Informed Patients May Help Reduce Antibiotic Prescribing

Lara C. Pullen, PhD

November 13, 2015

Antibiotic prescribing can be reduced by interventions that facilitate shared decision making between physicians and patients. Although shared decision making appears to reduce antibiotic prescribing in the short term, it is not clear that it will result in a sustained reduction in antibiotic prescribing.

Peter Coxeter, MPH, from Bond University, Gold Coast, Queensland, Australia, and colleagues published their Cochrane Review online November 12 in the Cochrane Database of Systematic Reviews. The team evaluated the results of 10 studies that focused on acute upper or lower respiratory tract infection in children and/or adults who consulted a primary care or academic general practice.

The reviewers note that shared decision making is a relatively new intervention, and thus, all the papers have been published in the last 10 years. The reviewers found the quality of the evidence to be moderate to low for all outcomes.

In the short term, primary care interventions that aimed to promote shared decision making significantly reduced antibiotic prescribing for acute respiratory infections by approximately 40% relative to usual care. In the long term (1 - 3 years), however, the results were more varied.

The researchers thus conclude that the results may not be sufficient or of long enough duration to reverse community-level resistance trends.

In the short term, however, the reduction in antibiotic prescribing was noteworthy and occurred without an increase in patient-initiated reconsultations (risk ratio, 0.87; 95% confidence interval, 0.74 - 1.03). Moreover, there was no decrease in patient satisfaction with the consultation (odds ratio, 0.86; 95% confidence interval, 0.57 - 1.30).

The review builds on previously published reviews that have shown that interventions that provided education to healthcare professionals and patients were effective at reducing antibiotic use for respiratory tract infections.

"My first impression is, how can you be against shared decision making?" William Schaffner, MD, from Vanderbilt University in Nashville, said to Medscape Medical News. "That seems very reasonable.... I have no doubt about the results," he added.

Dr Schaffner noted, however, that, in at least some of the studies, the physicians required special education and tutoring in how to conduct these conversations. He also pointed out a piece of information missing in the review: "It doesn't tell you how long it takes."

He explained that physicians currently have long conversations about vaccines, and this review suggests that potentially overextended primary care physicians should also engage in what might turn out to be long conversations about antibiotics. Such conversations require time, skill, and sustained energy on the part of the physician.

Dr Schaffner recalls conversations with pediatricians who describe their intention to limit the prescription of antibiotics but acknowledge that, "By midafternoon, I am exhausted and I write the prescription."

"Why does this have to be a long discussion?" asked Dr Schaffner. He suggested, instead, that efforts may be better spent in educating physicians on how best to just say no to patient requests for antibiotics.

The authors and Dr Schaffner have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. 2015;11:CD010907. Abstract

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