Balanced Advice May Reduce Antibiotic Prescriptions for Kids

Diana Swift

May 18, 2015

By offering parents positive advice on ways to reduce children's respiratory symptoms and explaining the reasons why antibiotics are not indicated, clinicians reduced inappropriate antibiotic prescribing, a new study suggests. At the same time, this two-sided approach improved parents' experience and provider care ratings.

Rita Magione-Smith, MD, MPH, a professor of pediatrics at the University of Washington, Seattle, and colleagues published the results of their cross-sectional study in the May-June 2015 issue of the Annals of Family Medicine.

The authors note that more than half of pediatric patients diagnosed with acute respiratory tract infections (ARTIs) receive antibiotics despite the fact that the estimated US prevalence of pediatric bacterial ARTIs is only 27%. Similarly, a Dutch study recently reported that almost half of general practitioner–prescribed antibiotics for RTIs failed to comply with clinical guidelines, with patient pressure and expectations the primary drivers of this overprescribing.

To find out whether positive or negative recommendations were more closely linked with antibiotic prescribing, Dr Magione-Smith and colleagues analyzed survey results from 1285 pediatric visits for ARTIs to 28 providers in 10 Seattle practices during 2007 to 2009. The children, 49% of whom were girls, were from predominantly white, well-educated families, and their ages ranged from 6 months to 10 years (mean, 4.2 years). Symptoms included cough, nasal congestion, sore throat, and ear tugging. Providers completed postvisit surveys on symptoms and physical examination findings, assigned diagnoses, and prescribed treatments. Parents completed postvisit surveys on provider communication practices and rated the care provided.

Overall, clinicians prescribed antibiotics in 34% of all ARTI visits (bacterial and viral combined), but only in 5% of viral ARTI visits. Parent care ratings during visits for viral ARTIs were high, with approximately two thirds of parents rating the visit as a 10 on the Consumer Assessment of Healthcare Providers and Systems rating scale.

Suggesting actions to reduce a child's symptoms (positive treatment recommendations) was associated with decreased risk of antibiotic prescribing both alone and in combination with negative treatment recommendations (ruling out the need for antibiotics). The respective adjusted risk ratios (aRRs) were 0.48 (95% confidence interval [CI], 0.24 - 0.95) and 0.15 (95% CI, 0.06 - 0.40). Exclusive use of negative recommendations during treatment discussions was rare.

Combining positive and negative recommendations was associated with a 16% greater probability of a parent's giving the visit the highest possible rating (10 vs 0 - 9; aRR, 1.16; 95% CI, 1.01 - 1.34; P = .04).

A combined communication approach may offer the best option for reducing the problem of antibiotic overprescribing. "With the growing threat of antibiotic resistance at the community and individual level, these communication techniques may assist frontline providers in helping to address this pervasive public health problem," the authors write.

This study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The funder had no involvement in the study or its preparation for publication. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2015;13:221-227. Full text

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