BACKGROUND: Many recent efforts to reduce unnecessary medical services have targeted care of upper respiratory infections (URIs). We tested whether patients who seek care very early in their illness differ from those who seek care later and whether they might require a different approach to care.
METHODS: We surveyed by telephone 257 adult patients and 249 parents of child patients who called or visited one of 3 primary care clinics within 10 days (adults) or 14 days (parents) of the onset of uncomplicated URI symptoms. Those who contacted the clinic within the first 2 days of illness were compared with those who made contact later.
RESULTS: Although 28% of adults and 41% of parents contacted their clinic within the first 2 days of symptom onset, we found very few differences in the characteristics of the caller or patient between those who called early and later. The illnesses of those who called early were not more severe, and they did not have different beliefs, histories, approaches to medical care, or needs. The only clinician-relevant difference was that adult patients calling in the first 2 days had a greater desire to rule out complications (84.7% vs 64.1% calling in 3-5 days and 70.6% calling after 5 days of illness, P .05).
CONCLUSIONS: Those who seek medical care very early for a URI do not appear to be different in clinically important ways. If we are going to reduce overuse of medical care and antibiotics for URIs, clinical trials of more effective and efficient strategies are needed to encourage home care and self-management.
Rising health care costs (especially for medications) and a growing concern that unnecessary antibiotic use is creating troublesome bacterial resistance patterns have triggered increasing attention to upper respiratory infection (URI) care.1 URIs are the most frequent reason for office visits and antibiotic use, and at least 50% of patient visits with the diagnosis of URI, cold, or bronchitis include the writing of antibiotic prescriptions.1-2 Also, there is reason to believe that antibiotic use for URI symptoms has increased during the past 2 decades, despite increasing public health efforts to the contrary.3
Much of the expanding literature on URI patients is descriptive, attempting to provide understanding of their expectations and the relationship of various characteristics to antibiotic use for this illness.4-12 Because of the belief that it is patients who create most of the visits and antibiotic use, most studies of URI care address patients’ perceptions, attitudes, and satisfaction.2,4-12 Some studies, however, have shown that the physician’s perception that a patient expects antibiotics is the strongest predictor of prescriptions, even though that perception is not always correct.4-5 This literature suggests that once patients with URIs appear in the clinic it is likely that they will leave with an antibiotic prescription, either because the clinician feels that the illness might be helped by antibiotics or because he or she believes that the patient will be unhappy if antibiotics are not provided. Miller and colleagues13 obtained physician questionnaires for patients with a suspected infection as the reason for the visit. They found that physicians responded to their perception that patients wanted an antibiotic only when the physicians were uncertain about the need for it. When they were fairly certain that an antibiotic was either needed or not needed, perceived patient demand was rarely a factor. Patient satisfaction does not appear to be related to the receipt of antibiotics even when they are expected.5-6
Patients who call or come in within the first few days of the onset of their illness constitute a particularly troubling subgroup of patients for most clinicians. Because it is usually difficult for a clinician to predict whether patients with early URI symptoms are going to encounter complications, it is hard for the clinician to avoid assuming that these patients are either sicker or unusually desirous of a test or treatment. In the absence of any studies of this subgroup, it is possible that those making early contact are particularly likely to receive antibiotics. They will continue to frustrate clinicians and to confound health care system efforts to reduce unnecessary visits and treatments.
To understand the local failure of the implementation of a URI clinical guideline targeted at reducing unnecessary patient visits and antibiotic prescriptions, we conducted a study of the characteristics of patients who seek care for URI symptoms.14 A study of that guideline’s implementation had demonstrated that only 13% of primary care patients with respiratory symptoms were eligible for guideline care, and that subgroup did not show a decrease in clinic visits, antibiotic use, or care costs after guideline implementation.15