Back-up Antibiotic Prescriptions for Common Respiratory Symptoms

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.

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.

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.