- John Macfarlane, consultant physiciana,
- William Holmes, general practitionerb,
- Rosamund Macfarlane, research administratora,
- Nicky Britten, senior lecturer in medical sociologyc
- 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
- Accepted 11 August 1997
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.
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
Acute lower respiratory tract symptoms are very common in primary care, and general practitioners prescribe antibiotics in three quarters of such consultations, labelling many as infection.1 2 Increasing antibiotic prescribing, particularly for respiratory infections, contributes to rising drug costs and increasing antibiotic resistance of respiratory pathogens in the community.3 4 5 We investigated patients' views about the cause of their illness and its management when they consulted with lower respiratory tract symptoms; the doctors' decision making process when they prescribed; and how patients' views affect management.
Subjects and methods
Seventy six general practitioners in our Community Respiratory Infection Interest Group agreed to recruit consecutive, previously well adults (defined as over 15 years and not under supervision or treatment for underlying disease) who consulted with an acute lower respiratory tract illness (defined as new cough and at least one other lower respiratory symptom, including sputum production, dyspnoea, wheeze, or chest pain for which there was no other obvious explanation). This definition derives from published criteria for community respiratory syndromes6 and our previous work.3 Management was then left to doctors' discretion, who, during the consultation, completed a data form1 7 that included their certainty as to whether antibiotics were indicated and also details of non-clinical “factors” influencing their decision. At the end of the consultation patients received a sealed envelope containing a confidential questionnaire (coded without their name) to complete at home and post to our research office. The patients were unaware of the views recorded by their doctor. The study had ethical committee approval, and patients gave informed verbal consent.
Data were analysed with EpiInfo 6 with statistical comparisons by χ2 test for categorical variables and Student's t test for continuous variables. The number of patients studied (1000 evaluable patients) was determined not by this observational study but by the statistical power needed for a separate randomised study in which these patients participated regarding reconsultation and the effect of an information leaflet about the clinical course of the cough.8 The leaflet, which was in a sealed envelope to be opened after completion of the questionnaire, included no reference to infection or antibiotics.
The 76 participating general practitioners median age 42 (range 28-63) years) practised in a variety of settings: 11% rural practice, 18% inner city, and 71% suburban; 3% single handed, 54% in 2–4 partner practices, and 43% in larger practices. They returned data sheets on 1054 patients, of whom 1014 were evaluable and 40 excluded (34 had underlying diseases—mostly chronic lung disease, asthma, and diabetes; four were too young; and two had missing data); 69 general practitioners entered 10–16 eligible patients and seven entered 6-9. Questionnaires were returned by 787 patients (78%), which formed the basis of this study.
Table 1 compares the 787 patients who returned the questionnaire and the 227 who did not. The latter were significantly younger and more likely to be smokers, to have complained of systemic symptoms, and not to have received an antibiotic at the index consultation.
Typically, patients thought that their problem was caused by infection (85%) and that antibiotics would help (87%) (table 2). Most patients had both wanted antibiotics (72%) and had expected to be prescribed them (72%). A fifth of patients had asked for an antibiotic.
Correlations within patients' replies
In the following bivariate analyses, denominators vary as not all patients answered every question.
Of patients who thought they had an infection, nearly twice as many wanted an antibiotic and thought they would help. Of 643 patients who thought their symptoms were caused by an infection, 582 (90%) considered antibiotics would help compared with 27 of 55 (49%) who did not think that they had an infection (χ2=74.5; P<0.0001). Of 657 patients who thought that an infection was present, 507 (77%) wanted antibiotics compared with 24 of 58 (41%) who did not think an infection was causing their illness (χ2=33.9; P<0.0001).
Over a quarter of those who wanted antibiotics asked for them. Of 561 patients wanting antibiotics, 144 (26%) asked for them versus 1/104 (1%) who had not wanted antibiotics (χ2=30.0; P<0.0001). One patient who asked for an antibiotic had not thought about wanting one.
Those wanting antibiotics were five times as likely to expect to be prescribed them. Of 561 patients who wanted antibiotics, 508 (90%) expected to be prescribed them compared with 18/104 (17%) who had not wanted them (χ2=280; P<0.0001).
General practitioners' views
Table 3 shows the doctors' certainty in prescribing antibiotics and the influence of non-clinical “other factors” on their decision.
Of 581 patients (74%) prescribed antibiotics, the doctor considered them definitely indicated in only a fifth of cases and not indicated in nearly a quarter. Non-clinical “factors” influenced prescribing in 249 (44%) of those receiving antibiotics, usually patient pressure (133 (54%)).
Patients' opinions and general practitioners' actions
Patients wanting antibiotics were more than three times as likely to receive them. Of 564 patients wanting antibiotics, 495 (88%) received them versus 24/104 (23%) who did not want them (χ2=208; P<0.0001).
Patients' views had a strong influence on prescribing. Of 125 patients given antibiotics even when the doctor thought that they were not indicated, 114 (91%) had wanted them. For the 570 patients receiving antibiotics, doctors stated their prescribing decision was influenced by patient pressure in 133 cases (23%). For these 133 patients, antibiotics were considered “definitely indicated” in only 1%, “probably indicated” in a third, and “not indicated” in two thirds. For the other 437 cases, when patient pressure was not present, doctors thought antibiotics were probably or definitely indicated in 91% and not indicated in only 9% (table 4).
Most patients expecting their doctor to prescribe antibiotics received them: of 560 patients expecting an antibiotic, 474 (85%) received them compared with 54/133 (41%) who did not (χ2=112; P<0.0001).
Dissatisfied patients reconsulted twice as frequently. Of 37 patients expressing dissatisfaction with their doctor's decision to prescribe antibiotics or not, 13 (35%) reconsulted for similar symptoms within 4 weeks compared with 127/740 (17%) of satisfied patients (χ2=7.0; P<0.008).
Patients wanting antibiotics but not receiving them were more likely to be dissatisfied with the consultation than those receiving them, but reconsultation rates were similar whether these patients received an antibiotic or not. Of 564 wanting an antibiotic, 77 (14%) did not get one. Of these, 22 (29%) were dissatisfied with the consultation and 12 (16%) reconsulted for the same illness within 4 weeks. For the remaining 484, only eight (2%) were dissatisfied and 91 (19%) reconsulted.
Attitudes of patients and their doctors
When patients wanted or asked for antibiotics doctors were much more likely to state that patient pressure had affected their decision. For the 555 patients wanting antibiotics, the doctor stated the decision to prescribe was affected by patient pressure in 124 cases (22%) compared with 4/103 (4%) who had not wanted a prescription (χ2=17.7; P<0.004). Of 144 patients who had asked for antibiotics, the doctor considered that patient pressure influenced prescribing in 53 cases (37%) versus 81/628 (13%) for those who had not asked (χ2=45; P<0.0001). Of 205 patients not prescribed antibiotics, only 76 (37%) stated that they had wanted a prescription.
This study provides an insight into patients' views and expectations when they consult their general practitioner with acute lower respiratory tract symptoms and the impact those views have on prescribing antibiotics; it highlights some of the problems in the management of this very common condition.
Use of questionnaire
We achieved a high rate of return for questionnaires (78%), but patients who did and did not respond differed somewhat. We do not know if non-responders declined to participate because of dissatisfaction. Reconsultation rates were similar, however, suggesting that this was not a significant factor. A good cross section of general practitioners participated, but the study was not designed to explore variations in prescribing, a subject that we have reported on previously.1
We thought it was impractical to issue questionnaires before the patient's consultation because of the difficulties of identifying in advance suitable patients in so many practices. We asked patients to take the questionnaire home before opening the sealed envelope in order to provide confidence that replies would not be seen by their doctor. We emphasised we were interested in their expectations before the consultation and their views on management after consultation. It remains possible that patients' views were influenced by their doctor's action during the index consultation. In previous studies, however, expectation of prescriptions differed little whether questionnaires were administered before9 10 or after consultations.11 12
Our study confirms previous reports that three quarters of patients consulting with acute lower respiratory tract symptoms receive antibiotics, a remarkably consistent finding.1 2 We studied only previously well patients to exclude those whose symptoms, views, or management may be influenced by underlying lung and other disease.
Most patients think that their symptoms are caused by infection and that antibiotics will help. They want antibiotics and often ask for them. Patients' expectations and requests have a powerful effect on prescribing, even when doctors consider an antibiotic is not indicated.
Factors affecting prescribing
Non-clinical factors influence the decision to prescribe antibiotics for nearly a half of those receiving one. Patient pressure was cited most frequently, a factor noted in other studies10 13 14 and identified by the Audit Commission as an important reason for the excess use of antibiotics in the community.3 Pressure from patients to prescribe antibiotics, particularly for respiratory symptoms, has been identified as the commonest reason for doctors' discomfort with prescribing decisions.13 General practitioners can, however, overestimate patients' expectations.15 A quarter of our patients received antibiotics when they stated that before the consultation they had not wanted antibiotics.
During analysis we found no correlation between patients wanting antibiotics or thinking them helpful and the duration of their symptoms or the presence of discoloured sputum, systemic symptoms, or signs on chest examination. This suggests that severity or the “bother” of the illness, at least as indicated by these surrogate markers, does not influence patients' views.
Prescribing decisions by doctors
Doctors' prescribing decisions are complex1 15 16 17 and may, as we found, be influenced more by the expectation of reducing reconsultation than by making a definite diagnosis of an infection. Howie found general practitioners used less information when deciding on management than diagnosis and also when deciding to prescribe,18 suggesting prescribing is the more “thoughtless” and quicker act. This may be counterproductive as inappropriate prescription of antibiotics may encourage the patient to relate the natural recovery of a commonly self limiting lower respiratory tract illness to the effect of medication, engendering a cycle of repeat consultations for minor respiratory symptoms.19 Prescribing antibiotics for sore throat enhances belief in antibiotics and raises future intentions to consult.20
Doctors seem aware of this dilemma and are willing to identify inappropriate use of antibiotics for lower respiratory tract illness. This suggests considerable scope for reducing antibiotic use, which anyway seems of little benefit for acute bronchitis.21 With no alternative management strategy and when prescribing decisions are made without seeking either markers of infection or specific pathogens, however, antibiotics will probably continue to be prescribed frequently.
Educating general practitioners can reduce antibiotic use22 and educating patients can reduce reconsultation.8 The initial investment may prove worthwhile,17 particularly for a condition for which a quarter of patients reconsult. Patients value time for explanation.23 24 A few of our patients were dissatisfied with their management, and they reconsulted twice as often. Dissatisfaction was prominent in patients wanting antibiotics but not receiving them, although as a group those given antibiotics were no less likely to reconsult. This suggests that prescribing does not reduce reconsultation and other, more complex factors are involved.7
Problems of definitions
The problem of loose and inconsistent definitions has long been recognised in clinical and research practice.1 25 Abandoning such terms as chest infection, lower respiratory tract infection, and bronchitis, which all imply infection and suggest to patients the need for antibiotics, and developing a more practical label for this symptom complex seems one way forward.
For research purposes and in the absence of known infection in a previously well adult, we suggest using the term acute lower respiratory tract illness, as developed by Monto6 and used by ourselves1 8 9 and others,26 and not lower respiratory tract infection. Perhaps general practitioners may be advised to return to such terms as chesty cough or chest cold to better describe to their patients this common symptom complex, the course of which is probably not influenced by antibiotics.
We acknowledge with grateful thanks the GP members of our Community Respiratory Infection Interest Group (CRIIG), who participated enthusiastically in this study, including Drs A Allen, P Baldwin, G Bajek, A Birchall, I Black, S Bolsher, R Booth, M Brown, S Brown, N Browne, D Child, M Clamp, J Clark, A Cockburn, T Connery, F Coutts, G Cox, P Davenport, J Donovan, H Earwicker, S Earwicker, P Enoch, A Felstead, A Flewitt, A Ford, S Ford, N Foster, P Gard, A Gibbons, P Goulding, K Hambleton, B Hammersley, G Hanlon, J Henry, I Henry, D Henry, K Hill, R Howard, B Holmes, D Hughes, M Hughes, G Ioannou, J Ioannou, J Jenkins, D Jenkinson, D Jones, V Karney, S Kelly, C Kennedy, S Knights, C Lawrenson, C Leiper, R Manley, G Mansford, G Marshall, J Macdonald, J McGill, J Merry, J Morewood, B Parsons, S Patel, K Patel, B Pathak, P Patrick, P Pavier, G Place, M Rhoden, N Robertson, R Sheikh, P Sprackling, P Sturton, B Sugden, K Sumner, D Thornhill, G Waters, and M Wiecek; also Miss Sue Allen, who coordinated questionnaire returns.
Funding: Rhône-Poulenc Rorer awarded an educational grant towards the study.
Conflict of interest: None.