Education During Office Visits to Reduce Antibiotic Use & Revisits

Abstract

Source: Francis NA, Butler CC, Hood K, et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomized controlled trial. BMJ. 2009;339(7711 ):b2885; doi:10.1136/bmj.b2885Investigators from Cardiff University, Wales, conducted a randomized controlled trial to assess the efficacy of an interactive booklet on respiratory tract infections in children in reducing return visits and antibiotic use. The booklet was eight pages long and facilitated the use of certain communication skills, mainly exploring the parents’ main concerns, asking about their expectations, and discussing prognosis, treatment options, and any reasons that should prompt re-consultation. Sixty-one general practices participated in this study and were randomized to either provide the booklet to parents during visits by children aged 6 months to 14 years presenting with symptoms of an acute respiratory tract infection (cough, cold, sore throat, earache) for seven days or less, or to provide standard care. Children with suspected pneumonia, asthma or a serious concomitant illness, or needing immediate hospital admission, were excluded.Physicians randomized to the intervention group were trained to use the booklet during the office visit. Up to 10 children from each participating practice were enrolled in the study. Parents were contacted 14 days after the index visit to collect data on return visits to healthcare providers, use of antibiotics, parental satisfaction with the visit, reassurance, parental “enablement,” and intention to have a visit in the future for similar symptoms in their child.A total of 588 children with a mean age of 5 years were enrolled in the study, including 274 from intervention practices and 284 from control practices. Outcome data were collected on 528 (94.6%). While satisfaction, reassurance, and parental enablement scores were not significantly different between parents of children in the two groups, the use of the booklet was associated with a reduced intention by parents to revisit the doctor for a similar illness in the future in their child (OR=0.34; 95% CI, 0.20–0.57). At the index visit antibiotics were prescribed for 19.5% of children seen in intervention practices and 40.8% of those from control sites (OR=0.29; 95% CI, 0.14–0.60).The authors conclude that use of an interactive booklet about respiratory infections in children may be an effective tool in reducing both antibiotic prescribing for this condition and physician visits for respiratory symptoms in children.Dr Serota has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The authors remind us that parental beliefs, fears, and expectations play an important part in both healthcare utilization and determining whether an antibiotic is prescribed.1 Parents fear serious illness and worry that they will not be able to recognize the symptoms.2 Establishing realistic expectations about the likely duration of illness can reduce parental anxiety and rates of visits. Parents value a thorough examination, explanation, reassurance, and advice or guidance more than a prescription for antibiotics.3,4Most pediatricians would agree that there is little need for antibiotics in uncomplicated viral infections and common upper respiratory tract illnesses. Despite an extensive literature on “fever phobia”, the lack of need for antibiotics, and even an increase in the discussion of the subject in the lay media, parents all too often demand an antibiotic for their child or leave the doctor’s office feeling shortchanged.The results of this study show that the simple use of an eight-page booklet on the measures a parent should take in managing their child’s viral infections helps them to understand that antibiotics are not needed. Knowing that taking the time to educate patients and parents about respiratory infections really does impact the overuse of antibiotics is reassuring. Now, if we could only get rid of the sample closet and pharmaceutical representatives’ visits...The results of this study are tantalizing: the use of the educational booklet led to a substantial decrease in antibiotic prescribing. However, since data were collected on a maximum of 10 patients seen by each physician, and these providers were unblinded and knew that they were being observed, it is quite possible that the results were strongly biased by a “Hawthorne effect” (see “Weighing the Evidence” on page 72). Caution in interpreting the findings is also suggested by the results of a study in the US in which no effect on antibiotic prescribing was apparent among children of parents given an educational intervention when observed over a 12-month period.5