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Research ArticleOriginal Research

Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial

Anna Ishani Perera, Mark Greenslade Thomas, Keith James Petrie, Janet Frater, Daniel Dang, Kiralee Ruth Schache, Amelia Frances Akroyd and Stephen Robert Ritchie
The Annals of Family Medicine May 2021, 19 (3) 232-239; DOI: https://doi.org/10.1370/afm.2672
Anna Ishani Perera
1Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
MBChB
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  • For correspondence: anna.perera@auckland.ac.nz
Mark Greenslade Thomas
2Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
3Department of Infectious Diseases, Auckland City Hospital, Auckland, New Zealand
MD
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Keith James Petrie
1Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
PhD
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Janet Frater
4Balmoral Doctors, Auckland, New Zealand
MBChB
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Daniel Dang
5Eastern Institute of Technology, Napier, New Zealand
PhD
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Kiralee Ruth Schache
1Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
MHP
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Amelia Frances Akroyd
1Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
MHP
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Stephen Robert Ritchie
2Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
PhD
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  • Figure 1.
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    Figure 1.

    CONSORT diagram showing participant flow through the study.

    CONSORT = Consolidated Standards of Reporting Trials.

    a A total of 19 participants were lost to follow-up at postconsultation (N = 306 were followed up).

    b An additional 2 participants did not have data available for analysis (N = 304 had complete data for analysis).

  • Figure 2.
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    Figure 2.

    Participants’ expectation of receiving an antibiotic.

    Notes: Participants used a 7-point Likert scale to express level of agreement with the statement, “I wish to receive antibiotics for my/my child’s cold/flu.” For graphical purposes, the Likert scores were collapsed to a 5-point scale by combining responses of 1 and 2 to represent “strongly disagree” and 6 and 7 to represent “strongly agree.” Values in circles are means.

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    Table 1.

    Characteristics of Study Participants

    CharacteristicFutility Group (n = 119)Adverse Effects Group (n = 104)Control Group (n = 102)Total (N = 325)
    Age, median (IQR), y36 (28-56)42 (32-56)40 (29-58)39 (31-49)
    Sex, No. (%)
        Male38 (32)30 (29)33 (32)101 (31)
        Female81 (68)74 (71)69 (68)224 (69)
    Ethnicity, No. (%)
        New Zealand European92 (77)94 (90)87 (85)273 (84)
        Asian17 (14)8 (8)6 (6)31 (10)
        Pacific5 (4)2 (2)4 (4)11 (3)
        Māori5 (5)05 (5)10 (3)
    Highest education level,a No. (%)
        School16 (14)22 (21)15 (15)53 (16)
        Trade/other18 (15)21 (20)19 (19)58 (18)
        University83 (71)60 (58)68 (67)211 (65)
    Predominant symptoms,b No. (%)
        Cough85 (71)77 (74)78 (77)240 (74)
        Sore throat64 (54)50 (48)51 (50)165 (51)
        Nasal68 (57)56 (54)61 (60)185 (57)
        Earache29 (24)28 (27)22 (22)79 (24)
    Child (aged 0-7 years), No. (%)34 (29)26 (25)31 (30)91 (28)
    Antibiotic prescription received,c No. (%)34 (31)28 (29)31 (32)93 (30)
    Antibiotic dispensed,d No. (%)34 (31)22 (22)28 (29)84 (28)
    • IQR = interquartile range.

    • Note: Distribution of participants: 37% in futility group, 32% in adverse effects group, and 31% in control group.

    • ↵a Three participants did not answer this question.

    • ↵b Participants were asked to select all symptoms that applied.

    • ↵c A total of 306 participants answered this question.

    • ↵d A total of 304 participants had this information available.

    • View popup
    Table 2.

    Adjusted Odds Ratios of the Likelihood of Continuing to Expect Antibiotics

    CharacteristicProportion Expecting Antibiotics, %aaOR (95% CI)P Value
    Group
    Control39Ref…
    Futility400.58 (0.35-0.95).03
    Adverse effects390.44 (0.26-0.74)<.01
    Sex
    Female36Ref…
    Male481.75 (1.12-2.74).02
    Age-group
    Adult40Ref…
    Childb390.72 (0.44-1.18).19
    Predominant symptoms
    Sore throat
        No39Ref…
        Yes391.62 (1.06-2.48).03
    Cough
        No33Ref…
        Yes421.30 (0.81-2.11).28
    Earache
        No38Ref…
        Yes441.28 (0.79-2.09).32
    Symptom severityc…1.16 (0.91-1.47).22
    Degree of concernc…1.15 (0.96-1.37).13
    • aOR = adjusted odds ratio; Ref = reference.

    • Note: Assessed after participants viewed 1 of the presentations, with the postpresentation questionnaire.

    • ↵a Unadjusted.

    • ↵b Parents provided response for children aged 0 to 7 years presenting with symptoms of upper respiratory tract infection.

    • ↵c Measured on a 7-point scale where higher score indicates greater severity or concern.

    • View popup
    Table 3.

    Adjusted Odd Ratios of Receiving an Antibiotic Prescription and Having an Antibiotic Dispensed

    CharacteristicAntibiotic Prescription ReceivedAntibiotic Dispensed
    Unadjusted Proportion, %aOR (95% CI)P ValueUnadjusted Proportion, %aOR (95% CI)P Value
    Group
    Control31Ref…32Ref…
    Futility300.86 (0.46-1.61).60271.09 (0.56-2.09).80
    Adverse effects310.83 (0.43-1.59).60240.73 (0.36-1.47).40
    Age in years…1.02 (1.00-1.04).10…1.01 (0.99-1.03).40
    Symptom severity…1.26 (0.95-1.66).10…1.49 (1.12-2.00).01
    Predominant symptoms
    Cough
        No28Ref…29Ref…
        Yes310.94 (0.50-1.76).80270.72 (0.38-1.38).30
    Sore throat
        No31Ref…28Ref…
        Yes300.59 (0.34-1.04).07270.57 (0.31-1.04).07
    Nasal
        No29Ref…24Ref…
        Yes320.96 (0.54-1.71).90311.20 (0.66-2.20).60
    Earache
        No27Ref…25Ref…
        Yes422.36 (1.30-4.30)<.01361.80 (0.96-3.41).07
    Age-group
    Adult30Ref…28Ref…
    Child311.25 (0.68-2.29).50261.16 (0.62-2.19).70
    Expect antibioticsa
    Neutral34Ref…27Ref…
    Strongly disagree170.71 (0.35-1.45).30112.01 (0.91-4.44).08
    Disagree250.90 (0.34-2.37).80251.61 (0.56-4.64).40
    Agree301.08 (0.46-2.54).90222.05 (0.78-5.35).10
    Strongly agree562.69 (1.27-5.69).01586.76 (2.92-15.67)<.01
    • aOR = adjusted odds ratio; Ref = reference.

    • Notes: Binomial logistic regression analyses, based on 306 participants for an antibiotic prescription received and 304 participants for an antibiotic dispensed.

    • ↵a Based on response on postpresentation questionnaire. Responses on the 7-point Likert scale were collapsed to a 5-point scale by combining responses of 1 and 2 to represent “strongly disagree” and 6 and 7 to represent “strongly agree.”

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  • The Article in Brief

    Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial


    Anna Ishani Perera, and colleagues

    Background Inappropriate antibiotic prescribing for upper respiratory tract infections contributes to antibiotic resistance, making some bacterial infections difficult to treat. This often leads to higher medical costs, prolonged hospital stays and increased mortality. Still, many physicians report prescribing antibiotics at their patients’ request. To address patients’ expectations for antibiotic prescribing for URTIs, researchers conducted an experiment in which study participants were assigned brief educational videos to watch on a tablet immediately prior to their appointment.


    What This Study Found The authors randomized patients into three groups – one that viewed a presentation about the futility of antibiotic treatment of URTIs; a second group that viewed a presentation about the adverse effects associated with antibiotics; and a third control group that learned about the benefits of healthy diet/exercise.The researchers then measured the effects of the presentations on patients’ beliefs that antibiotics are helpful for URTIs; their expectations to be prescribed an antibiotic; and whether they were actually prescribed antibiotics for their URTIs. Participants who viewed either the futility or adverse effects presentations had greater reductions in their expectations of receiving antibiotics compared to the group that viewed the video about the benefits of healthy/diet and exercise. However, there was no significant difference between the three groups when it came to doctors actually prescribing antibiotics to patients.


    Implications           

    • A brief, tablet-based waiting room intervention significantly changes participants’ expectations on receiving antibiotics for URTIs, but that future efforts to improve antibiotic prescribing need to involve both patients and their doctors.
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The Annals of Family Medicine: 19 (3)
The Annals of Family Medicine: 19 (3)
Vol. 19, Issue 3
1 May 2021
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Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial
Anna Ishani Perera, Mark Greenslade Thomas, Keith James Petrie, Janet Frater, Daniel Dang, Kiralee Ruth Schache, Amelia Frances Akroyd, Stephen Robert Ritchie
The Annals of Family Medicine May 2021, 19 (3) 232-239; DOI: 10.1370/afm.2672

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Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial
Anna Ishani Perera, Mark Greenslade Thomas, Keith James Petrie, Janet Frater, Daniel Dang, Kiralee Ruth Schache, Amelia Frances Akroyd, Stephen Robert Ritchie
The Annals of Family Medicine May 2021, 19 (3) 232-239; DOI: 10.1370/afm.2672
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