Original Articles
Back-up antibiotic prescriptions could reduce unnecessary antibiotic use in rhinosinusitis

https://doi.org/10.1016/j.jclinepi.2003.09.008Get rights and content

Abstract

Objectives

To examine the attitudes of patients with rhinosinusitis toward the availability of “back-up” antibiotics, and potential implications for antibiotic use rates.

Study design and setting

A survey that assessed actual and hypothetical antibiotic prescription patterns was administered to a convenience sample of patients treated for rhinosinusitis in one acute care facility between September 1 and December 1, 2001.

Results

Of 386 eligible patients, 114 completed the survey. Seventy-six percent of patients expected antibiotic treatment; satisfaction rates were significantly associated with receiving an antibiotic prescription (P < .05). Over two-thirds of patients (69.7%) reported preference for back-up antibiotic prescriptions in the future, with 91.1% stating they would wait at least 1 day, and 52.7% at least 7 days, to fill a backup prescription. In sensitivity analysis, back-up prescriptions significantly reduced antibiotic use over a wide range of assumptions.

Conclusions

The majority of patients with rhinosinusitis in this study expected antibiotic prescriptions, and were more satisfied if they were received. Back-up antibiotics have the potential to reduce unnecessary antibiotic use, mitigate risk of nontreatment, and preserve high levels of patient satisfaction.

Introduction

Acute rhinosinusitis is diagnosed in more than 30 million Americans every year [1]. Reliably distinguishing a viral from bacterial etiology for the condition based on symptomatology, physical exam, or radiologic tests is very challenging [2], [3], [4], [5], [6], [7], [8], [9]. As a result, prescription of antibiotics is frequent [10], [11].

Acute rhinosinusitis of fewer than 7–10 days' duration is usually viral [12], [13]. Only 0.5–2.0% of viral rhinosinusitis is complicated by bacterial infection [14]. The American Academy of Head and Neck Surgery has recently recommended that the etiologic diagnosis for acute rhinosinusitis be considered viral unless the symptoms have not improved over 10–14 days or are worse after 5–7 days. If symptoms have persisted or worsened, a diagnosis of acute bacterial rhinosinusitis can then be entertained [2]; viral rhinosinusitis generally lasts up to 9 days [15].

Use of antibiotics for rhinosinusitis is likely due to multiple influences [16], [17]. Patient pressure and patient satisfaction are the most commonly cited explanations from physicians [18], [19], [20], [21]. In multiple studies, patient expectation of antibiotic treatment has been shown to range from 50 to 76% [18], [22], [23], [24]. Many physicians also hypothesize that their patients may go to another practitioner for care if they do not receive an antibiotic [25], [26]. Although there is no definitive evidence to substantiate the claim that antibiotic prescriptions are associated with satisfaction, the conviction is widespread [16], [18], [27], [28], [29], [30]. Physicians generally perceive a patient expectation for antibiotics correctly only 41–50% of the time, however [18], [23], [31], [32], [33]. Few patients preferring not to take antibiotics express these feelings to their physician [16], [17]. Because of these factors, more than 20% of patients not expecting antibiotics leave their visit with a prescription for them [23], [32].

Several methods for decreasing the prescription of unnecessary antibiotics have been attempted including computer algorithms, desk reminders, academic detailing, and public education, all with varying success [34]. The strategy of back-up prescriptions, defined as the provision of a prescription to be filled and used only when circumstances or the disease course meet certain conditions, has been used successfully in other medical arenas, primarily for emergency contraception and malaria treatment [35], [36]. Studies of back-up prescriptions have shown rates of satisfaction varying from a slight decrease when compared to immediate antibiotic prescription in British studies to a satisfaction rate of over 96% in an American study [22], [37], [38].

Back-up prescriptions have also been shown to have a significantly lower fill rate, ranging from 24–45% in patients who had to return to the office to pick up their prescription, to 50.2% in studies where prescriptions were taken with the patient at the time of diagnosis [24], [37], [38], [39], [40]. In a study of delayed prescriptions for otitis media, the median number of prescriptions per month in one practice fell by approximately 20% [38], [39], [40], [41].

To date, little is known regarding the utility of back-up antibiotic prescriptions for rhinosinusitis. We therefore conducted a survey study among patients recently seen and treated for rhinosinusitis to explore preference, satisfaction, and likely antibiotic use rate associated with actual treatment and the back-up prescription approach.

Section snippets

Methods

A retrospective survey study was conducted at a community hospital (Griffin Hospital) based walk-in clinic in Derby, CT, to assess the influence of hypothetic back-up prescriptions on patient satisfaction and antibiotic use. This setting provides ambulatory care to patients of all ages. Providers are physicians and physician associates. The survey included questions to determine: (1) patient satisfaction with treatment; (2) patients' perceived need for an antibiotic; (3) patient receipt of an

Results

A total of 114 subjects completed the survey out of 386 eligible (29.5%). Participants ranged in age from 5 months to 86 years of age, with a mean age of 30.2 years. Age, sex, insurance status, diagnosis, and treatment did not differ between participants and nonparticipants; the age and sex of participants compared to all eligibles are shown in Table 1.

Prior to their visit with a physician, 76% of patients held the belief that their infection would require an antibiotic. Overall, 63% of

Discussion

This preliminary study, based on hypothetic rather than actual use of back-up antibiotic prescriptions for symptoms consistent with rhinosinusitis, suggests that this simple practice has the potential to maintain high levels of patient satisfaction with care, while significantly reducing prescription fill rates and antibiotic use.

In the study sample, 76% of patients expected to be treated with an antibiotic for their illness, and 63% received an antibiotic prescription. Multiple studies have

Acknowledgements

The authors gratefully acknowledge Dr. Glen R. Couchman for sharing his survey on back-up antibiotic prescriptions and Anastasia Martin, Nikki Pinkerton, and Michelle LaRovera for their technical assistance. Written permission from those acknowledged has been obtained, and is on file. Funding was provided by the Yale Office of Student Research and the Centers for Disease Control and Prevention. This grant was financially supported in part by CDC Grant # U48/CCU115802.

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