brackets. Also, patients with educational levels at both extremes, particularly those with less than a high school education, had significantly higher expectations regarding the timeliness of responses to queries on medical questions Table 3.
Discussion
Our findings confirmed some of our suppositions and brought new information to light. We were not surprised to find that slightly more than 50% of our patients had E-mail and Internet access. This statistic is similar to those reported in other published literature.2,3 However, we could not completely explain the large variation from site to site within our own health care system. One plausible explanation for the relatively high rate of E-mail access observed at the Bryan/College Station Clinic is its location in a university town, where the clinic clientele is more likely to have an overall higher level of education than that in some of our other sites.
Recently it was reported in the Dallas Business Journal17 that nearly half of 1000 adult patients interviewed during a Laurus Health.com telephone survey said they would like to have E-mail access to their physician’s appointment scheduling system. In our study, we found a very strong desire for this service (78%) among our patient population. The Laurus Health.com survey also reported that 37% of all patients wanted electronic access to their test results. Our study found that 84% of our patients with E-mail access desired this capability. In fact, our study found a degree of interest in electronic communication with their health care provider that was very similar to that of a University of Michigan study of patients in a general medicine clinic. In the University of Michigan study, 70% of patients surveyed indicated their willingness to communicate with their health care provider using E-mail.18
Although it has been reported that consumers are 35% more likely to choose a physician who offers to communicate with patients using E-mail,17 this is not a marketing strategy that physicians should take lightly. From our study, one could assume that patients have very high expectations regarding response times for this form of provider-patient communication. One of the more disconcerting findings of our study was the exceptionally rapid turnaround time patients expected for obtaining laboratory results or test reports, prescription refills, and answers to their medical questions. Knowing that patients would expect these results within 24 hours at least 70% of the time may be unsettling to many physicians who would feel that this time frame is not attainable with the current system of laboratory processing and handling patient requests. Meeting those expectations may require major changes for physician practices.
The Health Institution Portability and Accountability Act of 1996 places comprehensive new security requirements on the US health care industry.19,20 The standards for privacy and protection of all health information that can be linked directly to an individual mandate that all patient E-mail communication be as secure as possible. Physicians using E-mail with their patients must be familiar and be compliant with these federal regulations.* The Journal of the American Medical Informatics Association also recently published “guidelines for the clinical use of electronic mail with patients.”14 This is an excellent reference for any physician considering E-mail communication and is available at their Web site (www.amia.org).
Limitations
Our study has several limitations. The surveys involved patients who were being seen in 6 clinics in central Texas; therefore, this sample may not truly represent the population at large. Also, all patients were scheduled to see family physicians, limiting the ability to generalize our findings to other disciplines. Future studies should expand beyond one discipline to include other primary care and specialty care departments. Also, the survey results reflect patients’ self-reported anticipated behavior if services were available and do not reflect actual usage. Another limitation is the small number of racial/ethnic minority groups.
The survey instrument we used lacked specificity on some questions. For example, we do not know whether patient expectations vary by test (ie, Do patients expect a faster response to a blood test than to an x-ray or a Papanicolaou test?) Future studies should use more specific survey instruments. Our study did not include an assessment of urban versus rural differences in E-mail communication, although it would seem that factors such as access, time, and lack of knowledge about this new technology may make a difference.21 Additionally, many previous studies have unveiled disparities in health care access between urban and rural populations, defined as places with fewer than 2500 residents. For example, the 25% of Americans who live in rural areas are less likely to use preventive screening services and wear seat belts. Also, in 1996, 20% of the rural population was uninsured, compared with 16% of the urban population.22 Future studies should incorporate this variable in the data collection process.
Conclusions
In central Texas the majority of patients attending6 family practice clinics reported having access to E-mail and indicated they would use it to request prescription refills, obtain routine laboratory results or test reports, and for nonurgent consultations independent of their age group, sex, education, or income. Also, there was a wide variability of E-mail access from practice to practice. Independent of sex or race, patients have high expectations that these tasks can be completed in a relatively short time.
Acknowledgments
We wish to acknowledge the contributions made by all the family physicians, operations managers, and supervisors at the 6 participating clinics during the data collection. We are also grateful to Pat Kirkpatrick for her initial ideas, Saundra Mason for data management, and Marcine Chambers, Linda Teer, and Virginia Gray for secretarial support.
Related resources
- American Medical Informatics Association—nonprofit organization of individuals, institutions and corporations dedicated to developing and using information technologies to improve health care. http://www.amia.org
- California Academy Of Family Physicians—offers monograph on “Making the Most of Physician-Patient E-mail.” http://www.familydocs.org
STUDY DESIGN: A cross-sectional, in-person prevalence survey.
POPULATION: Patients (n=950) with scheduled appointments to see a primary care provider in 6 of 18 family practice clinics in a large health care delivery system in central Texas.
OUTCOMES MEASURED: The proportion of patients with E-mail access, their willingness to use it, and their expectations regarding the timeliness of responses to their E-mail queries about selected clinical services.
RESULTS: Overall, 54.3% of the patients reported having E-mail access, with significant variation among the 6 clinics (33%-75%). Reported areas of strongest desire for using E-mail were to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Patients’ expectations regarding the timeliness of responses to their E-mail queries varied by clinical service. For laboratory results, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26%.
CONCLUSIONS: Most patients attending family practice clinics in central Texas have E-mail access and indicate they would use it to request prescription refills, for nonurgent consultations, and to obtain routine laboratory results or test reports. Regardless of sex or race, patients have high expectations that these tasks can be completed within a relatively short time.
E-mail use has been reported in a variety of broad areas, including biomedical communication, general patient surveys2,3 and medical practice4-8; it is also used by several institutions.9 Approximately half of all US adults report that they currently use E-mail at home or at work, and as many as 40% of patients would use E-mail to communicate with their physicians.10 Experts estimate that 5% to 10% of physicians are already communicating with their patients by E-mail.11
There are many potential benefits to E-mail in medical practice.10,12 It allows for efficient asynchronous communication. It eliminates phone tag, and the caller does not incur long-distance phone charges. E-mail is also a good marketing tool and lends itself well to linkage with patient education Web sites. Another advantage is improved documentation. By simply printing and including or copying all E-mail communications in the medical record, excellent documentation of the provider-patient discourse is obtained. This form of provider-patient communication may be very beneficial financially in capitated environments, where simple medical problems can be addressed without an office visit.
Along with these benefits, however, come significant potential disadvantages.3,12,13 Many physicians are afraid that E-mail would allow patients too much access, and consequently they are reluctant to embrace this innovative communication tool. There are related concerns that patients will barrage their physicians with excessive E-mails on trivial matters. It could become another physician hassle factor of practice and create one more thing to do at the end of the day. Also, there are genuine fears that patients will think of E-mail as a hot line to the physician’s office and inappropriately use it for emergent situations, creating additional liabilities for the physician and staff. There are also very real concerns about privacy and security: How can this exchange of information between providers and patients be protected and kept confidential if it is on the Internet?
Although it is generally agreed that some guidelines are required to manage and regulate E-mail communication between patients and their health care providers,14,15 it is equally important to assess the actual desire for this technology in specific practices. We conducted a needs assessment for E-mail communication between family physicians, other health care providers, and their patients attending 6 family practice clinics in central Texas.
Methods
Study Design and Setting
We performed a cross-sectional, in-person prevalence survey using patients with scheduled appointments to see a primary care physician in 6 of the 18 clinics of the Scott & White Healthcare System in central Texas: Northside Clinic and Santa Fe Clinic in Temple, Belton Clinic, Killeen Clinic, Bryan/College Station Clinic, and Waco Clinic. Temple, Belton, and Killeen are all located in Bell County, while Bryan/College Station is located in Brazos County, the site of the main campus of Texas A&M University. The Scott & White Institutional Review Board reviewed the study protocol.
Study Participants and Data Collection
A concerted effort was made to enroll all patients who presented to each of the 6 clinics on preselected days for the surveys. The days differed by clinic and were selected to enroll a specified number of patients according to clinic size for a total of approximately 1000 subjects. The newly opened Northside Clinic was an exception.
The survey included questions about: (1) current Internet and E-mail access; (2) how likely it was that patients would use E-mail for selected clinical services, if available, scored on a 5-point Likert scale; (3) what in their opinion was a reasonable response time to their E-mail communication about routine laboratory results, prescription refills, and medical questions; and (4) demographic information including sex, age, race/ethnicity, education, and annual family income.
Statistical Analysis
Data management and analysis were performed using SPSS software16 on a personal computer. We determined the proportion of patients with access to the Internet and E-mail by clinic. Overall, reported desired areas for using E-mail for selected clinical services were computed as the combined responses of 3 to 5 on the 5-point Likert scale. Reported desired areas for using E-mail were also computed as mean responses on the scale. We determined patient expectations regarding the timeliness of their E-mail queries. Group differences were assessed for significance using the c2 statistic or Fisher exact test for categorical data and the nonparametric Kruskal-Wallis analysis of variance test for ordinal (Likert-style) data. Finally, multivariate logistic regression modeling was used to control for measured covariates on the 5 main outcome variables. All tests were 2-tailed and considered significant at P less than .05.
Results
E-mail Access
Overall, 54.3% of the patients reported having E-mail access, with a significant wide variation (33%-75%) among the 6 clinics Table 1. Internet access rates mirrored those of E-mail access rates.
Desired Areas for Using E-mail
On the basis of the combined responses of 3 to 5 on the 5-point Likert scale, we found that patients most wanted to use E-mail to request prescription refills (90%), for nonurgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Using E-mail to make or cancel appointments (78%) was the area of least interest reported by all patients Figure 1.
The reported desire to use E-mail for selected clinical services varied by patient demographic characteristics, using mean responses on the 5-point Likert scale. However, after multivariate adjustment for other measured variables, we only found 2 significant associations. African Americans were somewhat less likely than other groups to want to use E-mail to get laboratory results or test reports, and older patients were significantly less interested in using E-mail to consult a nurse on nonurgent simple medical questions.
Timeliness of Responses to E-mail Queries
Patients’ expectations of the timeliness of responses to their E-mail queries varied significantly by selected clinical services but not by clinic. For routine laboratory results, for example, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26% Table 2.
No sex or racial/ethnic differences were found regarding the timeliness of responses to E-mail queries for the 3 selected clinical services. Additionally, there were no demographic differences for the timeliness of responses to E-mail queries about prescription refills. However, there were significant age group and income differences in the timeliness of responses to patients’ E-mail queries on laboratory results or test reports. Although the majority of patients in each age group expected a response to their E-mail queries on laboratory results or test reports within 24 hours, only 6% of patients aged 65 years and older expected a response later than 24 hours compared with 20% to 29% of patients in other age groups. Surprisingly, patients with annual family incomes at both extremes had significantly higher expectations for the timeliness of responses to E-mail queries on laboratory results or test reports than their counterparts in the middle income brackets. Also, patients with educational levels at both extremes, particularly those with less than a high school education, had significantly higher expectations regarding the timeliness of responses to queries on medical questions Table 3.
Discussion
Our findings confirmed some of our suppositions and brought new information to light. We were not surprised to find that slightly more than 50% of our patients had E-mail and Internet access. This statistic is similar to those reported in other published literature.2,3 However, we could not completely explain the large variation from site to site within our own health care system. One plausible explanation for the relatively high rate of E-mail access observed at the Bryan/College Station Clinic is its location in a university town, where the clinic clientele is more likely to have an overall higher level of education than that in some of our other sites.
Recently it was reported in the Dallas Business Journal17 that nearly half of 1000 adult patients interviewed during a Laurus Health.com telephone survey said they would like to have E-mail access to their physician’s appointment scheduling system. In our study, we found a very strong desire for this service (78%) among our patient population. The Laurus Health.com survey also reported that 37% of all patients wanted electronic access to their test results. Our study found that 84% of our patients with E-mail access desired this capability. In fact, our study found a degree of interest in electronic communication with their health care provider that was very similar to that of a University of Michigan study of patients in a general medicine clinic. In the University of Michigan study, 70% of patients surveyed indicated their willingness to communicate with their health care provider using E-mail.18
Although it has been reported that consumers are 35% more likely to choose a physician who offers to communicate with patients using E-mail,17 this is not a marketing strategy that physicians should take lightly. From our study, one could assume that patients have very high expectations regarding response times for this form of provider-patient communication. One of the more disconcerting findings of our study was the exceptionally rapid turnaround time patients expected for obtaining laboratory results or test reports, prescription refills, and answers to their medical questions. Knowing that patients would expect these results within 24 hours at least 70% of the time may be unsettling to many physicians who would feel that this time frame is not attainable with the current system of laboratory processing and handling patient requests. Meeting those expectations may require major changes for physician practices.
The Health Institution Portability and Accountability Act of 1996 places comprehensive new security requirements on the US health care industry.19,20 The standards for privacy and protection of all health information that can be linked directly to an individual mandate that all patient E-mail communication be as secure as possible. Physicians using E-mail with their patients must be familiar and be compliant with these federal regulations.* The Journal of the American Medical Informatics Association also recently published “guidelines for the clinical use of electronic mail with patients.”14 This is an excellent reference for any physician considering E-mail communication and is available at their Web site (www.amia.org).
Limitations
Our study has several limitations. The surveys involved patients who were being seen in 6 clinics in central Texas; therefore, this sample may not truly represent the population at large. Also, all patients were scheduled to see family physicians, limiting the ability to generalize our findings to other disciplines. Future studies should expand beyond one discipline to include other primary care and specialty care departments. Also, the survey results reflect patients’ self-reported anticipated behavior if services were available and do not reflect actual usage. Another limitation is the small number of racial/ethnic minority groups.
The survey instrument we used lacked specificity on some questions. For example, we do not know whether patient expectations vary by test (ie, Do patients expect a faster response to a blood test than to an x-ray or a Papanicolaou test?) Future studies should use more specific survey instruments. Our study did not include an assessment of urban versus rural differences in E-mail communication, although it would seem that factors such as access, time, and lack of knowledge about this new technology may make a difference.21 Additionally, many previous studies have unveiled disparities in health care access between urban and rural populations, defined as places with fewer than 2500 residents. For example, the 25% of Americans who live in rural areas are less likely to use preventive screening services and wear seat belts. Also, in 1996, 20% of the rural population was uninsured, compared with 16% of the urban population.22 Future studies should incorporate this variable in the data collection process.
Conclusions
In central Texas the majority of patients attending6 family practice clinics reported having access to E-mail and indicated they would use it to request prescription refills, obtain routine laboratory results or test reports, and for nonurgent consultations independent of their age group, sex, education, or income. Also, there was a wide variability of E-mail access from practice to practice. Independent of sex or race, patients have high expectations that these tasks can be completed in a relatively short time.
Acknowledgments
We wish to acknowledge the contributions made by all the family physicians, operations managers, and supervisors at the 6 participating clinics during the data collection. We are also grateful to Pat Kirkpatrick for her initial ideas, Saundra Mason for data management, and Marcine Chambers, Linda Teer, and Virginia Gray for secretarial support.
Related resources
- American Medical Informatics Association—nonprofit organization of individuals, institutions and corporations dedicated to developing and using information technologies to improve health care. http://www.amia.org
- California Academy Of Family Physicians—offers monograph on “Making the Most of Physician-Patient E-mail.” http://www.familydocs.org
1. Costello R, Shaw A, Cheetham R, Moots RJ. The use of electronic mail in biomedical communication. JAMIA 2000;7:103-05.
2. Fridsma DB, Ford P, Altman R. A survey of patient access to electronic mail: attitudes, barriers and opportunities. Proc Annu Symp Comput Appl Med Care 1994;15-19
3. Mold JW, Cacy JR, Barton ED. Patient-physician e-mail communication. J Okla State Med Assoc 1998;91:331-34.
4. Sands DZ, Safran C, Slack WV, Bleich HL. Use of electronic mail in a teaching hospital. Proc Annu Symp Comput Appl Med Care 1993;306-10.
5. Nettelman MD, Olcahnski V, Perlin JB. E-mail medicine: dawn of a new era in physician-patient communication. Clin Perform Qual Health Care 1998;6:138-41.
6. Neill RA, Mainous AG, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
7. Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998;129:495-500.
8. Kuppersmith RB. Is e-mail an effective medium for physician-patient interaction? Arch Otolaryngol Head Neck Surg 1999;125:468-70.
9. Singarella T, Baxter J, Sandefur RR, Emery CC. The effects of electronic mail on communication in two health science institutions. J Med Syst 1993;17:69-86.
10. Badal P. Email contact between doctor and patient. BMJ 1999;318:1428.-
11. Provider-patient e-mail could transform medicine. Healthc Benchmarks 1999;6:53-55.
12. The Net. Medical email has benefits, risks. Available at:news.cnet.com/news/. Accessed January 20, 2000.
13. E-mail contact between doctor and patient. Med Pract Communicator 1999;6:5.-
14. Kane B, Sands DZ. for the AMIA Internet Working Group. Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. Guidelines for the clinical use of electronic mail with patients. JAMIA 1998;5:104-11.
15. Taylor K. The clinical e-mail explosion. Physician Exec 2000;26:40-45.
16. SPSS Inc. Statistical package for the social sciences for Windows. Version 8. Chicago, Ill: SPSS Inc; 1996.
17. Dallas Business Journal, August 28, 2000. [Author: Please provide author and title of article]
18. University of Michigan. University of Michigan study finds patients and physicians encourage E-mail use. Available at:www.med.umich.edu/choices/intel.html. Accessed November 27, 1999.
19. Braithwaite W. HIPAA and the administration simplification law. MD Comput 1999;16:13-16.
20. Amatayakul M. HIPAA update: achieving compliance with the new standards. MD Comput 2000;17:54-56.
21. Kalsman MW, Acosta DA. Use of the Internet as a medical resource by rural physicians. J Am Board Fam Pract 2000;13:349-52.
22. US Department of Health and Human Service. Healthy people 2010. Washington, DC: US Department of Health and Human Service; 2000.
1. Costello R, Shaw A, Cheetham R, Moots RJ. The use of electronic mail in biomedical communication. JAMIA 2000;7:103-05.
2. Fridsma DB, Ford P, Altman R. A survey of patient access to electronic mail: attitudes, barriers and opportunities. Proc Annu Symp Comput Appl Med Care 1994;15-19
3. Mold JW, Cacy JR, Barton ED. Patient-physician e-mail communication. J Okla State Med Assoc 1998;91:331-34.
4. Sands DZ, Safran C, Slack WV, Bleich HL. Use of electronic mail in a teaching hospital. Proc Annu Symp Comput Appl Med Care 1993;306-10.
5. Nettelman MD, Olcahnski V, Perlin JB. E-mail medicine: dawn of a new era in physician-patient communication. Clin Perform Qual Health Care 1998;6:138-41.
6. Neill RA, Mainous AG, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
7. Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998;129:495-500.
8. Kuppersmith RB. Is e-mail an effective medium for physician-patient interaction? Arch Otolaryngol Head Neck Surg 1999;125:468-70.
9. Singarella T, Baxter J, Sandefur RR, Emery CC. The effects of electronic mail on communication in two health science institutions. J Med Syst 1993;17:69-86.
10. Badal P. Email contact between doctor and patient. BMJ 1999;318:1428.-
11. Provider-patient e-mail could transform medicine. Healthc Benchmarks 1999;6:53-55.
12. The Net. Medical email has benefits, risks. Available at:news.cnet.com/news/. Accessed January 20, 2000.
13. E-mail contact between doctor and patient. Med Pract Communicator 1999;6:5.-
14. Kane B, Sands DZ. for the AMIA Internet Working Group. Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. Guidelines for the clinical use of electronic mail with patients. JAMIA 1998;5:104-11.
15. Taylor K. The clinical e-mail explosion. Physician Exec 2000;26:40-45.
16. SPSS Inc. Statistical package for the social sciences for Windows. Version 8. Chicago, Ill: SPSS Inc; 1996.
17. Dallas Business Journal, August 28, 2000. [Author: Please provide author and title of article]
18. University of Michigan. University of Michigan study finds patients and physicians encourage E-mail use. Available at:www.med.umich.edu/choices/intel.html. Accessed November 27, 1999.
19. Braithwaite W. HIPAA and the administration simplification law. MD Comput 1999;16:13-16.
20. Amatayakul M. HIPAA update: achieving compliance with the new standards. MD Comput 2000;17:54-56.
21. Kalsman MW, Acosta DA. Use of the Internet as a medical resource by rural physicians. J Am Board Fam Pract 2000;13:349-52.
22. US Department of Health and Human Service. Healthy people 2010. Washington, DC: US Department of Health and Human Service; 2000.
Back-up Antibiotic Prescriptions for Common Respiratory Symptoms
METHODS: In our observational study we obtained survey data from 28 physicians and 2 physician extenders in 3 family practice clinics and their patients presenting with complaints of common respiratory symptoms. We computed patient satisfaction and fill rates of back-up antibiotic prescriptions. Agreement between the perceived need of patients for antibiotics before the office visit and the subjective rating of their physicians of the clinical necessity to prescribe antibiotics for these patients was assessed using the k statistic. Finally, we determined correlates of satisfaction and the rate of filling back-up prescriptions.
RESULTS: Of the 947 patients enrolled in the study, 46.6% received no antibiotic prescriptions, 30.2% received back-up antibiotic prescriptions, and 23.2% were given immediate-fill prescriptions for an antibiotic. Patients’ self-reported satisfaction and fill rates for back-up antibiotic prescriptions were 96.1% and 50.2%, respectively.
CONCLUSIONS: Our findings indicate that patients were very satisfied with a back-up antibiotic prescription. The fact that half of the patients chose not to fill these prescriptions suggests a potential health care cost savings.
A large body of literature has addressed the frequent use of antibiotics for common upper and lower respiratory tract infections in the outpatient setting. The many dangers of this practice, including the development of bacterial resistance,1,2 adverse drug reactions,3-5 and negative financial implications,6 have been discussed, but very few methods to resolve the problem have been tested. Guidelines and educational strategies have been touted by some advocates as an essential part of the solution process and have been shown to have some degree of success in specific settings.7,8 Recently, the American Academy of Family Physicians, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention have collaborated to develop a set of recommendations to help clinicians use antibiotics more appropriately when treating patients with common respiratory illnesses.9-13 The results of these educational efforts have not been evaluated.
Although many aspects of the antibiotic overprescribing issue may start with physician beliefs, training, and practice setting, other factors have been postulated, including meeting patient expectations, economic issues, and time constraints. A practice that has not been reported in the literature but has been employed by many physicians (anecdotally) is the use of a back-up prescription strategy. This approach addresses the complex problem of satisfying patients in a timely manner while re-educating them in a nonconfrontational way.
The term “back-up prescription” applies to the writing of a prescription that is to be filled at a later time, and only if the patient’s condition deteriorates or fails to improve. At the time the prescription is written the physician explains to the patient (or the family) the reasons for not giving an immediate-fill antibiotic prescription and gives advice on symptomatic treatment for the current problem. Additionally, specific guidance is given on clinical parameters and the timing of when to fill the prescription if the condition progresses. To our knowledge, this practice has not been studied adequately in family medicine settings although similar strategies have been used for other health-related conditions.14-16 The use of back-up treatment for malaria (also referred to as reserve treatment) has been mentioned in the literature.15 Davy and colleagues16 have also reported the use of back-up antibiotics for the treatment of undifferentiated acute respiratory tract infection with cough among primary care family physicians and pediatricians. This study, which was based on a self-reported survey, primarily sought to identify the frequency with which reserve antibiotics were prescribed to this group of children. It did not address the actual practice of using a back-up prescription.
In exploring the use of the back-up antibiotic prescription strategy it is essential to assess the degree of patient satisfaction and the fill rates for back-up prescriptions and their predictors. In their study on patient satisfaction and antibiotic prescriptions for respiratory infections, Hamm and coworkers17 elicited patient satisfaction levels immediately following a physician encounter. However, seeking the opinions of patients about their satisfaction immediately after an encounter may not yield accurate responses because more time may be required to assess other factors such as the effect (or lack of effect) of the treatment suggested, including antibiotic prescriptions given.
Methods
Study Design and Setting
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.
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.
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.
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21. AC, Gonzales R, Steiner J, Sande M. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-77.
22. RH, Freij BJ, Ziai M, Sheridan MJ. Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners. Pediatr Infect Dis J 1997;16:185-90.
23. AG, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45:75-83.
24. L, Prins B, Weber M, McGaugh JL. Beta-adrenergic activation and memory for emotional events. Nature 1994;371:702-04.
25. DC, Lutz LJ. The effect of parental expectations on treatment of children with a cough; a report from ASPN. J Fam Pract 1993;37:23-27.
26. R, Stenier JF, Sande MA. Antibiotics prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04.
METHODS: In our observational study we obtained survey data from 28 physicians and 2 physician extenders in 3 family practice clinics and their patients presenting with complaints of common respiratory symptoms. We computed patient satisfaction and fill rates of back-up antibiotic prescriptions. Agreement between the perceived need of patients for antibiotics before the office visit and the subjective rating of their physicians of the clinical necessity to prescribe antibiotics for these patients was assessed using the k statistic. Finally, we determined correlates of satisfaction and the rate of filling back-up prescriptions.
RESULTS: Of the 947 patients enrolled in the study, 46.6% received no antibiotic prescriptions, 30.2% received back-up antibiotic prescriptions, and 23.2% were given immediate-fill prescriptions for an antibiotic. Patients’ self-reported satisfaction and fill rates for back-up antibiotic prescriptions were 96.1% and 50.2%, respectively.
CONCLUSIONS: Our findings indicate that patients were very satisfied with a back-up antibiotic prescription. The fact that half of the patients chose not to fill these prescriptions suggests a potential health care cost savings.
A large body of literature has addressed the frequent use of antibiotics for common upper and lower respiratory tract infections in the outpatient setting. The many dangers of this practice, including the development of bacterial resistance,1,2 adverse drug reactions,3-5 and negative financial implications,6 have been discussed, but very few methods to resolve the problem have been tested. Guidelines and educational strategies have been touted by some advocates as an essential part of the solution process and have been shown to have some degree of success in specific settings.7,8 Recently, the American Academy of Family Physicians, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention have collaborated to develop a set of recommendations to help clinicians use antibiotics more appropriately when treating patients with common respiratory illnesses.9-13 The results of these educational efforts have not been evaluated.
Although many aspects of the antibiotic overprescribing issue may start with physician beliefs, training, and practice setting, other factors have been postulated, including meeting patient expectations, economic issues, and time constraints. A practice that has not been reported in the literature but has been employed by many physicians (anecdotally) is the use of a back-up prescription strategy. This approach addresses the complex problem of satisfying patients in a timely manner while re-educating them in a nonconfrontational way.
The term “back-up prescription” applies to the writing of a prescription that is to be filled at a later time, and only if the patient’s condition deteriorates or fails to improve. At the time the prescription is written the physician explains to the patient (or the family) the reasons for not giving an immediate-fill antibiotic prescription and gives advice on symptomatic treatment for the current problem. Additionally, specific guidance is given on clinical parameters and the timing of when to fill the prescription if the condition progresses. To our knowledge, this practice has not been studied adequately in family medicine settings although similar strategies have been used for other health-related conditions.14-16 The use of back-up treatment for malaria (also referred to as reserve treatment) has been mentioned in the literature.15 Davy and colleagues16 have also reported the use of back-up antibiotics for the treatment of undifferentiated acute respiratory tract infection with cough among primary care family physicians and pediatricians. This study, which was based on a self-reported survey, primarily sought to identify the frequency with which reserve antibiotics were prescribed to this group of children. It did not address the actual practice of using a back-up prescription.
In exploring the use of the back-up antibiotic prescription strategy it is essential to assess the degree of patient satisfaction and the fill rates for back-up prescriptions and their predictors. In their study on patient satisfaction and antibiotic prescriptions for respiratory infections, Hamm and coworkers17 elicited patient satisfaction levels immediately following a physician encounter. However, seeking the opinions of patients about their satisfaction immediately after an encounter may not yield accurate responses because more time may be required to assess other factors such as the effect (or lack of effect) of the treatment suggested, including antibiotic prescriptions given.
Methods
Study Design and Setting
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.
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.
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.
METHODS: In our observational study we obtained survey data from 28 physicians and 2 physician extenders in 3 family practice clinics and their patients presenting with complaints of common respiratory symptoms. We computed patient satisfaction and fill rates of back-up antibiotic prescriptions. Agreement between the perceived need of patients for antibiotics before the office visit and the subjective rating of their physicians of the clinical necessity to prescribe antibiotics for these patients was assessed using the k statistic. Finally, we determined correlates of satisfaction and the rate of filling back-up prescriptions.
RESULTS: Of the 947 patients enrolled in the study, 46.6% received no antibiotic prescriptions, 30.2% received back-up antibiotic prescriptions, and 23.2% were given immediate-fill prescriptions for an antibiotic. Patients’ self-reported satisfaction and fill rates for back-up antibiotic prescriptions were 96.1% and 50.2%, respectively.
CONCLUSIONS: Our findings indicate that patients were very satisfied with a back-up antibiotic prescription. The fact that half of the patients chose not to fill these prescriptions suggests a potential health care cost savings.
A large body of literature has addressed the frequent use of antibiotics for common upper and lower respiratory tract infections in the outpatient setting. The many dangers of this practice, including the development of bacterial resistance,1,2 adverse drug reactions,3-5 and negative financial implications,6 have been discussed, but very few methods to resolve the problem have been tested. Guidelines and educational strategies have been touted by some advocates as an essential part of the solution process and have been shown to have some degree of success in specific settings.7,8 Recently, the American Academy of Family Physicians, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention have collaborated to develop a set of recommendations to help clinicians use antibiotics more appropriately when treating patients with common respiratory illnesses.9-13 The results of these educational efforts have not been evaluated.
Although many aspects of the antibiotic overprescribing issue may start with physician beliefs, training, and practice setting, other factors have been postulated, including meeting patient expectations, economic issues, and time constraints. A practice that has not been reported in the literature but has been employed by many physicians (anecdotally) is the use of a back-up prescription strategy. This approach addresses the complex problem of satisfying patients in a timely manner while re-educating them in a nonconfrontational way.
The term “back-up prescription” applies to the writing of a prescription that is to be filled at a later time, and only if the patient’s condition deteriorates or fails to improve. At the time the prescription is written the physician explains to the patient (or the family) the reasons for not giving an immediate-fill antibiotic prescription and gives advice on symptomatic treatment for the current problem. Additionally, specific guidance is given on clinical parameters and the timing of when to fill the prescription if the condition progresses. To our knowledge, this practice has not been studied adequately in family medicine settings although similar strategies have been used for other health-related conditions.14-16 The use of back-up treatment for malaria (also referred to as reserve treatment) has been mentioned in the literature.15 Davy and colleagues16 have also reported the use of back-up antibiotics for the treatment of undifferentiated acute respiratory tract infection with cough among primary care family physicians and pediatricians. This study, which was based on a self-reported survey, primarily sought to identify the frequency with which reserve antibiotics were prescribed to this group of children. It did not address the actual practice of using a back-up prescription.
In exploring the use of the back-up antibiotic prescription strategy it is essential to assess the degree of patient satisfaction and the fill rates for back-up prescriptions and their predictors. In their study on patient satisfaction and antibiotic prescriptions for respiratory infections, Hamm and coworkers17 elicited patient satisfaction levels immediately following a physician encounter. However, seeking the opinions of patients about their satisfaction immediately after an encounter may not yield accurate responses because more time may be required to assess other factors such as the effect (or lack of effect) of the treatment suggested, including antibiotic prescriptions given.
Methods
Study Design and Setting
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.
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.
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.
1. D, Drotman DP. Confronting antimicrobial resistance: a shared goal of family physicians and the CDC. Am Fam Pract 1999;59:2097-100.
2. SF, Schwartz B. Resistant pneumococci: protecting patients through judicious use of antibiotics. Am Fam Pract 1997;55:1647-54.
3. Mar CB, Glasziou PP, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ 1997;314:1526-29.
4. L, Glazier R, McIsaac W, et al. Antibiotics for acute bronchitis. In: Douglas R. Brifges-Webb C. Glasziou P, et al, eds. Cochrane Database Syst Rev Oxford, England: Update Software; 1998.
5. T, Stocks N, Thomas T. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. BMJ 1998;316:906-10.
6. AG, Hueston WJ, Clark J. Antibiotics and upper respiratory infection: do some folks think there is a cure for the common cold? J Fam Pract 1996;42:357-61.
7. JM, Russell IT. Effect of medical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-22.
8. R, Thomas S, Roberts R. Development and implementations of guidelines for family practice: lessons from the Netherlands. J Fam Pract 1995;40:435-39.
9. SF, Marcy SM, Phillips WR, Gerber MS, Schwartz B. Otitis media: principles of judicious use of antimicrobial agents. Pediatrics 1998;101 (suppl):165-71.
10. N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. The common cold: principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):181-84.
11. KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Acute sinusitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):174-77.
12. KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitis: principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):178-81.
13. B, Marcy SM, Phillips WR, Gerber MA, Dowell SF. Pharyngitis: principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):171-74.
14. E, Fraser IS, Carrick SE, Wilde FM. Emergency contraception: general practitioner knowledge, attitudes and practices in New South Wales. Med J Aust 1995;162:136-38.
15. G, Steffen R. Reserve treatment for malaria: pros and cons. Bull Soc Pathol Exot 1997;90:263-65.
16. 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;17:457-62.
17. RL, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996;43:56-62.
18. Institute Inc. SAS language and procedures: usage, version 6. Cary, NC: SAS Institute; 1989.
19. Package for the Social Sciences for Windows. Version 8. Chicago, Ill: SPSS Inc; 1996.
20. AG, Hueston WJ, Love MM. Antibiotics for colds in children: who are the high prescribers? Arch Pediatr Adolesc Med 1998;152:349-52.
21. AC, Gonzales R, Steiner J, Sande M. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-77.
22. RH, Freij BJ, Ziai M, Sheridan MJ. Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners. Pediatr Infect Dis J 1997;16:185-90.
23. AG, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45:75-83.
24. L, Prins B, Weber M, McGaugh JL. Beta-adrenergic activation and memory for emotional events. Nature 1994;371:702-04.
25. DC, Lutz LJ. The effect of parental expectations on treatment of children with a cough; a report from ASPN. J Fam Pract 1993;37:23-27.
26. R, Stenier JF, Sande MA. Antibiotics prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04.
1. D, Drotman DP. Confronting antimicrobial resistance: a shared goal of family physicians and the CDC. Am Fam Pract 1999;59:2097-100.
2. SF, Schwartz B. Resistant pneumococci: protecting patients through judicious use of antibiotics. Am Fam Pract 1997;55:1647-54.
3. Mar CB, Glasziou PP, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ 1997;314:1526-29.
4. L, Glazier R, McIsaac W, et al. Antibiotics for acute bronchitis. In: Douglas R. Brifges-Webb C. Glasziou P, et al, eds. Cochrane Database Syst Rev Oxford, England: Update Software; 1998.
5. T, Stocks N, Thomas T. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. BMJ 1998;316:906-10.
6. AG, Hueston WJ, Clark J. Antibiotics and upper respiratory infection: do some folks think there is a cure for the common cold? J Fam Pract 1996;42:357-61.
7. JM, Russell IT. Effect of medical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-22.
8. R, Thomas S, Roberts R. Development and implementations of guidelines for family practice: lessons from the Netherlands. J Fam Pract 1995;40:435-39.
9. SF, Marcy SM, Phillips WR, Gerber MS, Schwartz B. Otitis media: principles of judicious use of antimicrobial agents. Pediatrics 1998;101 (suppl):165-71.
10. N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. The common cold: principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):181-84.
11. KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Acute sinusitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):174-77.
12. KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitis: principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):178-81.
13. B, Marcy SM, Phillips WR, Gerber MA, Dowell SF. Pharyngitis: principles of judicious use of antimicrobial agents. Pediatrics 1998;101(suppl):171-74.
14. E, Fraser IS, Carrick SE, Wilde FM. Emergency contraception: general practitioner knowledge, attitudes and practices in New South Wales. Med J Aust 1995;162:136-38.
15. G, Steffen R. Reserve treatment for malaria: pros and cons. Bull Soc Pathol Exot 1997;90:263-65.
16. 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;17:457-62.
17. RL, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996;43:56-62.
18. Institute Inc. SAS language and procedures: usage, version 6. Cary, NC: SAS Institute; 1989.
19. Package for the Social Sciences for Windows. Version 8. Chicago, Ill: SPSS Inc; 1996.
20. AG, Hueston WJ, Love MM. Antibiotics for colds in children: who are the high prescribers? Arch Pediatr Adolesc Med 1998;152:349-52.
21. AC, Gonzales R, Steiner J, Sande M. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-77.
22. RH, Freij BJ, Ziai M, Sheridan MJ. Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners. Pediatr Infect Dis J 1997;16:185-90.
23. AG, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45:75-83.
24. L, Prins B, Weber M, McGaugh JL. Beta-adrenergic activation and memory for emotional events. Nature 1994;371:702-04.
25. DC, Lutz LJ. The effect of parental expectations on treatment of children with a cough; a report from ASPN. J Fam Pract 1993;37:23-27.
26. R, Stenier JF, Sande MA. Antibiotics prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04.