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Antibiotics for Upper Respiratory Tract Infections
A Trip to Abilene?
Arch Fam Med. 1999;8:431-432.
IN THIS issue of the ARCHIVES Hueston et al1 present data from a retrospective analysis of visits for almost 50,000 upper respiratory tract infections(URIs) in a large network of practices sharing an electronic medical record. Their data show that although most such illnesses result in a single medical visit, 17% of patients treated returned for a second visit. Prescribing an antibiotic at the initial visit produced a small but statistically significant decrease in the rate of second visits. Adults who returned were more likely to receive an antibiotic at a second visit if they did not receive an antibiotic at the initial visit. Not surprisingly, antibiotics prescribed at the second visit following an initial prescription for an antibiotic were often more expensive than initial antibiotic choices.
Because the study was retrospective, the authors relied on the coded clinical diagnoses of the physicians, and were unable to check the validity of the diagnoses. However, standard criteria in the universe of practice for URIs are difficult to come by, and practitioners often must rely on clinical standards and judgment We also do not know very much about the 45 participating practices. Physician-related factors, such as age and board-certification status, might have an effect on practice patterns for URIs. The described presence of academic practices in the sample should also be noted.
The potential for misclassification of subjects is potentially more serious. For example, the authors chose a 14-day window for each episode of illness. The natural history of acute bronchitis may actually be longer than this. Therefore, episodes of illness might have been included that were, in fact, related to earlier URIs. This may be important if the timing of antibiotic use during an episode of illness is of interest. A second type of misclassification might have occurred if a significant number of patients received subsequent care out of the participating network. If this occurred, an underestimation of the number of patients receiving antibiotics might have occurred. The authors provide a sensitivity analysis showing that a large number of such events would need to have occurred for the cost of antibiotic use to exceed the cost of cases in which antibiotics were initially prescribed.
By now it is not a surprise that physicians frequently prescribe antibiotics for infections that are presumably viral. The disadvantages of doing this are well known: needlessly exposing an individual to the risk of an allergic reaction, the cost of unnecessary drugs, and the potential for increasing drug resistance to commonly used antibiotics.
In a recent editorial in the ARCHIVES, Richardson2 called attention to the broad issue of changing physician behavior with respect to antibiotic prescriptions for viral illnesses. He lists several strategies, including the use of academic detailing, opinion leaders, increasing physician involvement, and financial incentives. Despite these clues as to how to proceed, most systems find the task of motivating physicians to change behavior vexing.
The question of antibiotics remains even more important for several reasons. First, there is evidence to suggest that not all patients understand the natural history and etiology of URIs, and that slightly more than 50% of patients come to the physician believing that antibiotics will help them. These individuals often expect to receive a prescription. Second, there is evidence that physicians prescribe antibiotics more frequently when they believe patients desire such a prescription, but are not always accurate in their perception. Third, patient satisfaction often relates to receiving timely information about their illness, having quality time with their primary physician, and understanding what they should do to feel better.3-6 Indeed, the experience in many managed care systems using demand management strategies, such as nurse telephone advice lines, indicates that patients may often be satisfied to receive timely information about their illness by telephone, rather than needing to be seen by a physician.
In his popular book and management training video, Harvey7 describes a situation that he calls "The Abilene Paradox." The vignette shows a family in Coleman, Tex, on a hot 104°F (40°C) day in July sweltering in a home without air conditioning. The father-in-law suggests that the family get in the car and go to Abilene to have dinner at the cafeteria. The other family members agree, all stating various reasons why they believe that taking a trip to Abilene is a good idea. So off they go. Four hours later, they return to Coleman, hot and exhausted. The younger man finally says, "It was a great trip, wasn't it?" Following a long silence, the other family members then all complain about how horrible the trip was, that it was a bad idea to begin with, and that they really did not want to go at all. They all just agreed to go because they thought everyone else wanted to.
Harvey goes on to say that what is unusually difficult in many management situations is not the need to manage disagreement, but the paradoxical need to manage agreement. A hallmark of a "trip to Abilene" is that individuals do not accurately communicate their desires and beliefs to each other and, therefore, make collective decisions that lead them to take actions contrary to what they really wish to do. This produces frustration, anger, irritation, and dissatisfaction. To make matters worse, if not dealt with, the cycle tends to repeat itself.
I would suggest that physicians and patients are engaged in an ongoing "trip to Abilene" with regard to the prescription of antibiotics for URIs. Physicians are generally aware of the reasons to avoid antibiotic treatment, but believe that patients expect antibiotics and are dissatisfied if they do not get them. It also takes less time to write a prescription than to explain the reasons why the drugs are unnecessary. Patients, however, desire information, and form opinions from the previous behaviors that they have experienced from their physicians.8
What is needed is a broader and more effective form of collective intelligence between physician and patient. Outcomes are improved when patient and physician agree about the nature of the problem being discussed, the diagnosis assigned, and the plan for addressing the problem. What strategies can busy clinicians use to bring about such alignment?
First, it is necessary to suspend assumptions about what patients want, and to approach each encounter with the idea that alternatives to care with antibiotics may be feasible. Second, physicians might seek to suspend their usual mode of "advocacy," in which they describe what they think is wrong, and make prescriptions about what should be done,9 in favor of a mode of "inquiry," in which they genuinely seek to understand what patients wish to accomplish in the context of the visit. Third, we should take advantage of the opportunity to educate about the causes and etiology of URIs, and to share with patients the real reasons why physicians often feel pressured to prescribe antibiotics. Fourth, a question can be posed to the patient: Would they be willing to treat their infection symptomatically, and stay in touch if they are not better or if symptoms of a bacterial infection supervene? Symptomatic treatment might include a bronchodilator, or one of the multiple well-known over-the-counter medications appropriate for the patient's symptoms.
There will be cases in which patient preference for antibiotics will not be overcome. In such situations the physicians might provide a prescription, but only after a thorough discussion, hoping that in time, and through continuity of care and effort, the patient will be convinced that a change in behavior is a good idea.
Overcoming the powerful urge to travel to Abilene takes a willingness to communicate in new ways, and a sincere effort to approach decisions collectively with patients. I, for one, would welcome a clinical trial of such an approach as a welcome addition to the literature.
AUTHOR INFORMATION
Reprints: James M. Herman, MD, MSPH, Department of Family and Community Medicine, Penn State College of Medicine, 500 University Dr, Hershey, PA 17033.
James M. Herman, MD, MSPH
Department of Family and Community Medicine
Penn State College of Medicine
Hershey, Pa
REFERENCES
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1. Hueston WJ, Mainous III AG, Ornstein S, Pan Q, Jenkins R. Antibiotics for upper respiratory tract infections: follow-up utilization and antibiotic use. Arch Fam Med. 1999;8:426-430.
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2. Richardson JP. Physician heal thyself: are antibiotics the cure or the disease? Arch Fam Med. 1998;7:51-52.
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3. Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract. 1996;43:56-62.
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4. Sanchez-Menegay C, Hudes ES, Cummings SR. Patient expectations and satisfaction with medical care for upper respiratory infections. J Gen Intern Med. 1992;7:432-434.
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5. Cowan P. Patient satisfaction with an office visit for the common cold. J Fam Pract. 1987;24:412-413.
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6. Mainous III 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.
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7. Harvey JB. The Abilene Paradox and Other Meditations on Management. San Francisco, Calif: Jossey-Bass Publishers; 1988.
8. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ. 1997;315:350-352.
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9. Rubin IM, Campbell TJ. The ABCs of Effective Feedback for Caring Professionals. San Francisco, Calif: Jossey-Bass Publishers; 1998.
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Antibiotics for Upper Respiratory Tract Infections: Follow-up Utilization and Antibiotic Use
William J. Hueston, Arch G. Mainous III, Steven Ornstein, Qin Pan, and Ruth Jenkins
Arch Fam Med. 1999;8(5):426-430.
ABSTRACT
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