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ObjectiveTo characterize people who want antibiotics for cold symptoms and to suggest reasons for antibiotic expectations.DesignCross-sectional telephone survey in the spring of 1997 (March 10 to May 16).SettingThree primary care clinics in metropolitan Minneapolis, Minn.ParticipantsTwo hundred forty-nine parents of symptomatic children and 256 symptomatic adults contacting their medical provider (primary care physician, nurse practitioner, or physician assistant) for care of cold symptoms.Main Dependent MeasureWanting an antibiotic prescription for cold symptoms.ResultsThirty percent of parents and 50% of symptomatic adults wanted an antibiotic prescription. Factors associated with desire for antibiotics differed between groups. Parents who wanted antibiotics for their children were more likely than other parents to report severe symptoms (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.16-3.85), to want relief for their child (OR, 2.63; 95% CI, 1.34-5.46), and to believe that antibiotic therapy helps cold symptoms (OR, 1.95; 95% CI, 1.08-3.55). Symptomatic adults who wanted antibiotics were more likely than other symptomatic adults to report severe cold symptoms (OR, 2.10; 95% CI, 1.22-3.67) that have lasted too long (OR, 2.40; 95% CI, 1.31-4.49), to previously have recovered faster with antibiotic therapy (OR, 2.82; 95% CI, 1.65-4.89), and to be confident that they know how to treat the cold (OR, 1.79; 95% CI, 1.03-3.16). They were less likely to believe that too many people take antibiotics for a cold (OR, 0.57; 95% CI, 0.33-0.98).ConclusionsParents may be amenable to clinical messages that other treatments may be more effective than antibiotics in managing cold symptoms. Experiences of symptomatic adults may conflict with this message. Previous cold-related medical management and drug resistance might need to be discussed with adult patients.PATIENTS WITH symptoms of upper respiratory tract infection are common on the schedules of pediatric and adult primary care practices. Although medical care providers (primary care physicians, nurse practitioners, or physician assistants) can effectively intercede in complicated cases of upper respiratory tract infections, most episodes of problematic respiratory symptoms are uncomplicated colds or viral infections that are unresponsive to antibiotic therapy. Yet, despite the volume of evidence documenting the ineffectiveness of antibiotics in treating viral cold symptoms,30% to 90% of adults who call their clinic with concerns about cold-related symptoms want a prescription for antibiotics from their providers.The desire for an antibiotic prescription may stem from misunderstanding the causes of a cold or current medical opinion regarding appropriate treatment modalities.Providers, in turn, continue to prescribe antibiotics to satisfy their patients' real or perceived desire for themor, inappropriately, to minimize the potential for cold-related complications.Hence, both patients and providers contribute to the problem of antibiotic overprescription.The Institute for Clinical Systems Improvement—a collaboration of 19 private medical care groups in the Minneapolis–St Paul, Minn, area—seeks to develop and implement clinical guidelines to improve patient care. The Institute for Clinical Systems Improvement commissioned a clinical impact study after development of guidelines for the management of viral respiratory tract infections. The results of that first study suggested that implementation of the guidelines in 4 primary care clinics resulted in fewer patients being prescribed antibiotics initially. However, there was no overall reduction in patient visits for respiratory symptoms or subsequent antibiotic prescription. No clinic-specific differences in these measures were evident (P. O'Connor, MD, G. Amundson, BS, J. Christianson, PhD, unpublished data, 1995). The hypothesized explanation was patients' expectations for antibiotics.The present study was commissioned by the Institute for Clinical Systems Improvement for 2 reasons: to characterize those who want antibiotics when they seek medical care for colds and to suggest reasons for antibiotic expectations among parents of symptomatic children and symptomatic adults.Accurate information describing who wants antibiotics and why might help providers better understand their patients and address their patients' needs without prescribing unnecessary, ineffective antibiotics.PARTICIPANTS AND METHODSSTUDY SAMPLEThree primary care clinics, all members of the Institute for Clinical Systems Improvement, identified patients with cold symptoms who contacted the medical care system. Consecutive patients were selected until approximately 80 symptomatic adults and 80 parents concerned about symptomatic children were enrolled at each site during 4 weeks in the spring of 1997 (March 10 to May 16). All patients reporting cold symptoms who contacted the nurse triage telephone line; the urgent care walk-in clinic; or the appointment receptionist in the departments of family practice, internal medicine, or pediatrics were eligible for inclusion. Inclusion criterion was a primary complaint of cold symptoms, such as rhinitis, cough, fever, or sore throat. Patients were excluded if they were older than 64 years; if they reported ear pain, asthma, or moderate to severe sore throat pain; if symptom duration exceeded 14 days in adults or 10 days in children; or if the patient was in poor general health. One symptomatic adult was unable to remember if an antibiotic was wanted at the time of contact; this patient was excluded from further analysis. The final study sample totaled 505 people, 249 parents of symptomatic children and 256 symptomatic adults, evenly distributed across the 3 sites.The institutional review board of HealthSystem Minnesota, Minneapolis, approved the study. Respondents gave verbal consent at the beginning of the telephone survey.DATA COLLECTIONA trained interviewer conducted the telephone survey 48 to 96 hours after the patient's initial medical system contact. By this time, patients were less likely to be uncomfortable and more able to complete the survey. To ensure eligibility, the script included the following statement: "We are talking with people who recently called or visited their clinic for care of cold symptoms or upper respiratory infections. . . . " All questions included a reference to the cold or the cold symptoms. The participation rate was 90% for parents of symptomatic children and 94% for symptomatic adults.VARIABLES OF INTERESTRespondents were asked if they had wanted a prescription for antibiotics when they contacted the medical care system. Those who answered yes were identified as wanting antibiotics; those who answered no or "if needed or recommended" were identified as not necessarily wanting antibiotics.Background patient information included age, sex, health status, number of children living in the patient's home, insurance coverage for these symptoms, and educational and employment status of the respondent.The specific questions included in the survey are listed in Table 1. Each respondent reported the patient's respiratory signs and symptoms leading to the medical system contact, including presence of a cough, fever, and nasal drainage. Respondents were asked to rate the severity of the respiratory symptoms and to specify the date of symptom onset. The number of days with symptoms was computed as the difference between the date of symptom onset and the date of medical contact.Table 1. Cold-Related Beliefs and Experiences of Parents of Symptomatic Children and Symptomatic Adults by Desire for Antibiotic MedicationParentsSymptomatic AdultsTotal (N=505)Did Not Want Antibiotics (n=174)Did Want Antibiotics (n=75)Did Not Want Antibiotics (n=129)Did Want Antibiotics (n=127)Symptom durationTime from symptom onset to medical care system contact, mean (SD), d3.6 (2.6)3.2 (2.6)4.5 (3.2)5.5 (3.7)*4.2 (3.2)Current signs and symptoms of a cold, % yesCough75.772.084.585.880.0Fever57.564.039.547.251.2Greenish nasal drainage9.216.017.326.816.7Patient rates symptoms as severe28.348.6*49.666.1*46.3Current symptom concerns, % yesReassurance that the patient did not have something more serious85.675.771.373.277.4Wanted relief from cold symptoms56.982.7*77.390.6*74.4Worried that the patient would develop complications74.481.368.076.474.3Cold symptoms seem to have lasted too long48.962.7*59.775.6*60.4Confident about how to treat this cold51.753.343.450.449.4Cold-related beliefs, % agreeColds generally resolve on their own87.488.090.776.4*85.5Too many people use antibiotics for a cold65.553.362.044.1*57.4Antibiotic use is helpful for a cold31.650.7*42.659.8*44.4Colds are caused by a virus, not bacteria50.037.349.631.5*43.4Usually develop or have other medical conditions with a cold, % agreeSinus infection17.822.742.649.632.9Ear infection42.536.010.919.7*27.7Bronchitis14.918.726.443.3*25.5Bacterial throat infection18.428.017.811.818.0Past medical experiences, % agreePatient usually recovers faster from these symptoms by taking prescription medications41.460.0*41.166.9*50.5Physician usually gives antibiotics for these symptoms25.338.7*25.638.6*30.7Patient usually sees a physician for these symptoms35.145.317.827.630.3Patient's colds usually last longer than those of most people17.224.029.544.1*28.1Physician wants the patient to come in for these symptoms12.616.07.011.811.5Current situational factors, % agreeRespondent was unsure whether the patient had just a cold88.582.786.181.985.4Patient wanted to return to normal activities73.680.088.492.183.0Family, friends, or coworkers said the patient should see a physician25.326.753.563.042.2Respondent needed to return to employment15.520.046.549.632.7Respondent's employer needed a note3.55.310.111.07.3*Differs by desire for antibiotic medication at P<.05.Previous literature was used to identify a comprehensive list of factors associated with care-seeking behavior. Respondents were surveyed to assess their cold-related beliefs, their reasons for contacting the medical care system, their history of cold-related sequelae, and cold-related medical experiences. They were also asked to describe their current nonmedical situational needs, such as employment concerns. Item responses were dichotomous, ie, yes or no, or Likert-like scales that were later collapsed from 4 categories into agree or disagree.DATA ANALYSISOverall frequency distributions were computed. χ2Analyses for categorical variables or ttests for continuous variables were used to compare the responses between those who wanted antibiotics when they called and those who did not necessarily want antibiotics. Analyses were stratified by respondent status—symptomatic adult or the parent of a symptomatic child—to determine whether the factors associated with a desire for antibiotics differed between the 2 groups.Stepwise logistic regression analysis was used to identify the most important factors associated with the desire for an antibiotic prescription. Only factors associated with the desire for antibiotics at P<.05 were retained in the final model. These multivariate analyses were stratified by respondent status because bivariate analyses showed that different factors were related to the desire for antibiotics in each group.RESULTSRespondents were most often women, with an average age of 37 years (Table 2). More than three quarters of the respondents lived in households including children. Approximately three quarters of the respondents had some education beyond high school, and most were employed full-time outside the home. Virtually all respondents reported full insurance coverage for medical management of cold symptoms. Fewer parents of symptomatic children (75 [30%] of 249 respondents) than symptomatic adults (127 [50%] of 256 respondents) wanted a prescription for antibiotics to manage cold symptoms (χ2=19.98; P<.001).Table 2. Sociodemographic Characteristics of Parents of Symptomatic Children and Symptomatic Adults by Desire for Antibiotic Medication*ParentsSymptomatic AdultsTotal (N=505)Did Not Want Antibiotics (n=174)Did Want Antibiotics (n=75)Did Not Want Antibiotics (n=129)Did Want Antibiotics (n=127)Age of respondents, mean (SD), y35.0 (7.1)35.7 (6.9)38.3 (9.7)40.6 (11.1)37.4 (9.2)Age of patients, mean (SD), yChildren5.8 (4.8)6.5 (4.9)NANA6.0 (4.8)AdultsNA†NA38.3 (9.7)40.6 (11.1)39.5 (10.5)Respondent sex, % women85.184.070.570.977.6Health status of patients, %Excellent54.052.032.625.241.0Very good28.226.742.641.735.1Good12.617.319.429.119.2Fair5.24.05.43.94.8Children in the household, %00041.147.222.5131.021.322.521.324.9269.078.736.431.552.6Educational attainment of respondents, %≤High school20.829.331.024.025.5Some college/vocational training37.033.328.734.433.6College graduate or more education42.237.340.341.641.0Employment status of respondents, %Not employed outside the home24.122.7†7.013.416.8Employed part-time25.39.316.318.118.8Employed full-time50.668.076.768.564.4Have insurance coverage, %98.998.795.496.997.4Clinic affiliation, %Clinic A33.930.729.537.033.1Clinic B35.132.034.933.134.1Clinic C31.037.335.729.932.9*Differs by desire for antibiotic medication at P<.05.†NAMindicates not applicable.SOCIODEMOGRAPHIC CHARACTERISTICSExcept for employment status among parents, none of the sociodemographic characteristics were associated with wanting antibiotics among either parents or symptomatic adults. Parents who wanted antibiotics were more often employed full-time and less often part-time than were parents who did not want antibiotics.CURRENT SIGNS AND SYMPTOMS OF A COLDThe average time from symptom onset to medical care system contact was 4.2 days (Table 1). Symptomatic adults who wanted antibiotics had symptoms, on average, 1 day longer than those not wanting antibiotics. Most patients (80.0%) reported having a cough, 51.2% reported a fever, and 16.7% reported greenish nasal drainage. Cold symptoms did not differ by desire for antibiotics among parents or symptomatic adults. However, parents and symptomatic adults who wanted antibiotics more often classified their symptoms as severe than did those not wanting antibiotics.CURRENT SYMPTOM CONCERNSMost respondents expressed concerns and anxiety about the current symptoms (Table 1). Respondents wanted reassurance that they or their child did not have something more serious than an uncomplicated cold (77.4%). To a lesser extent, respondents believed the cold symptoms had lasted too long (60.4%); only 49.4% were confident that they knew how to treat the cold symptoms.In parents and symptomatic adults, wanting antibiotics was associated with increased frequency of wanting relief from cold symptoms and of believing the cold symptoms had lasted too long.COLD-RELATED BELIEFSMost respondents (85.5%) believe that colds resolve on their own (Table 1). Slightly more than half agree that too many people use antibiotics for colds, whereas less than half agree that antibiotic use is helpful for a cold. Only 43.4% believe that colds are caused by viruses only, not bacteria.Cold-related beliefs were not generally associated with the desire for antibiotics among parents of ill children, except that parents wanting antibiotics were more likely to report that taking antibiotics is helpful for treating a cold compared with parents not wanting antibiotics (50.7% vs 31.6%). In contrast, all of the cold-related beliefs evaluated in this study were associated with the desire for antibiotics among symptomatic adults who contacted the medical care system. Compared with those not wanting antibiotics, symptomatic adults who wanted antibiotics were less likely to believe that colds are caused by a virus, that colds resolve on their own, and that too many people use antibiotics for cold symptoms. Those desiring antibiotics more often believe that antibiotic therapy is helpful for a cold.USUALLY DEVELOP OR HAVE OTHER MEDICAL CONDITIONS WITH A COLDA history of developing other, more serious medical conditions in conjunction with a cold was reported by 18% to 33% of respondents, depending on the condition (Table 1). In children, the frequency of previous development of other conditions was similar regardless of parental desire for antibiotics. Symptomatic adults who wanted antibiotics more frequently reported a history of developing bronchitis (43.3% vs 26.4%) and ear infections (19.7% vs 10.9%) in conjunction with a cold than did those not wanting antibiotics.PAST MEDICAL EXPERIENCESAbout half of the respondents believe that they or their child usually recovers faster from a cold when taking prescription medications (Table 1). Less than one third of the respondents reported that they or their child usually sees a physician for cold symptoms or that their physician usually prescribes antibiotics for these symptoms. A similar percentage reported that their or their child's colds usually last longer than most people's colds. Few said their physician wanted to see the patient with these symptoms.Parents and symptomatic adults who wanted antibiotics more often reported faster recovery from cold symptoms with use of prescription medications and that their physician had given them antibiotics for these symptoms on previous occasions (Table 1). Compared with symptomatic adults who did not want antibiotics, those who wanted antibiotics said that their colds lasted longer than most people's colds.CURRENT SITUATIONAL FACTORSWhen asked about situational factors that might have motivated them to contact the medical care system, more than 80% of respondents reported that they were unsure whether they or their child had a cold, and just as many reported wanting the symptomatic person to return to normal activities. Less than half agreed that their family, friends, or coworkers recommended that they see a physician (42.2%), and even fewer reported that they needed to return to work (32.7%) or needed a note for their employer explaining their absence (7.3%). There were no differences in situational factors related to the desire for antibiotics for either parents or symptomatic adults.MULTIVARIATE LOGISTIC REGRESSION ANALYSISMultivariate analyses yielded a parsimonious group of factors associated with the desire for antibiotic medication among parents of symptomatic children and symptomatic adults (Table 3). Parents who wanted antibiotics were twice as likely to rate their children's symptoms as severe and to believe that antibiotic therapy was helpful for a cold compared with parents who did not want antibiotics for their child's cold symptoms. These parents were also more than 2.5 times as likely to call because they wanted relief for their children.Table 3. Multivariate Analysis of Factors Associated With Wanting Antibiotics by Respondent Status*Odds Ratio (95% CI)Parents of Symptomatic Children (n=249)Symptomatic Adults (n=256)Current signs and symptoms of a cold (yes vs no)Patient rates symptoms as severe2.11 (1.16-3.85)2.10 (1.22-3.67)Current symptom concerns (agree vs disagree)Wanting relief from cold symptoms2.63 (1.34-5.46). . .Confident about how to treat this cold. . .1.79 (1.03-3.16)Cold symptoms seemed to have lasted too long. . .2.40 (1.31-4.49)Cold-related beliefs (agree vs disagree)Antibiotic use is helpful for treating a cold1.95 (1.08-3.55). . .Too many people use antibiotics to treat a cold. . .0.57 (0.33-0.98)Past medical experiences (agree vs disagree)Patient usually recovers faster by taking prescription medications. . .2.82 (1.65-4.89)*CI indicates confidence interval.A different set of factors was related to the desire for antibiotics among symptomatic adults. Compared with those not necessarily wanting antibiotics, those who wanted antibiotics were twice as likely to rate their symptoms as severe, more than twice as likely to believe that their symptoms had lasted too long, more than twice as likely to believe that they would recover sooner using prescription medications, and confident that they know how to treat the symptoms. They were half as likely to believe that too many people use antibiotics for the relief of cold symptoms.COMMENTThis study is unique for several reasons. First, it expands the findings of previous studies by including parents of symptomatic children and symptomatic adults and by examining clinically relevant differences in care-seeking behavior between them. Second, our explanatory variables cover a broad range of factors related to seeking antibiotics for cold-related signs and symptoms. We include cold-related knowledge, current signs and symptoms, past experiences, and current situational factors. Finally, our study design involves systematic identification and inclusion of people who contact the medical care system for cold-related evaluation and treatment, an unstudied but large segment of the primary care population.Most respondents, regardless of their desire for an antibiotic prescription, recognized that colds resolve on their own. They called their medical provider because they were unsure whether the symptoms reflected an uncomplicated cold; they wanted reassurance that the symptoms were not a sign of something more serious. This primary need should be addressed during a patient encounter without belittling the patient's concerns. Such reassurance, or legitimization, provides the foundation for further educational messages.Beyond reassurance, the implications for clinical practice differ between parents of symptomatic children and symptomatic adults. Only about one third of parents contacting the medical care system for cold-related management specifically wanted a prescription for antibiotics; they were motivated by the severity of the current symptoms and a belief that antibiotic therapy would help their child. These parents are likely to be amenable to a strong message from their medical provider that other treatments might be more effective than an antibiotic prescription in managing these symptoms.In contrast, 50% of symptomatic adults specifically wanted antibiotics for their cold symptoms. Although they, too, were motivated by the severity of the current symptoms, symptomatic adults who wanted antibiotics had a history of antibiotic prescription use for treating cold symptoms. They reported more successful management with antibiotic use and were sure that they knew how to treat their symptoms. They were less aware of the current medical controversy regarding antibiotic overprescription for cold symptoms compared with those not wanting antibiotics. Their personal experiences are likely to conflict with provider recommendations for over-the-counter medications. Clinicians incorporating a discussion of the patient's previous cold-related medical management and drug resistance into the educational component of the visit might preserve a positive doctor-patient relationship while reducing antibiotic prescriptions.Results of this study must be evaluated with the following considerations: (1) the study sample characteristics, (2) the timing of the survey, (3) the reliance on self-report, and (4) the nonspecific nature of the presenting complaints. Respondents tended to be in very good health, highly educated, and employed. Most were fully insured for medical evaluation of cold symptoms. Factors associated with the desire for antibiotics might be different in a less affluent, less educated population.Parents of symptomatic children and symptomatic adults were surveyed 2 to 4 days after contacting the medical care system. One previous study reported mild discrepancies in patients' recall of their initial motives 7 to 10 days after receiving antibiotics for treating cold-related symptoms.Our delay was shorter and was selected to allow sufficient resolution of cold symptoms before participation in a telephone survey. Nevertheless, respondents may not accurately recall their reasons for contacting their medical care provider.Although the patient's self-described symptoms are key components in formulating a medical diagnosis and treatment plan, self-report might be biased, and medical providers acknowledge variations in patient tolerance for similar symptoms.The nonspecific symptoms may suggest that our sample included different diagnostic groups. Several design features help limit the sample to patients with uncomplicated colds. First, the symptoms reported by each patient were evaluated and deemed appropriate by a trained study manager. Second, patients with signs or symptoms of a specific, serious respiratory condition were excluded. Third, we collected multiple symptom measures, including a severity rating. Finally, our interview script and questionnaire included consistent references to cold symptoms. Nevertheless, the study participants may be a biased sample of those who contact the medical system for cold symptom management.Future research efforts should be directed toward developing and evaluating clinical strategies that help providers and those seeking care reach a common understanding of the role of antibiotics in the management of uncomplicated cold symptoms.TFaheyNStocksTThomasSystematic review of the treatment of upper respiratory tract infection.Arch Dis Child.1998;79:225-230.BLorberThe common cold.J Gen Intern Med.1996;11:229-236.JMGwaltneyThe common cold.In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases.4th ed. 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We also acknowledge the assistance of Ruth Taylor, who was the study manager; Mary Kvanbeck, Cheryl Craft, RN, and Susan Adlis, MS, who compiled and analyzed the data set; and Sharon McDonald, RN, PhD, and Diane Jacobsen, MPH, who served as liaisons with the Institute for Clinical Systems Improvement.Reprints: Barbara L. Braun, PhD, Institute for Research and Education, HealthSystem Minnesota, Health Research Center, 3800 Park Nicollet Blvd, Minneapolis, MN 55416.
Archives of Family Medicine – American Medical Association
Published: Jul 1, 2000
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