Do Delayed Prescriptions Reduce the Use of Antibiotics for the Common Cold?

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Original Research

Do Delayed Prescriptions Reduce the Use of Antibiotics for the Common Cold?

J Fam Pract. 2002 April;51(4):324-328

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References

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We do not know how many patients were excluded or refused to participate; the recruiting physicians did not supply this information as requested. There was no systematic difference in symptom scores for patients of the different recruiting doctors. As with the study by Little and colleagues, the doctors found themselves too busy to enroll patients. Such problems are always an issue in general practice research.¹⁸ Little and colleagues checked the internal validity of their telephone information; therefore, we did not repeat this. In an earlier study,¹⁴ the recruiting family physicians’ preference for using delayed prescriptions may have made them more supportive of the delayed prescription than of the immediate prescription. This issue cannot be resolved, since we needed doctors who would prescribe either a delayed prescription or an immediate prescription in order to recruit enough patients.

The strength of this study lies in the blinded nature of the intervention delivery to the patient, the analysis by intention to treat, and the study’s originality. Our intervention had no impact on patients’ satisfaction, concerns, or the likelihood of seeing a doctor for next illness (Table 3). In contrast, Little¹¹ found that antibiotic use predicted future consultations for sore throat and the belief that antibiotics were effective for sore throat.^11,19 The differences may relate to the different patient symptoms and geographical differences (common cold in New Zealand versus sore throat in the UK) or the fact that all patients in our study left with a prescription. Another possible reason is that the patients knew they were participating in a study, whereas in the Little study, the instructions were more vague.¹¹

Doctors often misinterpret patient expectations. Improving communications between patient and doctor may be central to reducing patients’ demand for antibiotics. Britten makes the claim that “all the misunderstandings were associated with lack of patients’ participation in the consultation in terms of voicing of expectations and preferences or the voicing of responses to doctors’ decisions and actions.”²⁰ The need for delayed prescriptions had been highlighted as a solution. We know that the common cold presents no great diagnostic dilemma but can produce enormous treatment dilemmas.²¹ Barry believes that by changing doctors’ views and helping patients to explain what they want from the office visit may lead to changes in treatment patterns.²² We concur with Little that unless patients are very ill, general practitioners should consider exploring their concerns, explaining the natural history of their illness, and avoiding or delaying prescribing antibiotics.¹¹

We were pleased to see a reduction of antibiotics consumed (89% to 48%). However, 48% still represents a high proportion of patients who consumed antibiotics for an illness that is most unlikely to respond to those drugs. More placebo-controlled randomized trials of antibiotics for respiratory tract infections in the primary care setting are needed. We suggest that FPs clarify patients’ expectation for antibiotics and not prescribe them unless the patient insists. For patients who expect to take antibiotics and cannot be persuaded otherwise, a delayed prescription may be the first step in educating them that these medicines are not routinely required.

Conclusions

Delayed prescriptions are a safe and effective means of reducing antibiotic use in patients with the common cold who want antibiotics. The additional barrier of asking the patient to pick up the prescription from the office if symptoms persist after 3 days may reduce antibiotic use even further. When the patient demands a prescription, delaying its delivery has the potential to provide gentle education that antibiotics are an unnecessary treatment.

Acknowledgments

The authors acknowledge the support of the Health Research Council for funding the study, Tania Milne for data collection, and Alistair Stewart for statistical advice. The authors further thank the participating family physicians and patients for their contribution.