Summary of main findings
General practitioners who have been informed about the use of wait-and-see prescriptions in RTIs, most often use the strategy in cases of acute sinusitis and acute otitis media. These are also the diagnoses for which the GPs find the strategy most reasonable. The reported reason for issuing a wait-and-see prescription is most commonly uncertainty about indication for antibiotics.
Patients receiving a wait-and-see prescription are confident in the decision whether to start taking the medication, and half of the patients report to consume the antibiotics. Feeling very ill, having fever, and being more than 16 years predict consumption of antibiotics, while reporting nasal congestion is negatively associated with consuming antibiotics.
Comparison with existing litterature
To our knowledge, this is the first survey on delayed prescribing in which different diagnoses are compared, and in which the feasability of the strategy among GPs is measured.
We found that GPs issue wait-and-see prescription most commonly in sinusitis and otitis. When compared to a similar group of GPs in Norway [4], our numbers show an over-representation of sinusitis and otitis, which indicates that patients receiving antibiotics for otitis or sinusitis more often will be instructed to wait than patients receiving antibiotics for other conditions. This may be because otitis and sinusitis are the two conditions for which the Norwegian National Treatment Guidelines recommend "watchful waiting" [16]. A Norwegian prescription study shows that tonsilitis is the diagnosis that would most often warrant a prescription for antibiotics, while URTI is at the other extreme [4]. This may explain why patients with tonsilitis in our study felt less ill, and patients with URTI felt more ill, as one could assume that the moderately ill patients with tonsilitis would be given an immediate prescription for antibiotics, and the moderately ill patients with URTI would not be given antibiotics at all.
The first evidence on the advantages of delayed prescribing came from studies on patients with sore throat in the United Kingdom in 1997 [7], and the spreading of this evidence is considered as one of the reasons why antibiotic consumption continued to decrease in the UK from the late 1990s and onwards [25]. However, in our study sore throat is not a condition in which the GPs readily give wait-and-see prescriptions. This may be due to the widespread use of point-of-care streptococcal throat tests in Norwegian general practice [26], and that the GPs let the test results decide whether to prescribe antibiotics.
In our study, 46% of the patients reported to consume the antibiotics and 86% reported confidence in deciding whether to take the antibiotics. These findings are similar to Edwards et al, who in a comparable British study [22] found a consumption rate of 53%, and 87% confident patients. In both studies, fever was found as a predictor for consuming antibiotics. Fever is shown to be the most important cue when parents take treatment decisions on behalf of their sick child [27].
There were some interesting differences regarding patient expectations. Fewer patients in our study expected antibiotics (52%) compared to the findings of Edwards et al (65%). This may be due to a real difference in antibiotic expectation, despite similar antibiotic prescription rates in the two countries [3]. Another explanation may be that the GPs in our study to a lesser degree used delayed prescribing as a tool to meet patient expectation for antibiotics. Substantially more patients in our setting expected tests or referral (50% vs Edwards et al: 2%). This indicates that the more widespread use of point-of-care tests in our setting compared to Edwards et al's UK setting [28] has had an influence on patients' expectations.
We found differences in reported consumption rates for the various diagnoses, and the internal variation shows some resemblence with the results achieved in various diagnose-specific RCTs on delayed prescribing; 35% vs 24 - 38% (otitis media) [5, 6], 46% vs 31% (sore throat) [7], 51% vs 20 - 45% (lower RTI/cough) [8, 9], and 57% vs 48% (upper RTI/common cold) [10]. The results are understandably not directly comparable, as the methods of issuing delayed prescriptions differ between various studies, the diagnostic criteria varies, and the antibiotic prescription rates [3] and the patients' views on respiratory tract infections show great variance between countries [29]. Nevertheless, the variance between diagnose groups in our study may give valuable information as the prescriptions for various conditions were given in the same setting.
The natural course of otitis in children is a spontaneous recovery after a few days in approximately 80% of the cases [30], whereas other RTIs may not have this sudden relief. This might explain why ear infection is the diagnose with the lowest pick up rate.
The overall satisfaction with delayed prescribing was high both among GPs and patients. GPs consider overuse of antibiotics a problem [31], and may feel uncomfortable prescribing antibiotics [32]. Thus, there is no surprise that GPs in our study found wait-and-see prescriptions most reasonable among patients who they thought would not pick it up.
Although small numbers, our findings suggest that GPs find delayed prescribing more reasonable in situations of clinical uncertainty rather than in situations where patients demand antibiotics, which is in accordance with the findings in a previous, qualitative study among a similar group of GPs [13].
The GPs found delayed prescribing most reasonable in cases of otitis and sinusitis while the strategy was less valued in cases of upper and lower respiratory tract infections. This may also, as suggested above, be due to the difference in the current understanding and recommended treatment of the various conditions; indication for antibiotics in otitis and sinusitis depends partly, according to Norwegian guidelines, on the duration of symptoms. When it comes to bronchitis and URTI/common cold, the main recommendation is to avoid antibiotics altogether. This might explain why these diagnoses were found less appropriate for delayed prescribing.
Strengths and limitations
The response rate (80%) was relatively high in comparison to a previous study [22]. The aim of this study was not to explore clinical outcomes and safety of the delayed prescribing strategy, and potential differences in treatment outcomes for different diagnoses have not been investigated.
This study does not allow to directly compare the use of wait-and-see prescriptions with the use of prescriptions for antibiotics to be taken immediately, since we have no record of the latter. For illustrative means, we have compared our findings with a reference material of antibiotic prescriptions for RTIs during two winter months.
The participating GPs had agreed to take part in a study on delayed prescribing, and they might hold a more positive view towards the strategy compared to the relatively large group of invited GPs who did not participate. However, both high and low prescribers of wait-and-see-prescriptions were represented.
As in all questionnaire surveys, our results depend on the respondents report, and not necessarily on their action. The patient questionnaire and information leaflet were carefully constructed to avoid an impression that not picking up the prescription would be the preferred solution, so as to minimize a desirability bias. Still, the reported antibiotics consumption rate of 46% may be a underreporting of what actually happened.
The diagnoses referred in this study are the ones chosen by the GPs. We do not know if, and to what extent, diagnostic criteria were followed, and the diagnostic accuracy may have varied between the different GPs.
