Background. Emergence of resistant bacterial pathogens has increased concerns about antibiotic prescribing patterns. Parent expectations and pressure may influence these patterns.
Objective. To understand how parents influence the prescribing patterns of physicians and what strategies physicians believe are important if we are going to reduce inappropriate use of oral antimicrobial agents.
Designs and Methods. One thousand pediatricians who are members of the American Academy of Pediatrics were asked to complete a semi-structured questionnaire. The physicians were chosen randomly by the American Academy of Pediatrics.
Results. Nine hundred fifteen pediatricians were eligible and 610 surveys were analyzable, for a response rate of 67%. The majority of respondents were male (56%), worked in a group practice (51%), saw an average of 114 patients per week and were in practice for 14 years. Forty percent of the pediatricians indicated that 10 or more times in the past month a parent had requested an antibiotic when the physician did not feel it was indicated. Forty-eight percent reported that parents always, most of the time, or often pressure them to prescribe antibiotics when their children are ill but antibiotics are not indicated. In follow-up questions, approximately one-third of physicians reported they occasionally or more frequently comply with these requests. Seventy-eight percent felt that educating parents would be the single most important program for reducing inappropriate oral antibiotic use and 54% indicated that parental pressure, in contrast to concerns about legal liability (12%) or need to be efficient in practice (19%), contributed most to inappropriate use of oral antibiotics.
Conclusions. Pediatricians acknowledge prescribing antimicrobial agents when they are not indicated. Pediatricians believe educating parents is necessary to promote the judicious use of antimicrobial agents.
Over the past decade, decreasing susceptibility ofStreptococcus pneumoniae to antimicrobial agents has been increasingly reported around the world.1–3S pneumoniae is the most common causative bacterial agent for meningitis, pneumonia, bacteremia, acute otitis media (AOM), and sinusitis, and this pattern of resistance has profound implications for pediatrics.4 Some investigators have suggested that the emerging resistance among pneumococci is a result of increased use of antimicrobial agents.
In 1980, 4 206 000 prescriptions were written for amoxicillin for the treatment of AOM.5 In 1992, the number had grown to 12 381 000—an increase of 194%. In 1980, 876 000 prescriptions for cephalosporins were recorded for the treatment of AOM; in 1992 the number was 6 892 000—an increase of 687%. Based on these data, we estimate that in 1999, 30 000 000 prescriptions will be written for the treatment of AOM. The increase in prescriptions written for the treatment of AOM is attributable to at least three factors, including increase in real disease, due in part to widespread day care attendance, improved access to care, and overprescription of antimicrobial agents.6
The relationship between increased use of antimicrobial agents and bacterial resistance is controversial, although many experts believe that use of inappropriate antibiotics must be curtailed if we are going to reduce the prevalence of bacterial resistance.7–9 In addition, previous antimicrobial use is a risk factor for bacterial disease caused by resistant S pneumoniae.10–12The Centers for Disease Control and Prevention has announced a national plan to reduce the occurrence of bacterial resistance.13The plan includes community monitoring of resistance, limiting use of antimicrobial agents for diseases likely to be attributable to viruses, and encouraging clinicians to use narrow spectrum antimicrobials.
The American Academy of Pediatrics (AAP), The Centers for Disease Control and Prevention, and the American Society of Microbiology14 recently released a pamphlet to educate parents about antibiotics. It emphasizes differences between viruses and bacteria, describes how resistant bacteria emerge, reviews appropriate indications for antibiotics, and counsels parents that all infections do not require antibiotics.
Before we can change use of inappropriate oral antimicrobial agents, we need to understand what parents and physicians believe about their indications. Recently we reported parents' views about antibiotics.6 In a survey of 400 parents, approximately one-half of the parents interviewed were concerned about the effect of antibiotics on the immune system. Many misunderstood appropriate indications for antibiotics. Twenty percent had given antibiotics to their children without consulting a physician. As part of that study, we surveyed a small number of Massachusetts pediatricians about their experiences with parents about antibiotics. Using that survey as the basis for the current project, we have surveyed a national sample of pediatricians. The objective was to understand how parents influence the prescribing patterns of physicians and what strategies physicians believe are important if we are going to reduce inappropriate use of oral antimicrobial agents.
A semi-structured questionnaire (see “Appendix”), previously piloted and then modified, was mailed to a random sample of 1000 pediatricians in the United States. Modifications included 1): an additional question about the pressure pediatricians feel to dispense antibiotics; 2) a change in the quantitative ranges that physicians could select as an answer to a number of the questions; and 3) a change in the choices about what physicians feel contributes most to inappropriate oral antibiotic use and what they think is important to curtail such use. The pressure that pediatricians feel to dispense inappropriate oral antibiotics was asked twice, using two different time frames: 1) by quantifying how often this had happened in the past month; and 2) by describing how often this happens when children are ill (see “Appendix”). Following these two inquires (question 10 and question 16) follow-up questions regarding how often the physician complied with these requests were asked. Quantitative ranges, so-called anchors, were provided for each descriptive term (see “Appendix”). These ranges were chosen during the piloting of the questionnaire.
The list of pediatricians was provided by the AAP. Resident fellows, emeritus fellows, and subspecialty fellows were excluded from the list in an attempt to focus solely on pediatricians in practice. After the initial mailing, a second and then a third mailing of the survey was sent to nonresponders 6 weeks to 2 months after the previously mailing. Retired and specialist pediatricians who responded to the questionnaire were considered ineligible.
The χ2 statistic was used to describe differences in responses for gender (male versus female), length of time in practice (< or ≥14 years), type (group versus solo versus other), location of practice (community health center versus staff model health maintenance organization versus urban noninner-city versus urban inner-city) and number of patients seen weekly (< or ≥the 114). The length of time in practice and number of patients seen weekly were used as a proxy for comparing experienced to less experienced physicians. Responses examined included the pressure parents exert on physicians to dispense antibiotics inappropriately (questions 10) and what program (question 19) and which issue (question 20) physicians believe most impacts on inappropriate antibiotic use. Multiple regression was used to simultaneously evaluate all the potential confounding variables. The study was approved by the Human Investigation Committee of the Boston Medical Center.
Six hundred and eighty-seven surveys were returned, of which 77 were excluded from analysis because the physicians were retired (n = 30), specialists (n = 43), refused (n = 1), or the address was unknown (n= 3), leaving a final sample of 610. Assuming that the ineligibility rate was similar in those returned (73 out of 687) and not returned (n = 313) the final sample size of 610 represents a response rate of 67%.15
The majority of responders were male (56%), worked in a group practice (51%), saw an average of 114 patients per week and were in practice for 14 years (Table 1). Overall, 22% felt that most or many parents were worried about the number of antibiotics their children were receiving.
Ninety-six percent of pediatricians had parents request antibiotics during the previous month when they were not indicated (Table 2). Forty percent reported that this occurred 10 or more times, 16% reported 7 to 9 times, 19% reported 4 to 6 times, and 20% reported 1 to 3 times. Forty-eight percent reported that parents always, most of the time, or often put pressure on them to prescribe antibiotics when their children are ill, but antibiotics are not clearly indicated (Table 2). In follow-up questions, approximately one-third of the respondents reported that they occasionally or more frequently comply with the inappropriate request (Table 2).
Seventeen percent, 15%, and 24% of pediatricians, had parents request a specific antibiotic or a different one than they were going to prescribe 10 or more, 7 to 9 times, and 4 to 6 times during the previous month, respectively. Thirty percent of respondents had parents request antibiotics over the telephone 10 or more times in the previous month. The vast majority (79%) rarely or never complied with this request.
Educating parents was cited by 78% of respondents as the single most important program for reducing inappropriate oral antibiotic use (Table 3). This was in contrast to developing more careful diagnostic criteria (15%), and reducing legal liability (4%) or drug detailing (<1%). Consistent with those responses, 54% indicated that parent pressure contributed the most to inappropriate use of oral antibiotics (Table 3).
Differences in responses did emerge with respect to certain sociodemographic factors and selected outcomes. Physicians who see more patients (≥114 per week) were more likely to report that parents pressured them 10+ times in the previous month to dispense antibiotics (51% vs 31%, P < .001). The same was true for physicians who practice in a rural setting (56%) versus those in suburbia (43%), urban noninner-city (36%) or urban inner-city (26%,P < .001); and those in group practice (49%) versus solo (36%) or other (28%, P < .001). No sociodemographic factor impacted on either single most important program for reducing antibiotic use or which issue contributes most to inappropriate antibiotic use. Less experienced physicians (<14 years in practice) were more likely to cite parent education as the single most important program for reducing inappropriate antibiotic use (81% vs 73%, P = .08). Similar findings emerged from multiple regression analysis, with busier physicians (P< .001), those practicing in a rural setting (P = .001), and those in group practice (P = .026) more likely to report that parents pressured them 10+ times in the previous month to dispense antibiotics inappropriately. In addition, in the multiple regression, females (80%) listed parent education as more important than males (75%, P = .035).
In this survey, physicians responded that they acquiesce to parent pressure and prescribe antimicrobial agents when they are not indicated. The physicians believe that parents must be reeducated if inappropriate antimicrobial use is to decline. Physicians did not report that more careful diagnostic criteria, reducing drug detailing, or legal liability or the need to be efficient in practice were nearly as important as educating parents. In a recent editorial, Edwards16 commented that in a era of managed care and an emphasis on efficiency in practice, sufficient time may not be available to discuss issues about antibiotics.
Changing antimicrobial prescribing habits is likely to be easier in the hospital then in the outpatient setting. The use of restricted formularies and the need to obtain previous approval in the hospital limits antimicrobial choice. These restrictions are less available in the ambulatory setting. To reduce use of inappropriate antimicrobial agents in the ambulatory setting we need to alter patient-physician communication.
This study has a number of limitations. We relied on physician self-report. It is possible that there are differences between what physicians report and what actually occurs. However, it is unlikely that physicians prescribe inappropriate antimicrobials less than reported, although it is possible that they misinterpret parent expectations. Second, in any survey, there is always concern whether the nonresponders differ from the responders. We have no information on the nonresponders, although the response rate approached 70%. In addition, the demographic characteristics of the responders are similar to AAP periodic surveys of its membership,17 suggesting that this sample is representative of pediatricians who are members of the AAP.
There have been a number of studies that have addressed the issue of patient expectations for antimicrobial agents, although the majority have focused on adults. Recently, Macfarlane18reported in a study of 787 adults with lower respiratory tract illness, that they often believe that infection is the problem and antibiotics are the answer. Even when the doctor judges that antibiotics are not indicated, patients' expectations increase the likelihood that antibiotics will be prescribed.18 Vinson and Lutz19 asked clinicians to indicate, after a visit with families, if they sensed that parents of acutely ill children wanted an antibiotic. In a study of 1398 patients, they found that physician perception of parental expectations for antibiotics was associated with a diagnosis of bronchitis and prescribing an antibiotic.19Hamm et al20 found that 65% of 113 adult patients with respiratory infections expected antibiotics. Physicians had some ability to perceive this expectation and frequently prescribed antibiotics for patients who expect them. Interestingly, no association was found between a prescription for antibiotics and patient satisfaction.
The physicians who responded to this survey cited parent pressure has the most important issue that impacts on the use of inappropriate oral antibiotics. There are data that suggest that clinicians do not always follow diagnostic criteria carefully and indications for antimicrobials. Recently, Schwartz and colleagues21reported that many pediatricians and family practitioners dispense antibiotics for rhinorrhea lasting only a couple of days. Gonzales and others,22 in an analysis from the National Ambulatory Medical Care Survey, reported that office visits for colds, upper respiratory tract infections, and bronchitis resulted in ∼12 million antibiotic prescriptions to adults.21 It is likely that this also occurs in the pediatric population. It is not clear when physicians dispense antimicrobials for reasons that are not considered appropriate by some clinicians if they are responding to patient pressure, issues related to satisfaction, their beliefs that antimicrobials help in these circumstances, legal liability, need to be efficient in practice, or misunderstand diagnostic criteria and indications for antimicrobials. It is likely that all these issues contribute to the use of inappropriate oral antimicrobial agents.
Changing physician behavior is complex. Davis and others23reported in a metaanalysis of 99 trials that four strategies: reminders, patient-mediated interventions, outreach visits, and opinion leaders were effective in changing physician behavior. Of these, patient-mediated strategies are particularly effective when physicians are ready to change their practice. Pathman and colleagues24 found that physicians who disagreed with indications for hepatitis B vaccine or varicella vaccine, nevertheless administered the vaccines if parents requested them. These data and those reported in this survey suggest that educating parents about appropriate indications for antimicrobials must be part of any comprehensive plan to reduce inappropriate oral antibiotic use. It is possible that if parents are educated about appropriate indications for oral antimicrobials, they may not only pressure physicians less to dispense antibiotics, but also influence physician behavior by appropriately questioning the role that antibiotics play in the treatment of some medical conditions.
Pediatricians need to promote the judicious use of antimicrobial agents. We believe that the approach to the problem of inappropriate oral antimicrobial use must be balanced: parents must be reeducated, either directly by clinicians or through public health campaigns; and physicians need to sharpen their diagnostic skills and become more familiar with specific indications for antibiotic.25,,26
This work was supported in part with grants from the Bureau of Health Professions (Faculty Development Award and Institutional National Research Service Award).
The authors would like to thank Chris McElroy for her spirited views on this subject. Beth Kastner and Colleen Pearson were once again invaluable in this research endeavor.
- Received December 5, 1997.
- Accepted July 1, 1998.
Reprint requests to (H.B.) Boston Medical Center/Maternity 415, 818 Harrison Ave, Boston, MA 02118.
- AOM =
- acute otitis media •
- AAP =
- American Academy of Pediatrics
- ↵Palmer D, Bauchner H. Parents' and physicians' views on antibiotics. Pediatrics. 1997;99(6). URL: http://www.pediatrics.org/cgi/content/full/99/6/e6
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- ↵American Academy of Pediatrics, Centers for Disease Control and Prevention, American Society for Microbiology. Your Child and Antibiotics. 1997
- ↵Council of American Survey Research Organizations. On the Definition of Response Rates; a Special Report From the CASRO Task Force on Completion Rates. Port Jefferson, NY: Council of American Survey Research Organizations; 1982
- Campbell JR,
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- Szilagyi PG,
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- Macfarlane J,
- Holmes W,
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- ↵Dowell S. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics. 1998;101(suppl):163–184
- Copyright © 1999 American Academy of Pediatrics