Summary
In this observational study of adults presenting with acute cough, delayed prescribing was used in the minority (6.3%) of consultations, but there was large variation between networks in the frequency with which this approach was used. The median advised delay period was 3 days, with a median advised delay of ≥7 days in only two of the networks. Over half (54.4%) of those prescribed delayed antibiotics took an antibiotic at some point in the 4-week follow-up period, and nearly half (44.4%) took the antibiotic prescribed at the index consultation. Two-thirds of those who took their delayed prescription started it on the day it was prescribed. Patients with a working diagnosis of upper respiratory tract infection (URTI), viral infection or non-specific infection were less likely to consume their delayed antibiotic prescription. Patient’s who indicated that they wanted an antibiotic were more likely to consume their delayed prescription, but patients whose clinician had a perception that they wanted antibiotics were less likely to consume them.
Strengths and limitations
The study described routine care in 14 networks in 13 European countries. The patient eligibility criteria were broad and patients were not randomised. Data on routine prescribing behaviour in everyday clinical practice can only be obtained through observational data. The nature of this study, with clinicians asked to record their usual practice, and patients asked to record their behaviours prospectively, meant that these results are likely to reflect routine care in these practices. The multinational nature of the study also increases the generalisability of the results and allows for comparisons between countries.
Although clinicians were asked to record the use of the delayed prescribing strategy, there are no data on what was actually said to patients in consultations, and it is possible that some clinicians suggested, either overtly or subtly, delaying use of the antibiotics but did not record this advice. As delayed prescribing was used in a minority of cases, the study may not have sufficient power to clearly describe the association of some factors with consumption of a delayed antibiotic. Furthermore, the use of a delayed prescribing approach was dominated by a few networks with only the Southampton and Milan networks using the strategy in more than 10% of consultations and only the Southampton and Balatonfüred networks with 30 or more patients who had received a delayed prescription. Therefore, the results of the regression model may reflect local factors. For the same reason, the description of how frequently the strategy was used and the median advised delay has limited precision in networks where the approach was used infrequently.
Comparison with existing literature
Despite delayed prescribing being widely researched since the late 1990s, and recommended in National Institute for Health and Clinical Excellence (NICE) guidance on antibiotic prescribing for respiratory tract infections in the UK,2 little is known about how frequently this strategy is used in conditions of usual clinical care. This is largely because the advice to delay taking a prescription is generally not coded in general practice electronic records, and therefore not easily accessible in database studies.17 The data shows that delayed antibiotic prescribing has not been widely adopted for acute cough/LRTI throughout Europe. The approach was used in approximately one-third of consultations in the English network (Southampton), and therefore may be used more extensively in England than the rest of Europe. However, this network is linked to a university department that led many locally recruiting studies of delayed prescribing, and therefore may not be representative of the rest of the UK. In the Cardiff network, delayed prescribing was used in only 3.3% of consultations. Sharland and colleagues compared data on prescribing with data on prescriptions issued by pharmacists in England and found evidence of a reduction in the proportion of antibiotic prescriptions taken to pharmacists during the late 1990s and early 2000s following the publication of a trial of delayed prescribing in 1997.10 They hypothesised that this was explained by uptake of delayed prescribing and suggested that at least in the UK use of the approach is likely to be widespread. An observational study of 273 patients with respiratory tract infections presenting in general practices in Germany found that delayed prescribing was not used at all.18 This study’s data therefore describe the largest experience so far on the use of this strategy across Europe.
Possible explanations for the apparent lack of use of delayed prescribing for acute cough across Europe include a lack of inclusion in many national guidelines, a lack of awareness of the strategy and concerns about the approach among primary care clinicians and/or patients. A qualitative interview and focus group study of primary care clinicians in the UK found low reported use of delayed prescribing and concerns about sending out conflicting messages and altering the locus of control from the clinician to the patient.19 However, the latter study provided no details about how clinicians conceived of/operationalised delayed prescribing, and the results are in contrast to the trial evidence, where the change in beliefs and behaviour are similar to no prescribing. A similar study in New Zealand, that also explored the views of patients, found considerable variation in reported use and opinions about the strategy.20 Some patients reported feeling uncomfortable about being given the decision about when to use antibiotics, and others reported taking ‘delayed’ antibiotics immediately. Some clinicians thought that the strategy helped empower patients, provided reassurance, and helped to meet their expectations, while others expressed concerns about patients using them inappropriately, about masking serious illness, and about medicolegal problems.
The study found that just under half of the patients given a delayed prescription took them; a proportion that is higher than in trials of this approach.4,6 The results are not dissimilar to observational studies of this approach in children with acute otitis media in the US, where 31% consumed a delayed prescription,21 and patients with upper respiratory tract infections (URTI) in south-east England, where 53.1% consumed their delayed antibiotics.22 However, both of these studies were conducted in a relatively small group of practices and therefore the results probably provide more accurate data on use in everyday practice.
The finding that two-thirds of those who consumed their delayed prescription did not adhere to any delay (started their antibiotics on the day they were prescribed) is in contrast to the 23.7% who started taking their antibiotics immediately in a study of URTI.22 However, this is consistent with the finding that URTI was associated with reduced odds of consuming a delayed antibiotic prescription compared with LRTI. Only nine of the 53 (17.0%) patients who received a delayed prescription in Southampton consumed their delayed prescription. Many of the Southampton practices had previously participated in trials of delayed prescribing, so this may reflect the benefit of having taken part in these trials or the effects of local opinion leaders.
In trials of delayed prescribing clinicians are usually instructed to use the approach as part of a package that includes; i) advice about the (limited) effectiveness and disadvantages of using antibiotics for their illness, and ii) advice about the likely time-course of their symptoms and how to decided when to take the antibiotic. RTI symptoms commonly last longer than patients expect, and therefore advice about how long to delay the prescription is an important element of this package. Inadequate provision of advice, or provision of inaccurate or inappropriate advice, are possible reasons for the difference in the reported consumption found in trials of this approach and in this study. In particular, the duration of delay advised by clinicians in this study was considerably shorter than the 1 to 2 weeks used in the trials and recommended in guidelines.4,6 The study did not find a significant association between a longer delay and lower consumption. However, the point estimate (0.38) was in the direction of such an association, and a lack of association may have been a Type II error. The study has no data concerning the advice given by clinicians when a delayed prescription was used. However, given the poor adherence of clinicians to the advice about duration of delay, it seems likely that other elements of the delayed prescribing strategy (such as providing advice regarding the limited effectiveness of antibiotics, their disadvantages, and when to consider using the antibiotics) were also poorly adhered to, which is likely to undermine the effectiveness of the strategy.
The method of delivering the delayed prescription to the patient may also have influenced how delayed prescriptions were used. Consumption of delayed antibiotics is likely to be lower if it is left up to the patients to collect the prescription at a later point rather than being given to the patient during the consultation.3 There is no data for this study concerning the method of providing the delayed prescription employed. The finding that the clinician’s perception that the patient wanted an antibiotic was associated with less consumption may seem at odds with the finding that patient’s express hope for antibiotics was associated with greater consumption. The most likely explanation is that clinicians would be more likely to discourage use of the delayed prescription when they had opted for a delayed (rather than immediate) prescribing approach and thought that the patient wanted to take antibiotics.
Implications for practice and research
Delayed prescribing has been shown to be an effective approach to reducing antibiotic prescribing for acute cough in clinical trials. However, it was found that the strategy was used infrequently across research Networks in Europe, and is therefore currently likely to be having little overall effect on antibiotic consumption. Indeed the finding that two-thirds of those who consumed antibiotics prescribed in their delayed prescription did so on the day it was prescribed suggests either poor communication about the delayed prescribing strategy or a degree of resistance among patients to adopt this approach. Opinion leaders may be able to play a role in increasing awareness about the need for clear communication as part of any delayed prescribing package.
Further studies can be used to explore the barriers and opportunities for improving uptake of this approach and understand how the various components of the delayed prescribing ‘package’ affect uptake of the approach and subsequent consumption of antibiotics. Two elements that deserve further clarification are the acceptability and effect of varying the advised delay period, and effect of different methods of delivery on antibiotic consumption and patient satisfaction. Finally, a clearer understanding of the views and behaviours of clinicians and patients around use of this approach is needed; for example, whether clinicians and patients feel happy with advice to delay antibiotics by 1–2 weeks, and what advice they give patients about when to use their prescription (symptoms not resolved, not getting better, getting worse) and about safety netting (when to reconsult).
