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Parent Expectations for Antibiotics, Physician-Parent Communication, and Satisfaction
Rita Mangione-Smith, MD, MPH;
Elizabeth A. McGlynn, PhD;
Marc N. Elliott, PhD;
Laurie McDonald, MS;
Carol E. Franz, PhD;
Richard L. Kravitz, MD, MSPH
Arch Pediatr Adolesc Med. 2001;155:800-806.
ABSTRACT
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Objectives To explore how parents communicate their preferences for antibiotics
to their child's physician and to examine whether physicians can communicate
why antibiotics are not being prescribed in a way that maintains satisfaction
with the visit.
Design Previsit survey of parents, audiotaping of the study encounters, and
a postvisit survey of parents and physicians.
Setting Two private pediatric practices.
Participants Ten physicians (response rate = 77%) and a consecutive sample of 295
eligible parents (response rate = 86%) who attended acute care visits for
their children between October 1996 and March 1997.
Main Outcome Measures Physician-perceived pressure to prescribe antibiotics and parental visit-specific
satisfaction.
Results Fifty percent of parents expressed a previsit expectation for antibiotics.
Among these parents, only 1% made a direct verbal request for them. Even when
no direct requests for antibiotics were made, physicians still perceived an
expectation for antibiotics 34% of the time. Among parents who did not receive
expected antibiotics, those offered a contingency plan from the physician
(ie, the possibility of receiving antibiotics in the future if their child
did not get better) had a higher mean satisfaction score than parents not
receiving a contingency plan (76 vs 58.9; P<.05).
Conclusion Physicians should consider providing a contingency plan to parents who
expect antibiotics for their children when there is no clinical indication.
Further study is needed to determine how parents indirectly communicate their
desire for antibiotics and what additional communication techniques physicians
can use to resist the overprescribing of antibiotics.
INTRODUCTION
DESPITE A LARGE body of evidence that antibiotics have no role in the
treatment of upper respiratory tract infections (URTIs),1, 2, 3, 4, 5, 6, 7
an estimated 38% of children diagnosed with these infections leave the physician's
office with an antibiotic prescription.8 Approximately
$40 million is spent annually in the United States on antibiotics for the
common cold.9 Frequent antibiotic use is a
risk factor for the spread of drug-resistant strains of bacteria10, 11, 12, 13
that are costly,14 are more difficult to treat, 10, 15, 16 and result in increased
mortality.17
Several studies indicate that patient and parental pressure to prescribe
antibiotics leads to increased rates of overprescribing,18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28
but the mechanisms by which pressure is exerted are unknown. Physicians often
do not correctly assess what the patient or parent expects.20, 21, 23, 26, 27
This failure to accurately assess patient and parental expectations underscores
the need to better understand what parental communication behaviors make physicians
think that antibiotics are expected.
What happens in physician-patient and physician-parent interactions
is a key determinant of the overprescribing of antibiotics.18, 20, 21, 22, 23, 24, 25, 27, 28, 29
However, little is known about whether parents influence prescribing choices
when they directly or indirectly communicate their desire for antibiotics
or whether physicians can effectively communicate reasons for not prescribing
antibiotics inappropriately while maintaining satisfaction. This study examined
physician-parent communication behaviors for the following reasons: (1) to
determine how parents communicate their desire for antibiotics to physicians;
(2) to explore what parent communication behaviors make physicians feel pressured
to prescribe; and (3) to explore what physician communication behaviors enhance
parent visit-specific satisfaction.
SUBJECTS AND METHODS
The study design and survey data collection methods have been described
in detail elsewhere.23 Parents completed (1)
a 15-item previsit expectations inventory that included 1 item about whether
they thought it was necessary for the physician to prescribe antibiotics;
(2) a postvisit questionnaire that asked whether previsit expectations were
fulfilled; and (3) a postvisit satisfaction questionnaire. Physicians completed
a postvisit checklist to indicate diagnosis, treatment, and whether they believed
that the parent expected antibiotics for the child. Parents were eligible
for participation if their child was between the ages of 2 and 10 years, was
being seen for URTI symptoms (cough, rhinorrhea, throat pain, ear pain, or
ear tugging), had not been taking antibiotics for the previous 2 weeks, and
was seeing a participating physician. Parents of children younger than 2 years
were excluded because the University of California, Los Angeles, Human Subjects
Protection Committee believed that these subjects were too vulnerable to be
approached for study participation. Parents of children older than 10 years
were excluded because this study focused on physician-parent communication
rather than physician-patient communication. We also excluded ongoing or concurrent
episodes of presumed bacterial illness by excluding parents of children treated
with antibiotics within 14 days of the study visit. This was done because
we were most interested in studying encounters where parents potentially expected
antibiotics but had not yet received them, rather than encounters likely to
result in a change in the type of antibiotic prescribed for an ongoing bacterial
illness.
AUDIOTAPE DATA COLLECTION AND INTERACTION ANALYSIS
Encounters were audiotaped, transcribed, and coded for communication
events of interest. We used a modified version of a valid and reliable interaction
analysis scheme called Taxonomy of Requests by Patients (TORP).30
This scheme codes parent requests for information (eg, "Is this infection
contagious?") and action (eg, "Can you start her on some Suprax before this
gets out of hand?"), and physician responses to those requests. The pediatric
version of TORP, TORP-P, was developed in collaboration with the team of researchers
who created the original version. Because we were specifically interested
in the outcome of satisfaction, we added a new dimension to TORP-P, which
codes for physician-initiated information giving. We hypothesized that visit-specific
satisfaction among parents would be higher when physicians responded to requests
for information and action and when physicians spontaneously offered information
without any prompting. We developed codes for physician-initiated statements
of fact (eg, "Sally has the flu") and physician-initiated explanations (eg,
"Sally has the flu, which is caused by a virus, so antibiotics really won't
help"). We hypothesized that giving parents unprompted explanations would
be associated with higher satisfaction than simply making factual statements
about their child's illness or the treatment plan.
Encounters were also analyzed using 4 new codes developed specifically
for this study. Codes were developed to identify whether discussions about
antibiotics occurred and, if so, whether the parent or the physician initiated
the discussion. Two additional codes were developed using qualitative analysis
techniques. We performed a qualitative analysis on a subset of 10 audiotapes
of encounters where (1) parents expected but did not receive antibiotics;
and (2) parent satisfaction levels fell into either the upper or lower quartile.
This was done to identify recurrent communication themes subjectively associated
with higher levels of satisfaction. The analysis was performed independently
by 2 of the authors (R.M.S. and C.E.F.). Two themes emerged, and interaction
analysis codes were developed. For the first theme, we developed a code called
"MD contingency plan." We applied this code to statements in which the physician
indicated that although antibiotics would not be prescribed at the current
visit, if the child did not improve during the next day or two, they might
be prescribed then. To account for situations where the physician invested
substantial time or effort in addressing parental concerns that were subsidiary
to the main reason for the visit, we developed a second code called "MD extra."
For example, we applied this code when the main reason for the visit was an
earache, the parent subsequently raised concerns about possible hyperactivity
in the child, and the physician responded by giving a detailed explanation
about possible approaches to evaluating the child for attention-deficit/hyperactivity
disorder.
All audiotaped encounters were coded by 2 of 3 coders (R.M.S. coded
287 encounters; 2 trained research assistants coded 247 and 40 encounters,
respectively). Of the original 295 encounters, 8 were not coded because of
incomplete audiotape data. Both unitizing and interpretive reliability were
calculated for the 2 coders on each encounter using the  statistic.31 Unitizing reliability is a measure of how often beyond
chance 2 coders agreed that a statement should be coded. Interpretive reliability
assesses only those statements that are coded by both coders, and examines
how often beyond chance the 2 coders select the same code category. Our adapted
version of TORP, TORP-P, was found to have both excellent unitizing and interpretive
reliability. The unitizing statistic ranged between 0.76 and 0.78
for the 2 pairs of coders, and the interpretive statistic ranged between
0.89 and 0.91.
ANALYTIC METHODS
Previously analyzed survey data and coded audiotape data were merged
to examine the relationships between parent communication behaviors and physician-perceived
pressure to prescribe antibiotics, and between physician communication behaviors
and parent visit-specific satisfaction. We tested the relationship between
our predictor and outcome variables using bivariate analyses ( 2 test of independence, Fisher exact test, t
test, 1-way analysis of variance, and multiple linear regression). Results
of these analyses were used (1) to develop a multivariate model to predict
physician-perceived pressure to prescribe antibiotics; and (2) to assess which
of the new communication variables should be added to our existing ordinary
least squares regression model predicting parent visit-specific satisfaction.23 Results of the first logistic regression model are
reported as odds ratios with 95% confidence intervals. For the second model,
which predicted parent satisfaction with the visit, results are reported as ß
coefficients. In ordinary least squares regression analysis, the ß coefficient
is the change in outcome associated with a 1-unit change in a predictor variable,
holding all other predictor variables in the model constant. To examine the
relationships between satisfaction, expectation fulfillment for antibiotics,
and receiving a contingency plan, analysis of variance and the Tukey Studentized
Range test were performed.
RESULTS
As previously reported, 10 (77%) of 13 physicians agreed to participate,
and 306 (86%) of 356 parents were willing to participate.23
Of 295 audiotaped encounters, data were complete for 287 (97%). Parents in
the sample were older (mean, 38 years), highly educated (mean, 16 years),
and had high incomes (75% had an annual income >$50 000). Non-Hispanic
white people made up two thirds of the sample, and 60% were enrolled in managed
care plans.
Among the total sample of 287 encounters, physicians initiated discussions
of antibiotics 74% (n = 211) of the time, whereas parents initiated these
conversations 8% (n = 23) of the time. Antibiotics were not discussed at all
in 18% (n = 53) of encounters. In encounters where physicians did not initiate
a discussion of antibiotics (n = 76), parents who indicated on the previsit
survey that they expected antibiotics (n = 36) initiated conversations about
them 11% of the time vs 5% if they reported no expectation for antibiotics
(P = .07). Most discussions initiated by parents
concerning antibiotics were not direct requests for them but indirect mentions.
For example, the parent might say, "My neighbor's little boy was started on
antibiotics yesterday because he's coughing and having fevers too. He plays
with Jimmy a lot." Parents made direct requests for antibiotics in only 4
encounters, or 1% (eg, "I think you need to start Suprax before this gets
too bad").
Physician perceptions of parent expectations for antibiotics were related
to parent communication behaviors. Multivariate logistic regression analysis
revealed that physicians were significantly more likely to perceive parents
as expecting a prescription for their child when parents initiated a discussion
about antibiotics during the visit (Table
1). When parents initiated discussions about antibiotics, physicians
were 4 times more likely to believe that they expected antibiotics than if
no discussion occurred. Physicians who initiated discussions about antibiotics
were 4.5 times more likely to perceive parents as expecting antibiotics than
physicians who did not initiate such discussions. Actual parental expectations
for antibiotics were not associated with physician-perceived expectations
(Table 1).
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Table 1. Adjusted Predictors of Physician-Perceived Expectations for
Antibiotics
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For patients diagnosed as having a virus, if the physician perceived
a parental expectation for antibiotics without a direct request from the parent,
antibiotics were prescribed 48% of the time vs 10% if no parental expectation
was perceived (P<.001).
The mean ± SD satisfaction score for parents (scale, 0-100) was
65 ± 19. The only parent demographic characteristics that were related
to satisfaction were ethnicity and level of education (Table 2). Being white or Asian American was associated with an increase
of 5.7 points in the satisfaction score, compared with being African American
or Hispanic (P = .03). Parents with a graduate degree
were 8 points less satisfied than those with a high school degree (P = .002). Providing a contingency plan (ie, the possibility that antibiotics
might be provided if the child did not improve during the following 1 to 2
days) was associated with an additional 4 points in the satisfaction score
(P = .04).
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Table 2. Adjusted Predictors of Parent Satisfaction With the Visit
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Parents who expected antibiotics but did not receive them were significantly
more satisfied if the physician provided a contingency plan (P<.05; Figure 1). The
top line in Figure 1 indicates the
mean and the upper and lower 95% confidence limits for satisfaction scores
among parents who expected antibiotics, did not receive them, and were provided
with a contingency plan (mean = 76; 95% confidence limit [66, 86]). This mean
score is 11 points higher than the mean for the entire study population and
17 points higher than the mean score for parents who expected antibiotics,
did not receive them, and did not receive a contingency plan (mean = 59; P<.05). Contingency plans were important only for parents
who expected antibiotics but did not receive them. Parents who did not expect
antibiotics, did not receive them, and also did not receive a contingency
plan had a mean satisfaction score of 68. Parents who did not expect antibiotics,
did not receive them, but did receive a contingency plan had a mean satisfaction
score of 66. Parents who expected antibiotics, did not receive them, but received
a contingency plan tended to be more satisfied (mean = 76) than parents who
expected antibiotics and received them (mean = 65; P
= .07).
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Contingency plans enhance satisfaction of parents who want antibiotics
but do not receive them. Comparing groups A through E, the only 2 that were
significantly different from each other at P <.05
were groups A and B.
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Parents also reported higher levels of satisfaction when physicians
took the time to address subject matter outside the main reason for the visit
("extra" communication); however, this relationship only trended toward significance
(P = .07). The original finding that unfulfilled
expectations for communication events was a significant predictor of satisfaction
did not change with the addition of the new communication variables to the
right-hand side of the ordinary least squares model.23
In bivariate analyses, physician-initiated factual statements were observed
to enhance satisfaction with the visit. Satisfaction was 3 points higher when
1 factual statement was provided and an additional 3 points higher if 2 to
4 such statements were made (P<.05). However,
this communication variable was not a significant predictor of satisfaction
in multivariate analyses (P = .15). Physician-initiated
explanations were not predictive of satisfaction in either bivariate or multivariate
analyses.
COMMENT
PREDICTORS OF PHYSICIAN-PERCEIVED EXPECTATIONS FOR ANTIBIOTICS
Perceived patient and parental pressure has been shown in multiple investigations
to result in increased overprescribing of antibiotics.18, 19, 20, 21, 22, 23, 24, 25
In many cases, however, physicians are not good at predicting what parents
or patients actually expect.20, 21, 23, 26, 27
The current study represents an advance because it includes an in-depth analysis
of what was said during the physician-parent encounter and links communication
events to physician reports of pressure to prescribe antibiotics. Understanding
how physicians acquire both accurate and inaccurate perceptions of parent
expectations may facilitate the development of effective interventions to
decrease inappropriate prescribing. Physicians' reports of pressure to prescribe
have previously been assumed to result from parents directly asking for antibiotics
during their child's visit.32 In contrast,
we found that parents rarely made direct requests for antibiotics; in 287
encounters, only 4 parents asked for them directly. This finding is consistent
with those of Korsch and colleagues,33 who
reported that parent expectations often were not verbalized. However, we also
found that any parent-initiated statement about antibiotics, whether it was
a direct request or an indirect mention, increased the likelihood that the
physician perceived the parent as expecting antibiotics. This finding may
partially explain why physicians were frequently incorrect about parent expectations.
Physicians in our study may have interpreted indirect mentions about antibiotics
as direct requests for them. They may have been overresponsive to parent-initiated
discussions about antibiotics.
Although there was a trend toward parents being more likely to initiate
discussions of antibiotics when they expected a prescription than when they
did not (11% vs 5%; P = .07), only 11% of those who
expected antibiotics initiated such discussions. Physicians believed that
a parent expected antibiotics in 34% of the study encounters, whereas parents
brought the subject up (directly or indirectly) in only 8% of encounters.
This leads us to conclude either that physicians are attributing expectations
to parents that they do not actually have or that parents are communicating
their expectations indirectly without ever mentioning antibiotics. Further
work is needed to elucidate what parent communication behaviors, both verbal
and nonverbal, are leading physicians to come to the conclusion (correctly
or incorrectly) that antibiotics are desired. If this set of parent communication
behaviors can be identified, physicians could be trained to directly assess
what the parent expects when indirect communication cues are used. This may
help physicians to avoid prescribing inappropriate antibiotics that the parent
may not expect. We hypothesize that parents may be influencing physician perceptions
of their expectations through indirect comments made during the visit (eg,
bringing up additional symptoms when the physician clearly is not planning
to prescribe antibiotics for their child). For example, the physician says,
"Well, I think she's got the common cold," and the parent responds, "But her
fever has been so high."
The current study is limited; we were unable to assess nonverbal communication
cues because audiotapes rather than videotapes were used for data collection.
Parent facial expressions or body language may also be influencing physician
perceptions of their expectations. Future studies should attempt to assess
this potentially important aspect of communication.
When physicians perceived an expectation for antibiotics, they were
significantly more likely to initiate discussions about them. This may represent
physicians bringing up the subject of antibiotics in an attempt to prevent
an inappropriate request for them by the parent. Alternatively, physicians
may be acquiescing to perceived pressure and initiating the discussion about
antibiotics to explain the treatment course they are planning to follow.
SATISFACTION
In the current competitive marketplace, many physicians worry that if
they do not satisfy patient desires for medications, the patient will go elsewhere
for care.34 However, previous work has shown
that satisfaction is not tied to the receipt of desired antibiotics or treatment,
but rather to the quality of communication during the visit.20, 23, 33, 35
In our study we found that physicians can use a relatively simple communication
technique in the face of feeling pressured to prescribe inappropriately; this
is to provide the parent with a contingency plan. A contingency plan involves
the physician suggesting that the parent make contact in the next couple of
days if their child is not improving or is getting worse, and explaining that
antibiotics might then be provided. Parents in our study who expected antibiotics
but did not receive them were significantly more satisfied if the physician
provided them with this type of follow-up plan. Using this communication technique
has definite promise for potentially decreasing unnecessary prescribing of
antibiotics. In a recent study by Cates,36
the monthly number of amoxicillin prescriptions issued in a private physician's
office decreased by 32% when parents were provided with a pamphlet on the
potential risks of antibiotics for otitis media. They were also given a prescription
for amoxicillin and were instructed to fill it only if their child did not
get better in the next couple of days. In the current study, we found that
simply indicating that antibiotics might be prescribed if a child did not
improve not only prevented inappropriate prescribing but also significantly
enhanced parents' satisfaction with care. Providing a follow-up plan that
requires communication between the physician and parent emphasizes the continuity
of the relationship to that parent. Previous studies have found continuity
of care to be a key predictor of satisfaction.37, 38
Thus, it is not surprising that providing a contingency plan enhances satisfaction
with care. However, in systems of care where continuity is not assured or
where parents may not have easy telephone access to their child's physician,
providing a contingency plan may not be an option. In such cases, a contingency
prescription as in the Cates study might be a more reasonable alternative.36
In our data set, 52% of contingency plans implied that a second visit
would not be necessary for antibiotics to be provided. Thus, the enhancement
in satisfaction we observed with contingency plans may have resulted from
the parent believing that a second visit would be unnecessary if the child
became more ill and ultimately needed antibiotics, and that antibiotics could
be prescribed by telephone. Theoretically, receiving expected antibiotics
during the index visit would also have reduced the need for return visits.
In our study, however, receiving expected antibiotics had no effect on parental
reports of satisfaction with the visit (P>.20). Therefore,
we believe that the continuity of care implied by the contingency plan is
more likely to explain the observed increase in satisfaction.
It is imperative that the medical-legal aspects of providing a contingency
plan or a delayed prescription, as in the Cates study, be considered by any
physician who chooses to give one. If a parent calls back because a child
is not improving or is worse, and if a physician provides antibiotics without
reassessing that child, the physician clearly has put himself or herself at
risk medical-legally. Future studies should examine how often children ultimately
receive antibiotics when a contingency plan has been provided and how frequently
this occurs without a second assessment by the physician. When giving a contingency
plan, the physician should use language that implies the necessity of a return
visit before antibiotics will be provided (eg, "If she's not doing better
in the next day or 2 or certainly if she gets worse, we definitely need to
have a second look to see if some antibiotics are in order"). We do not know
how often this will result in a second visit or what the economic implications
would be, that is, the parent's additional loss of time from work or the cost
of a second visit. However, in a recent study by Pichichero et al,39 the investigators reported that 29% (86 of 293) of
children with respiratory illnesses who were not prescribed antibiotics during
an initial visit ended up having a second unplanned visit. In contrast, children
who received antibiotics at the first visit returned unexpectedly in 44% (40
of 90) of cases. Thus, it would seem reasonable that most parents receiving
a contingency plan would not require a return visit. Pichichero et al also
reported that 43% of the children not given antibiotics initially did not
receive them at the second visit either. Future work in this area should assess
how often giving a contingency plan results in the need for additional visits
and the ultimate provision of antibiotics.
LIMITATIONS
Because our study was done in one geographic location with a small and
relatively homogeneous group of parents and physicians, we do not know whether
our findings would generalize to other settings with parents from different
backgrounds. Our results also may not generalize well to encounters between
physicians and parents of children younger than 2 years or older than 10 years.
Because members of the University of California, Los Angeles, Human Subjects
Protection Committee felt that parents with an ill child younger than 2 years
were too vulnerable and should not be approached for study participation,
our ability to completely assess the nonjudicious use of antibiotics for children
with URTI was limited. We hope that future studies will include this group
of parents. We elected to exclude parents of children older than 10 years
because we hoped to capture physician-parent communication rather than physician-patient
communication. Studying these issues in visits with adolescents would likely
yield different conclusions and is an area of research that should be pursued.
Because we excluded parents of children prescribed an antibiotic in
the previous 2 weeks, we may have failed to include an important predictor
of the physician's decision to prescribe antibiotics at the current visit.
Although parent expectations and physician-parent communication are likely
to be influenced by visits during the prior 2 weeks that resulted in an antibiotic
prescription, previous research indicates that most episodes of presumed bacterial
illness in pediatric patients (66%-86%) result in only 1 physician visit per
episode.39, 40 Thus, we do not
believe that excluding these parents substantially affected our conclusions.
Because this was an observational study, we cannot make any conclusions
about causation. Although we controlled for several confounding variables
related to parent satisfaction, it is possible that other unknown confounders
exist.
CONCLUSIONS
When physicians feel pressured to prescribe antibiotics that they believe
are unnecessary, they should consider providing the parent with a contingency
plan. This communication technique will enhance parent satisfaction and will
simultaneously allow the physician to avoid prescribing antibiotics inappropriately.
Further research is needed to identify other communication techniques physicians
can use to avoid overprescribing antibiotics in the pediatric outpatient setting.
The more communication tools physicians have at their disposal, the more successfully
they will be able to avoid this problem. Further investigation is also needed
to delineate more clearly what parent communication behaviors lead physicians
to feel pressured to prescribe. Increasing physician awareness of such communication
behaviors may facilitate direct responses that do not include inappropriate
prescribing. In such cases, physicians should ask parents what they expect
from the visit. Parents who seem to expect antibiotics may actually be seeking
reassurance that their children are not seriously ill.
Investigating how to improve physician-parent communication will be
most important for the next generation of physicians, who will be dealing
with resistant infections on a daily basis if we are unable to find successful
techniques for curbing inappropriate antibiotic prescribing. Additionally,
as parents become more actively involved in health care decisions, successful
physician-parent communication will be critical.
AUTHOR INFORMATION
Accepted for publication March 2, 2001.
This project was funded by the Bayer Institute for Health Care Communication,
West Haven, Conn, and the Robert Wood Johnson Foundation, Princeton, NJ.
Presented at the annual meeting of the Association for Health Services
Research, Los Angeles, Calif, June 26, 2000.
We would like to thank Zoey Goore, MD, and Christina Page, MD, for their
assistance with transcript coding.
From the Department of Pediatrics, University of California, Los Angeles
(Dr Mangione-Smith); RAND, Santa Monica, Calif (Drs McGlynn, Elliott, and
McDonald); and the Center for Health Services Research in Primary Care, University
of California, Davis (Drs Franz and Kravitz).
Corresponding author and reprints: Rita Mangione-Smith, MD, MPH,
UCLA Department of Pediatrics, 12-365 Marion Davies Children's Center, 10833
LeConte Ave, Los Angeles, CA 90095-1752 (e-mail: ritams{at}ucla.edu).
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