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Calling Acute Bronchitis a Chest Cold May Improve Patient Satisfaction with Appropriate Antibiotic Use

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Calling Acute Bronchitis a Chest Cold May Improve Patient Satisfaction with Appropriate Antibiotic Use J Am Board Fam Pract: first published as 10.3122/jabfm.18.6.459 on 1 December 2005. Downloaded from Calling Acute Bronchitis a Chest Cold May Improve Patient Satisfaction with Appropriate Antibiotic Use T. Grant Phillips, MD, and John Hickner, MD, MS Background: Overuse of antibiotics for acute respiratory infections is an important public health prob- lem and occurs in part because of pressure on physicians by patients to prescribe them. We hypothe- sized that if acute respiratory infections are called “chest colds” or “viral infections” rather than “bron- chitis,” patients will be satisfied with the diagnosis and more satisfied with not receiving antibiotics. Methods: Family medicine patients were presented with a written scenario describing a typical acute respiratory infection where they were given one of 3 different diagnostic labels: chest cold, viral upper respiratory infection, and bronchitis, followed by a treatment plan that excluded antibiotic treatment. Data was analyzed for satisfaction with the diagnosis and treatment plan based on the diagnostic label. A total of 459 questionnaires were collected. Results: Satisfaction (70%, 63%, and 68%) and dissatisfaction (11% 13%, and 13%) with the diagnos- tic labels of cold, viral upper respiratory infection, and bronchitis, respectively, showed no difference However, more patients were dissatisfied with not receiving an antibiotic when .(832. ؍ P ,0.368 ؍ ␹2) the diagnosis label was bronchitis. A total of 26% of those that were told they had bronchitis were dis- satisfied with their treatment, compared with 13% and 17% for colds and viral illness, respectively, Binary logistic regression showed no difference in satisfaction with diagnosis .(009. ؍ P ,9.380 ؍ ␹2) -respectively), or for satis ,0.98 ,1.00 ,1.09 ؍ (for educational attainment, age, and sex (odds ratio (OR .(respectively ,1.00 ,1.02 ,1.1 ؍ faction with treatment (OR Conclusions: Provider use of benign-sounding labels such as chest cold when a patient presents for care for an acute respiratory infection may not affect patient satisfaction but may improve satisfaction with not being prescribed an antibiotic. (J Am Board Fam Pract 2005;18:459–63.) Antibiotic resistance is an important public health evidence from randomized trials that antibiotics are 1, 2 problem, and inappropriate antibiotic prescribing ineffective for most patients with ARIs, there is still by primary care practitioners for acute respiratory considerable antibiotic overprescribing. Combined http://www.jabfm.org/ infections (ARI) is a contributing factor.3 No uni- National Ambulatory Medical Care Survey data versal definition for ARI exists, although the term from 2001 and 2002 show that 48.3% of patients ARI is generally applied to a self-limited upper presenting for office care to family physicians and respiratory illness associated with some or all the general internists who have a diagnosis of upper following symptoms: cough, nasal congestion, respiratory infection received a prescription for an runny nose, sinus pressure, fever, and sore throat. antibiotic, as did 58.7% of those diagnosed with Depending on the predominate symptom, the ill- acute bronchitis. (Special analysis performed for on 27 September 2021 by guest. Protected copyright. ness may be called pharyngitis, upper respiratory this study by David Woodwell from the National infection, sinusitis, or acute bronchitis when the Center for Health Statistics, March 2005.). The predominant symptom is cough. Despite consistent antibiotic-prescribing rate for acute bronchitis has not changed from 1999 when 59% of adults in community-based outpatient practices received an Submitted 24 March 2005; revised 15 June 2005; accepted 4 26 July 2005. antibiotic prescription for acute bronchitis. From the Washington Family Practice Residency Pro- Patient pressure plays a role in antibiotic over- gram, Washington, PA 15301 (TGP); and Department of 5 6 Family Medicine, The University of Chicago Pritzker prescribing. Bauchner et al found that 54% of School of Medicine, Chicago, IL 60637 (JH) pediatricians felt parental pressure to prescribe an- Funding: This study was funded by a research stimulation grant G0405RS from the AAFP Foundation. tibiotics inappropriately. This pressure is often ef- Conflict of interest: none declared. fective. Hamm et al7 found that when patients Corresponding author: T. Grant Phillips, MD, Washington Family Practice Residency Program, 95 Leonard Avenue, wanted antibiotics for acute respiratory infections, Washington, PA 15301 ([email protected]). physicians prescribed them 77% of the time, but http://www.jabfp.org 459 J Am Board Fam Pract: first published as 10.3122/jabfm.18.6.459 on 1 December 2005. Downloaded from they prescribed them only 29% of the time when otic prescription? Patients were asked about their the patient did not ask for an antibiotic. level of satisfaction using a 5-point Likert scale One possible way to decrease antibiotic pre- ranging from very satisfied to very dissatisfied. Pa- scribing for acute bronchitis would be to reduce tients were also asked to provide their sex, age, and patient pressure on physicians to prescribe them. educational attainment on the form. This might be accomplished through patient edu- Equal numbers of surveys representing the 3 cation, but it is also possible that “reframing” the different labels were printed and shuffled repeat- seriousness of the condition by using a more benign edly by 2 people to randomize the order of presen- label such as “chest cold” rather than “acute bron- tation to patients. The surveys were given to pa- chitis” will reduce patient expectations for an anti- tients who presented to the office for routine biotic. appointments other than acute respiratory infec- We hypothesized that when presented with a tions. Office staff asked patients to participate in scenario describing acute bronchitis, patients will the study and gave them questionnaires to com- be as satisfied with receiving the diagnosis of chest plete in the waiting room. Completed question- cold as they would be if they had received a diag- naires were returned to the receptionist. If a patient nosis of either bronchitis or viral upper respiratory chose to return a blank questionnaire, this was infection. Furthermore, we hypothesized that pa- returned to the pool and counted into the denom- tients will be more satisfied with not receiving a inator for the response rate. prescription for an antibiotic if they are told they The questionnaire was distributed in 3 separate have a chest cold rather than bronchitis. sites. Two offices were family practice residency clinics of the same residency in southwestern Penn- sylvania, and the third was a private family practice Methods in central Pennsylvania without an academic affili- We developed a written scenario representing a ation. The proportion of questionnaires distributed typical case of acute bronchitis. Six family practi- to each office was based on estimates of the full- tioners or pediatricians reviewed the scenario and time physician equivalents at the offices. The com- agreed that it represented a typical acute respira- munity office has 3 physician FTEs and 80 ques- tory illness that might be called bronchitis but does tionnaires were distributed there. The family not require antibiotic therapy. practice residency clinics had 13 physician FTEs The scenario reads: and 362 questionnaires were distributed. http://www.jabfm.org/ Description of Visit: You have had a cough for 1 To detect an absolute difference in satisfaction ␣ ␤ week that is not going away. You are bringing of 15% with a 2-tailed of 0.05 and of 80%, up phlegm that is a dark gray color. You had a approximately 136 useable surveys were needed for fever at the beginning of the illness, but do not each satisfaction group. For the analysis, we col- have one now. You do not have a runny nose or lapsed the patient satisfaction categories by group- sore throat. The doctor examines your ears, ing the 2 “satisfied” categories and the 2 “dissatis- nose, throat, and listens to your chest with a fied” categories. Those who responded “neither on 27 September 2021 by guest. Protected copyright. stethoscope. You came in because you won- satisfied nor dissatisfied” were excluded from the dered if an antibiotic would help you get better analysis because they would not contribute to dis- faster. tinguishing satisfied from dissatisfied patients. Differences in satisfaction rates were analyzed At the conclusion of the scenario, the following using a ␹2 test. To check for differences in the statement was made with 3 variations: The doctor distribution of the 3 questionnaire types by age, tells you that you have (a chest cold, a viral upper sex, and educational attainment, we used analysis of respiratory infection, or bronchitis). He says that variance (ANOVA) for age and ␹2 for sex and you will get over it just as fast without an antibiotic educational attainment. We used binary logistic and does not prescribe an antibiotic for you. regression to control for differences in age, sex, and The scenario was followed by 2 questions that educational attainment in the analyses of satisfac- were identical for all 3 illness labels: (1) How sat- tion with the diagnosis and satisfaction with the isfied are you with the diagnosis of (condition)? (2) treatment. The data were analyzed using Minitab How satisfied are you with not receiving an antibi- 14 statistical software (Minitab, State College, PA). 460 JABFP November–December 2005 Vol. 18 No. 6 http://www.jabfp.org J Am Board Fam Pract: first published as 10.3122/jabfm.18.6.459 on 1 December 2005. Downloaded from Results Discussion A total of 466 questionnaires was distributed. Four Physicians may use terms like viral syndrome and questionnaires were unaccounted for, and 3 were chest cold with the idea that this term represents a incomplete or unusable, leaving a total of 459 ques- less serious illness that does not require antibiotic tionnaires available for analysis. treatment. The term bronchitis means acute or The average age of respondents was 43.
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