Factors Affecting Antibiotic Prescribing for Acute Respiratory Infection by Emergency Physicians

Nasia Safdar, Thomas G. Tape, Barry C. Fox, James E. Svenson, Robert S. Wigton

College of Medicine, University of Nebraska Medical Center, Omaha, USA.
Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, Madison, USA.
Section of Emergency Medicine, Department of Medicine, University of Wisconsin-Madison, Madison, USA.
William S. Middleton Memorial Veterans Hospital, Madison, USA.

DOI: 10.4236/health.2014.68099                

Abstract

Background: Antibiotics are frequently prescribed for upper acute respiratory tract infections (ARI) in the emergency department. To reduce inappropriate overprescribing, it is necessary to understand factors influencing physicians’ decisions to prescribe antibiotics. Objective: Analyze the judgment policies of emergency physicians to determine factors predicting antibiotic use. Design: Paper case vignette study. Participants: 104 emergency physicians from Wisconsin. Measurements: We used judgment analysis to derive the policies of 104 emergency physicians from their responses to 20 case vignettes. We designed the cases such that each physician’s use of clinical findings and patient factors could be inferred from the decisions they made about each case. Findings were compared to primary care practitioners (PCPs) in Colorado responding to the same paper cases to examine differences in factors influencing prescribing among the two groups. Results: The emergency physicians said they would prescribe an antibiotic (yes/no) in 51.4% of cases compared with 44.5% in the Colorado study. The majority of emergency physicians gave the greatest weight to duration of illness (51%), followed by temperature (20%) and cough (12%). Conclusions: These emergency physicians prescribed antibiotics more frequently than the Colorado PCPs. There was little difference in how clinical findings were weighted, suggesting this was not the source of the higher prescription rate among the emergency physicians. The considerable emphasis on duration of illness suggests that this would be a productive area for educational efforts to reduce antibiotic prescribing for ARI in the emergency department.

Keywords

Antibiotic; Infection; Prescribing

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Gonzales, R., Bartlett, J.G., Besser, R.E., et al. (2001) Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods. Annals of Emergency Medicine, 37, 690-697. http://dx.doi.org/10.1067/S0196-0644(01)70087-X
[2]	Hickner, J.M., Bartlett, J.G., Besser, R.E., Gonzales, R., Hoffman, J.R. and Sande, M.A. (2001) Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background. Annals of Emergency Medicine, 37, 703-710. http://dx.doi.org/10.1067/S0196-0644(01)70089-3
[3]	Gonzales, R., Bartlett, J.G., Besser, R.E., Hickner, J.M., Hoffman, J.R. and Sande, M.A. (2001) Principles of Appropriate Antibiotic Use for Treatment of Nonspecific upper Respiratory Tract Infections in Adults: Background. Annals of Emergency Medicine, 134, 490-494. http://dx.doi.org/10.7326/0003-4819-134-6-200103200-00015
[4]	Gonzales, R., Bartlett, J.G., Besser, R.E., et al. (2001) Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis: Background. Annals of Emergency Medicine, 37, 720-727. http://dx.doi.org/10.1067/S0196-0644(01)70091-1
[5]	Roumie, C.L., Halasa, N.B., Grijalva, C.G., et al. (2005) Trends in Antibiotic Prescribing for Adults in the United States—1995 to 2002. Journal of General Internal Medicine, 20, 697-702. http://dx.doi.org/10.1111/j.1525-1497.2005.0148.x
[6]	Gonzales, R., Corbett, K.K., Wong, S., et al. (2008) Get Smart Colorado: Impact of a Mass Media Campaign to Improve Community Antibiotic Use. Medical Care, 46, 597-605. http://dx.doi.org/10.1097/MLR.0b013e3181653d2e
[7]	Belongia, E.A., Knobloch, M.J., Kieke, B.A., Davis, J.P., Janette, C. and Besser, R.E. (2005) Impact of Statewide Program to Promote Appropriate Antimicrobial Drug Use. Emerging Infectious Diseases, 11, 912-920.
[8]	Vanderweil, S.G., Pelletier, A.J., Hamedani, A.G., Gonzales, R., Metlay, J.P. and Camargo, Jr., C.A. (2007) Declining Antibiotic Prescriptions for Upper Respiratory Infections, 1993-2004. Academic Emergency Medicine, 14, 366-369.
[9]	Thorpe, J.M., Smith, S.R. and Trygstad, T.K. (2004) Trends in Emergency Department Antibiotic Prescribing for Acute Respiratory Tract Infections. Annals of Pharmacotherapy, 38, 928-935. http://dx.doi.org/10.1345/aph.1D380
[10]	Gonzales, R., Camargo, Jr., C.A., MacKenzie, T., et al. (2006) Antibiotic Treatment of Acute Respiratory Infections in Acute Care Settings. Academic Emergency Medicine, 13, 288-294. http://dx.doi.org/10.1111/j.1553-2712.2006.tb01695.x
[11]	Ong, S., Nakase, J., Moran, G.J., Karras, D.J., Kuehnert, M.J. and Talan, D.A. (2007) Antibiotic Use for Emergency Department Patients with Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction. Annals of Emergency Medicine, 50, 213-220. http://dx.doi.org/10.1016/j.annemergmed.2007.03.026
[12]	Gonzales, R., Barrett, Jr., P.H., Crane, L.A. and Steiner, J.F. (1998) Factors Associated with Antibiotic Use for Acute Bronchitis. Journal of General Internal Medicine, 13, 541-548. http://dx.doi.org/10.1046/j.1525-1497.1998.00165.x
[13]	Mangione-Smith, R., McGlynn, E.A., Elliott, M.N., Krogstad, P. and Brook, R.H. (1999) The Relationship between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior. Pediatrics, 103, 711-718. http://dx.doi.org/10.1542/peds.103.4.711
[14]	Wigton, R.S., Darr, C.A., Corbett, K.K., Nickol, D.R. and Gonzales, R. (2008) How Do Community Practitioners Decide Whether to Prescribe Antibiotics for Acute Respiratory Tract Infections? Journal of General Internal Medicine, 23, 1615-1620. http://dx.doi.org/10.1007/s11606-008-0707-9
[15]	Cooksey, R.W. (1996) Judgement Analysis: Theory, Methods and Applications. Academic Press, Waltham.
[16]	Wigton, R.S. (1988) Use of Linear Models to Analyze Physicians’ Decisions. Medical Decision Making, 8, 241-252. http://dx.doi.org/10.1177/0272989X8800800404
[17]	Gonzales, R., Bartlett, J.G., Besser, R.E., Cooper, R.J., Hickner, J.M., Hoffman, J.R., et al. (2001) Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods. Annals of Internal Medicine, 134, 479-486. http://dx.doi.org/10.7326/0003-4819-134-6-200103200-00013
[18]	Aspinall, S.L., Good, C.B., Metlay, J.P., Mor, M.K. and Fine, M.J. (2009) Antibiotic Prescribing for Presumed Nonbactrial Acute Respiratory Tract Infections. Annals of Emergency Medicine, 27, 544-551.
[19]	Stearns, C.R., Gonzales, R., Camargo, Jr., C.A., Maselli, J. and Metlay, J.P. (2009) Antibiotic Prescriptions Are Associated with Increased Patient Satisfaction with Emergency Department Visits for Acute Respiratory Tract Infections. Academic Emergency Medicine, 16, 934-941. http://dx.doi.org/10.1111/j.1553-2712.2009.00522.x
[20]	Belongia, E.A., Naimi, T.S., Gale, C.M. and Besser, R.E. (2002) Antibiotic Use and Upper Respiratory Infections: A Survey of Knowledge, Attitudes, and Experience in Wisconsin and Minnesota. Preventive Medicine, 34, 346-352. http://dx.doi.org/10.1006/pmed.2001.0992
[21]	Kirwan, J.R., Chaput de Saintonge, D.M., Joyce, C.R., Holmes, J. and Currey, H.L. (1986) Inability of Rheumatologists to Describe Their True Policies for Assessing Rheumatoid Arthritis. Annals of the Rheumatic Diseases, 45, 156-161. http://dx.doi.org/10.1136/ard.45.2.156
[22]	Bakwin, H. (1946) Pseudodoxia Pediatrica. The New England Journal of Medicine, 232, 691-697. http://dx.doi.org/10.1056/NEJM194506142322401