Family Practice Vol. 16, No. 1, 50-53
© Oxford University Press 1999
Reasons for non-guideline-based antibiotic prescriptions for acute otitis media in The Netherlands
Damoiseaux RAMJ, de Melker RA, Ausems MJE and van Balen FAM. Reasons for non-guideline-based antibiotic prescriptions for acute otitis media in The Netherlands. Family Practice 1999; 16: 50–53.
Received 9 February 1998; Accepted 7 October 1998.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background. Appropriate use of antibiotics is a major issue in today's medicine. The increasing worldwide bacterial resistance to antimicrobial agents is forcing us to prescribe antibiotics more rationally. It is known that overuse of antibiotics for upper respiratory tract infections exists. Little is known about the reasons for actual prescribing of antibiotics. In order to be able to implement strategies to restrict inappropriate antibiotic prescriptions, insight into the reasons for the actual prescribing could be important.
Objective. We aimed to explore the reasons, other than those stated in the guidelines of the Dutch College of GPs, for prescribing antibiotics for acute otitis media.
Method. Seventy antibiotic prescriptions for acute otitis media, prescribed by 22 Dutch GPs, were evaluated to see whether they followed the guidelines on acute otitis media of the Dutch College of General Practitioners. Non-guideline-based antibiotic prescriptions were discussed in stimulated recall interviews with the prescribing GPs regarding their prescribing behaviour of antibiotics for acute otitis media.
Results. In total, 77% of the antibiotic prescriptions did not follow the guidelines of the Dutch College of General Practitioners. Medical reasons for prescribing antibiotics were mentioned most often for non-guideline-based antibiotic prescriptions; however, in a substantial number of cases doctors gave non-medical reasons as well.
Conclusions. Appropriate use of antibiotics might not be reached by focusing only on the efficacy of these drugs. The impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further.
Keywords. Acute otitis media, antibiotics, general practice, guidelines, prescribing behaviour..
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The prescription of antibiotics and the reasons for it are major issues in medicine today.1 The increasing worldwide bacterial resistance to antimicrobial agents is forcing us to prescribe antibiotics more rationally.2,3 Nevertheless, what is rational prescribing? In 1995 Barber stated that good prescribing is more than just maximizing effectiveness, minimizing risks, and minimizing costs. Respecting patients' choices should also be taken into account.4
It is known from studies with simulated cases that the decision to prescribe antibiotics is not based on biomedical factors alone. Social information about the patient also influences the decision to prescribe antibiotics.5,6 Observational studies have shown relationships between antibiotic prescriptions and prescribers' characteristics.7 To date, however, little is known about the reasons for actual prescribing of antibiotics.8 Bradley performed a critical incident study on uncomfortable prescribing decisions that take place in general practice involving all kind of drugs. Reasons for uncomfortable prescribing decisions were medical, social and logistical ones. The prescribing of antibiotics led most often to feelings of discomfort, but the reasons for the decision to prescribe antibiotics were not given separately.9 In order to be able to improve the antibiotic prescribing behaviour of doctors in a more rational way, it may be important to know the reasons doctors have for prescribing antibiotics and to make the prescribers aware of them.
Dutch GPs are well acquainted with the guidelines for the treatment of acute otitis media (AOM) of the Dutch College of General Practitioners.10 This study was aimed at finding reasons for the actual prescribing of antibiotics for AOM other than those provided by the guidelines of the Dutch College of General Practitioners on AOM (Table 1
).11
|
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Setting
Data for this study were collected within the framework of a more-extended international observational study on AOM. GPs were asked to include 13 consecutive patients with AOM in three different age categories (6–12 months, 13–24 months and 2–15 years). Children with chronic illness, congenital ear, nose and throat (ENT) malformations, or a complication which needed antibiotic treatment were excluded. All participating GPs were asked to give their standard treatment for AOM, and register the patients' clinical signs and resulting treatment on a registration form.
All Dutch GPs participating in the international study agreed to follow the guidelines on AOM of the Dutch College of General Practitioners (Table 1
). It has to be mentioned that they were free to choose a different treatment if they considered that to be more appropriate for a specific patient.
Antibiotic prescriptions
Twenty-two Dutch GPs who each had more than 10 patients with AOM, between October 1994 and August 1995, were asked to participate in this study. All antibiotic prescriptions given to the included patients at the first encounter were evaluated to assess whether they followed the guidelines on AOM of the Dutch College of General Practitioners. The prescriptions that did not follow the guidelines were discussed with the prescribing GP in an interview.
Nature of the interviews
The interviews were held from July 1995 until November 1995, using a stimulated recall procedure.12 In order to enhance the recall, the GP received the registration form from the international study before the interview. This form contained all clinical data, assessment of the severity of the illness, treatment given and possible reasons to deviate from the standard treatment. This form had been completed during the patient encounter by the same GP. The GP was also stimulated to use his own patient file. The nature of the interview was semi-structured, using a list with possible reasons that had been separated into three categories: medical reasons, patient-related reasons (e.g. request of patient) and doctor-related reasons (including logistical reasons) to elicit their perceptions during the encounter. The list was generated by the authors based on studies concerning reasons for prescribing.5,6,8,9 This list was used merely to facilitate the discussion and not as a prompt list. The doctors were allowed to give more than one reason.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
All 22 GPs agreed to participate in this study, which included in total 362 patients with an AOM episode. Antibiotics were prescribed during the first visit in 70 episodes (19%). Of all antibiotic prescriptions, 54 (77%) did not follow the guidelines of the Dutch College of General Practitioners. From these 54 antibiotic prescriptions, 42 (78%) were discussed with the prescribing GP. Twelve cases could not be discussed due to lack of data.
Medical reasons were given in 40 (95%) non-conforming cases. Reasons from one category (medical, patient- or doctor-related) were given in 16 cases (38%); from two categories in 18 cases (43%) and from three categories in eight cases (19%) (Table 2).
|
Of the 81 listed medical reasons, ‘severity of illness at first contact’ was mentioned 32 (40%) times (Table 3
). Of the 38 patient-related reasons ‘the disease behaviour’ of the specific patient was mentioned 23 (60%) times (Table 4), and finally of the 20 doctor-related reasons, ‘habit’ was mentioned seven (35%) times (Table 5).
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
In this study about reasons for the actual prescribing of antibiotics, most of the reasons given were medical, although patient- and doctor-related reasons also played a substantial role. This qualitative study does not address the question of the relative importance of the different reasons.
The percentage of patients in our study receiving antibiotic therapy during the first encounter did not differ from that found in another Dutch observational study.13
The study of Hepler et al., on the reasons for the actual prescribing of antibiotics in 82 cases, revealed almost only medical pharmacological reasons; only twice was the request of the patient mentioned.14
Severity of illness at first contact was the reason most often given in our study. Efficacy studies will answer the question of when antibiotics are most effective. Howie has mentioned that the diagnosis may tend to be a justification for treatment rather than the reason for it.15 Another reason for clinical reasoning when prescribing antibiotics might be the fact that doctors are led especially by their expectations of the effectiveness when choosing a therapy, rather than by their knowledge of possible side-effects.16
In this study ‘the disease behaviour’ of the specific patient was mentioned most often as the non-medical reason. The Dutch GP has enlisted patients and therefore he is familiar with the disease behaviour of most patients.
Our study might have been limited by the use of a selected group of GPs. They agreed to participate in an international study which dictated that they had to follow the Dutch guidelines on AOM. But since this was a qualitative study to gain insight in the matter of prescribing of antibiotics, systematic sampling was not necessarily a problem.17 The results of this study could even be more meaningful considering that even doctors who say that they follow the guidelines use non-medical reasons as well to prescribe antibiotics. Another limitation could be the time delay between the prescribing incident and the interview. This may introduce recall bias. The use of a stimulated recall interview with extensive details of the prescribing incident on the form of the international study can bridge this distance in time.12 A further limitation could be the fact that we used a list with possible reasons, which could suppress a spontaneous reaction. However, when asked directly about their rationale, doctors tend to give purely pharmacological reasons.8 And our list, by containing medical as well as non-medical reasons, could have made it more acceptable for the doctors to mention non-medical reasons as well.
In order to change their prescribing behaviour, it might be important that doctors are aware of their motives for prescribing antibiotics when there is insufficient medical reason for it. This study does not say anything about the role of the patient in the process of prescribing. We obtained information only about the doctors' perceptions of the expectations of the patients. It is known that the doctor's perception does not always agree with the patient's expectations of receiving a prescription.18–20 If there is no medical reason for prescribing an antibiotic, the doctor should try to find out whether the patient really wants an antibiotic or merely desires the reassurance that there is nothing seriously wrong with them.
It is remarkable that despite the existing guidelines, which are well accepted by Dutch GPs,10 77% of the antibiotic prescriptions did not conform. The process of prescribing is an interaction between the doctor and the patient and many reasons for prescribing, objective as well as subjective, can be found. Because of the complexity of this process, guidelines will never be able to control this behaviour completely. In 1993, Kassirer asked, ‘If guidelines do become rules, can they be sufficiently detailed to cover the myriad clinical variations among patients?’21 Guidelines, instead, should be of help in choosing the best treatment, but each individual case needs to be judged as such. The value of guidelines in the process of rational antibiotic prescribing in general practice should not be overestimated.
The fight against the inappropriate use of antibiotics should not only be focused on the efficacy of these drugs. The impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further.
|
Acknowledgments |
|---|
This study was supported by The Netherlands Organisation for Scientific Research.
|
Notes |
|---|
a Correspondance to RAMJ Damoiseaux, Department of General Practice/Family Medicine, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1 World Health Organization. Control of infectious diseases, rational use of drugs. In: The World Health Report 1996, Fighting disease, Fostering development. Geneva: World Health Organization, 1996.
2 Cohen ML. Epidemiology of drug resistance: Implications for a post-antimicrobial era. Science 1992; 257: 1050–1055.
3
Gold HS, Moellering RC. Antimicrobial-drug resistance. N Engl J Med 1996; 335: 1445–1453.
4
Barber N. What constitutes good prescribing? Br Med J 1995; 310: 923–925.
5 Howie JGR. Clinical judgment and antibiotic use in general practice. Br Med J 1976; 2: 1061–1064.
6 Stephenson MJ, Henry N, Norman GR. Factors influencing antibiotic use in acute respiratory tract infections in family practice. Can Fam Physician 1988; 34: 2149–2152.
7
Kuyvenhoven M, Melker RA de, Velden K van der. Prescription of antibiotics and prescribers' characteristics. A study into prescription of antibiotics in upper respiratory tract infections in general practice. Fam Pract 1993; 10: 366–370.
8
Bradley CP. Decision making and prescribing patterns—a literature review. Fam Pract 1991; 8: 276–287.
9 Bradley CP. Uncomfortable prescribing decisions: a critical incident study. Br Med J 1992; 304: 294–296.
10 Dalhuizen J, Zwaard AM, Grol RPTM, Mokkink HM. Het handelen van huisartsen volgens de standaard Otitis media acuta van het Nederlands Huisartsen Genootschap. (The performance of general practitioners according to the guide-line on acute otitis media of the Dutch College of General Practitioners.) Ned Tijdschr Geneeskd 1993; 137: 2139–2144.[Medline]
11 Appelman CLM, Bossen PC, Dunk JHM, Lisdonk EH, Melker RA de, Weert HCPM van. NHG standard Otitis Media Acuta. (Guideline on acute otitis media of the Dutch College of General Practitioners.) Huisarts Wet 1990; 33: 242–245.
12 Timpka T, Westergren V, Hallberg N, Forsum U. Study of situation-dependent clinical cognition: a meta-analysis and preliminary method. Meth Inform Med 1997; 36: 44–50.[Web of Science][Medline]
13 Bohnen AM, Bruijnzeels MA, Velden J van der, Wouden JC van der. Otitis media acuta: incidentie en beleid. (Acute otitis media: incidence and management.) Huisarts Wet 1992; 35: 134–136.
14 Hepler CD, Clyne KE, Donta ST. Rationales expressed by empiric antibiotic prescribers. Am J Hosp Pharm 1982; 39: 1647–1655.[Medline]
15 Howie JGR. Diagnosis: the achilles heel. J R Coll Gen Pract 1972; 22: 310.[Medline]
16 Denig P, Haaijer-Ruskamp FM, Zijsling DH. How physicians choose drugs. Soc Sci Med 1988; 27: 1381–1386.
17
Mays N, Pope C. Rigour and qualitative research. Br Med J 1995; 311: 109–112.
18 Thomas KB. The consultation and the therapeutic illusion. Br Med J 1978; 1: 1327–1328.
19
Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctor's perceptions of patients' expectations—a questionnaire study. Br Med J 1997; 315: 520– 523.
20
Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. Br Med J 1997; 315: 1506–1510.
21
Kassirer JP. The quality of care and the quality of measuring it. (Editorial) N Engl J Med 1993; 329: 1263–1264.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  P. L. Thompson, R. E. Gilbert, P. F. Long, S. Saxena, M. Sharland, and I. C. K. Wong Has UK guidance affected general practitioner antibiotic prescribing for otitis media in children? J. Public Health Med., December 1, 2008; 30(4): 479 - 486. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. J. Worrall One hundred coughs: Family practice case series Can Fam Physician, February 1, 2008; 54(2): 236 - 237. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. K Choudhry, G. M Anderson, A. Laupacis, D. Ross-Degnan, S.-L. T Normand, and S. B Soumerai Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis BMJ, January 21, 2006; 332(7534): 141 - 145. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. E. Akkerman, M. M. Kuyvenhoven, J. C. van der Wouden, and T. J. M. Verheij Analysis of under- and overprescribing of antibiotics in acute otitis media in general practice J. Antimicrob. Chemother., September 1, 2005; 56(3): 569 - 574. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Marchetti, L. Ronfani, S. C. Nibali, G. Tamburlini, and for the Italian Study Group on Acute Otitis Media Delayed Prescription May Reduce the Use of Antibiotics for Acute Otitis Media: A Prospective Observational Study in Primary Care Arch Pediatr Adolesc Med, July 1, 2005; 159(7): 679 - 684. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Thrane, C. Olesen, H. C. Schonheyder, and H. T. Sorensen Socioeconomic factors and prescription of antibiotics in 0- to 2-year-old Danish children J. Antimicrob. Chemother., March 1, 2003; 51(3): 683 - 689. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Coenen, P. Van Royen, E. Vermeire, I. Hermann, and J. Denekens Correspondence Fam. Pract., April 1, 2000; 17(2): 210 - 210. [Full Text] [PDF]
|
|
|
|
|
|
M. Lindbaek, G Sandhu, A Frosh, A Wright, P. Williamson, S. Patel, R. Herdman, and P. O'Neill Acute otitis media BMJ, January 15, 2000; 320(7228): 182 - 182. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||