BMJ 1997;315:1211-1214 (8 November)

General practice

Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study

John Macfarlane, consultant physician,a William Holmes, general practitioner,b Rosamund Macfarlane, research administrator,a Nicky Britten, senior lecturer in medical sociology c

a Respiratory Infection Unit, Nottingham City Hospital, Nottingham NG5 1PB,, b Sherrington Park Medical Practice, Nottingham NG5 2EJ, c Department of General Practice, United Medical and Dental Schools of Guy's and St Thomas's Hospitals, London SE11 6SP

Correspondence to: Dr J Macfarlane

Objective: To assess patients' views and expectations when they consult their general practitioner with acute lower respiratory symptoms and the influence these have on management.
Design: General practitioners studied consecutive, previously well adults and recorded clinical data, the certainty regarding their prescribing decision, and the influence of non-clinical factors on that decision. Patients completed a questionnaire at home after the consultation.
Setting: 76 doctors from suburban, inner city, and rural practices.
Subjects: 1014 eligible patients entered; 787 (78%) returned the questionnaire.
Main outcome measures: The views of the patient, the views of and antibiotic prescription by the doctor.
Results: Most patients thought that their symptoms were caused by an infection (662) and that antibiotics would help (656) and had both wanted (564) and expected (561) such a prescription. 146 requested an antibiotic, 587 received one. Of the 643 patients who thought they had an infection, 582 wanted an antibiotic and thought it would help. Severity of symptoms did not relate to wanting antibiotics. For those prescribed antibiotics, their doctor thought they were definitely indicated in only 116 cases and not indicated in 126. Patient pressure most commonly influenced the decision to prescribe even when the doctor thought antibiotics were not indicated. Doctors considered antibiotics definitely indicated in only 1% of the group in whom patient pressure influenced the prescribing decision. Patients who did not receive an antibiotic that they wanted were much more likely to express dissatisfaction. Dissatisfied patients reconsulted for the same symptoms twice as often as satisfied patients.
Conclusion: Patients presenting with acute lower respiratory symptoms often believe that infection is the problem and antibiotics the answer. Patients' expectations have a significant influence on prescribing, even when their doctor judges that antibiotics are not indicated.

Key messages

  • Three quarters of previously well adults consulting with the symptoms of an acute lower respiratory tract illness receive antibiotics even though their general practitioners assess that antibiotics are definitely indicated in only a fifth of such cases

  • Most patients think their symptoms are caused by infection, think an antibiotic will help, and want antibiotics; a fifth ask for them

  • Patients' expectations and views and doctors' concern that the patient may otherwise reconsult have a powerful effect on doctors' decision to prescribe, even when they consider that an antibiotic is not indicated

  • Patients who did not receive an antibiotic that they wanted were more likely to be dissatisfied. Dissatisfied patients reconsulted twice as frequently

  • Terms such as chest infection and bronchitis, which imply infection needing antibiotics, are probably unhelpful. Patient education may be more effective in altering the cycle of antibiotic prescription and consultations


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