The New Human Papilloma Virus Vaccine

William T. Basco, Jr, MD, FAAP


July 27, 2006

Does It Really Take Longer Not to Prescribe Antibiotics for Viral Respiratory Tract Infections in Children?

Hare ME, Gaur AH, Somes GW, Arnold SR, Shorr RI
Ambul Pediatr. 2006;6:152-156

Hare and colleagues evaluated the relationship between encounter length and antibiotic prescription rates using data from the National Ambulatory Medical Care Survey (NAMCS) to determine whether physician visits are shorter when antibiotics are prescribed than when they are not prescribed. One potential explanation for prescribing antibiotics inappropriately is that doing so would allow a practitioner to complete any given encounter sooner, rather than taking the time to explain why antibiotics are not indicated (eg, for many respiratory illnesses seen in the ambulatory setting).

The data for this study were collected over a 10-year period, from 1993-2003. The surveys are meant to provide nationally representative estimates of patient visits, diagnoses, and treatments provided by practitioners. Each participating practitioner provided data on visits for a 1-week period. The authors included information on visits for children aged 18 and younger who were seen for viral respiratory tract infections, including common cold, nasopharyngitis, upper respiratory tract infection, bronchitis, and bronchiolitis. They excluded conditions that might have been associated with a longer encounter length (eg, patients with diagnoses for chronic medical conditions) and visits at which a secondary diagnosis might have indicated the need for antibiotics.

In the NAMCS, physicians self-report face-to-face time with patients on the data collection forms. The analyses controlled for multiple patient, physician, practice, and geographic factors as well as temporal trends. There were more than 2700 patient visits in the sample, seen by over 1100 practitioners. With weighting, those 2739 visits extrapolated to more than 199,000 visits. Cold or upper respiratory infection comprised 77% of the study visits, with bronchitis comprising 17% and bronchiolitis 6%.

Among patients with cold or upper respiratory infection, 30% received antibiotic prescriptions compared with 54% of patients with bronchiolitis and fully 75% with bronchitis. This amounted to an overall rate of 39% of patients receiving antibiotics even though they had a diagnosis that would not benefit from these drugs. The average visit lasted 13.1 minutes. Visits at which no antibiotics were prescribed lasted an average of 13.0 minutes compared with 13.4 minutes for visits at which antibiotics were prescribed. This difference was not statistically significant once all patient variables and other factors were accounted for.

On the promising side, physicians were less likely to prescribe antibiotics for the respiratory conditions listed above after 1998, when growing interest in judicious use of antibiotics led to the release of several statements by professional organizations. The authors concluded, on the basis of their study results, that prescribing antibiotics for viral respiratory illnesses is not associated with shorter visit times.

I included this article in an attempt to dispel any misperceptions practitioners may have about what takes longer – talking patients out of antibiotics, or giving in and then having to explain how to take them, refrigerate them, etc. Of course, this study still does not capture all of the nuances of discussions with patients about antibiotics, but the overall view is that there is no time benefit. The authors make an interesting point; they suggest that explaining to parents why antibiotics are not indicated for a viral illness may be more stressful for the physician than simply prescribing antibiotics. The authors speculate that this stress leads to the perception that such visits take longer. In any case, across numerous practitioner types, practice types, regions, and patients, there is no time advantage to prescribing antibiotics when not indicated. This study goes toward removing another potential barrier to judicious use of antibiotics.



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