Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study
Abstract
:1. Introduction
2. Results
2.1. Respondent Characteristics
2.2. Importance Ranking of the Attributes
2.3. Choice Responses
2.4. Choice Modelling
3. Discussion
Limitations
4. Methods
4.1. Defining Survey Attributes and Levels
4.2. Choice Questions
4.3. Survey and Experimental Design
4.4. Data Collection
4.5. Analysis
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Abbreviations
abx | antibiotics |
GP | general practitioner |
NHS | National Health Service |
NICE | National Institute for Health and Care Excellence |
RTI | respiratory tract infection |
References
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Attribute a | Levels | Basis |
---|---|---|
Symptoms the patient is experiencing b | 1: Sore and red throat, and swollen lymph nodes in the neck 2: Productive cough and runny nose 3: Sore throat, swollen lymph nodes in the neck, pyrexia and purulent tonsils 4: Productive cough, pyrexia and pain on breathing | Two upper respiratory tract symptoms, and two lower, to allow exploration of differences in perception of ‘throat’ and ‘chest’ infections. Clinical guidelines [14,15], diagnostic criteria (such as FeverPAIN [35]) and practising clinicians were consulted to identify two plausible levels of severity for each, identified as ‘minor’ (1 and 2) and ‘serious’ (3 and 4) throughout this paper. |
How long the person has had the symptoms when they see the primary care physician | 3 days 7 days 10 days | Durations identified from literature [8], to cover a wide yet realistic range for RTIs. |
Relevant comorbidities of the patient b | 1. None 2. One 3. Two or more | Reflects clinical guideline CG69 [14], which identifies comorbidities as a risk factor for developing complications, and particularly for acute cough, increasing risk with additional comorbidities or other patient factors. |
Length of the consultation with the primary care physician | 5 min 10 min 15 min | Proxy for quality of information exchange between primary care physician and patient. Levels represent plausible consultation durations; the longest consultation is intended to allow for use of tools such as TARGET patient leaflets [36] to explain treatment. |
Patient opinion on taking antibiotics b | 1. Preference to have antibiotics 2. No preference expressed 3. Preference not to have antibiotics | Patient opinion can influence clinician choices [19,37]. Levels allow for patient preference in either direction, or neutral. |
Risk of harm from not having antibiotic treatment straight away | 1% 10% 20% | The GP’s judgement of the risk of harm, explained as symptom persistence or recurrence, or complications. Shown as a percentage, as a graphic, and also described in words (‘In 1 case out of every 100 like this, the patient would…’). Levels identified from literature. Rates of complications typically range from <1% to 2% for RTIs in primary care studies without antibiotics [11,38,39,40]. Symptom persistence at follow-up in the case of acute bronchitis ranges from 18% to 35% in meta-analyses depending on the measure [41], with a reconsultation rate of ~20% for non-resolution for RTIs [10,21], without antibiotics. |
Risk of an adverse effect from taking antibiotics | 1% 10% 20% | The GP’s judgement of the risk of adverse effect, explained as allergy, side effects, or future resistance. Shown in three formats, as above. Levels identified from literature and public information on rates of side effects and allergy [8,42]. |
How a delayed prescription would be provided b | 1: prescription plus advice to delay collection of antibiotics 2: post-dated prescription 3: collect prescription from the practice reception at a later date | Policy relevance: these formats have been tested in clinical trials [11] and referred to in guidelines [14], but there are no quantitative data on clinician preferences. |
Respondent Characteristic | N (Percentage) | Quota (%) # | |
---|---|---|---|
Sex | Male | 98 (54%) | 56 |
Age (years) | 39 and under | 40 (22%) | 26 |
40–49 | 76 (42%) | 41 | |
50–59 | 50 (28%) | 24 | |
60 or over | 15 (8%) | 10 | |
Median age | 46 | ||
Country | England | 152 (84%) | 83 |
Scotland | 17 (9%) | 10 | |
Wales | 9 (5%) | 4.5 | |
Northern Ireland | 3 (2%) | 2.5 | |
Practice size | 1–2500 patients | 5 (3%) | 4 |
2501–5000 | 28 (15%) | 15 | |
5001–7500 | 40 (22%) | 20 | |
7501–10,000 | 35 (19%) | 20 | |
10,001–12,500 | 32 (18%) | 41 | |
12,501–15,000 | 14 (8%) | ||
More than 15,000 patients | 27 (15%) | ||
Role in practice | Partner | 96 (53%) | |
Salaried GP | 57 (31%) | ||
Locum | 28 (15%) | ||
Level of local deprivation * | High | 49 (27%) | |
Medium | 72 (40%) | ||
Low | 56 (31%) | ||
Practice’s level of antibiotic | Very low/Low | 36 (20%) | |
prescribing compared to | Average | 100 (55%) | |
similar practices * | Very high/high | 35 (19%) | |
Usual format of delayed prescription * | Standard prescription with recommendation to wait | 145 (80%) | |
Post-dated prescription | 23 (13%) | ||
Electronic post-dated prescription | 7 (4%) | ||
Prescription available from practice at future date | 4 (2%) | ||
Other | 2 (1%) | ||
RTI prescribing *: mean | An immediate antibiotic prescription (range) | 31% (1 to 90%) | |
percentage of patients | A delayed antibiotic prescription (range) | 17% (0 to 85%) | |
who leave with… | No antibiotic prescription (range) | 52% (0 to 95%) | |
Found the survey * | Very easy/easy/quite easy | 90 (50%) | |
Neither easy nor difficult | 52 (29%) | ||
Very difficult/difficult/quite difficult | 39 (21%) |
Attribute/Level | 1. Attributes Only | 2. Respondent Characteristics | |||
---|---|---|---|---|---|
Coefficient | 95% CI | Coefficient | 95% CI | ||
Symptoms | Sore and red throat, and swollen lymph nodes in the neck (‘minor throat’) | 3.17 | 2.48 to 3.86 p < 0.001 | 3.17 | 2.48 to 3.86 p < 0.001 |
Productive cough and runny nose (‘minor chest’) | 3.47 | 2.79 to 4.14 p < 0.001 | 3.47 | 2.79 to 4.14 p < 0.001 | |
Sore throat, swollen lymph nodes in the neck, pyrexia and purulent tonsils (‘serious throat’) | −0.90 | −1.31 to −0.49 p < 0.001 | −0.90 | −1.31 to −0.49 p < 0.001 | |
Productive cough, pyrexia and pain on breathing (‘serious chest’) a | 0 | - | 0 | - | |
Symptom duration | Per day longer | −0.33 | −0.43 to −0.23 p < 0.001 | −0.33 | −0.43 to −0.23 p < 0.001 |
Relevant comorbidities | None a | 0 | - | 0 | - |
One | 0.05 | −0.31 to 0.42 p = 0.769 | 0.06 | −0.31 to 0.42 p = 0.762 | |
Two or more | −1.18 | −1.64 to −0.72 p < 0.001 | −1.18 | −1.64 to −0.72 p < 0.001 | |
Consultation length | Per minute longer | 0.05 | 0.02 to 0.09 p = 0.003 | 0.05 | 0.02 to 0.09 p = 0.003 |
Patient opinion | Preference to have antibiotics | 0.39 | −0.72 to −0.05 p = 0.022 | −0.39 | −0.72 to −0.05 p = 0.023 |
No preference expressed a | 0 | - | 0 | - | |
Preference not to have antibiotics | 0.33 | 0.05 to 0.60 p = 0.020 | 0.33 | 0.05 to 0.60 p = 0.020 | |
Risk of harm from not starting antibiotics | Per 1% higher | −0.13 | −0.17 to −0.10 p < 0.001 | −0.13 | −0.17 to −0.10 p < 0.001 |
Risk of adverse effect from taking antibiotics | Per 1% higher | 0.03 | 0.01 to 0.05 p = 0.001 | 0.03 | 0.01 to 0.05 p = 0.001 |
Format of the delayed prescription | Advice to delay a | 0 | - | 0 | - |
Post-dated prescription | −0.03 | −0.37 to 0.31 p = 0.872 | −0.03 | −0.37 to 0.31 p = 0.872 | |
Collect from practice | −0.43 | −0.82 to −0.08 p = 0.016 | −0.45 | −0.82 to −0.08 p = 0.016 | |
Self-reported prescribing behaviour: percent immediate prescriptions for RTI | −0.02 | −0.04 to −0.01 p = 0.002 | |||
Intercept | 2.23 | 1.49 to 2.97 p < 0.001 | 3.44 | 2.46 to 4.42 p < 0.001 | |
Var(intercept) b | 1.57 | 0.96 to 2.57 | 1.41 | 0.88 to 2.28 | |
Pseudo R2: attributes only | 0.61 | 0.62 | |||
Pseudo R2: attributes and respondent-level effect | 0.65 | 0.66 | |||
Akaike Information Criterion | 1955 | 1943 | |||
Bayesian Information Criterion | 2043 | 2037 |
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Morrell, L.; Buchanan, J.; Roope, L.S.J.; Pouwels, K.B.; Butler, C.C.; Hayhoe, B.; Moore, M.V.; Tonkin-Crine, S.; McLeod, M.; Robotham, J.V.; et al. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics 2020, 9, 608. https://doi.org/10.3390/antibiotics9090608
Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Moore MV, Tonkin-Crine S, McLeod M, Robotham JV, et al. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics. 2020; 9(9):608. https://doi.org/10.3390/antibiotics9090608
Chicago/Turabian StyleMorrell, Liz, James Buchanan, Laurence S. J. Roope, Koen B. Pouwels, Christopher C. Butler, Benedict Hayhoe, Michael V. Moore, Sarah Tonkin-Crine, Monsey McLeod, Julie V. Robotham, and et al. 2020. "Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study" Antibiotics 9, no. 9: 608. https://doi.org/10.3390/antibiotics9090608