Reducing Inappropriate Antibiotics Prescribing

The Role of Online Commentary on Physical Examination Findings

Published in: Patient Education and Counseling, v. 81, no. 1, Oct. 2010, p. 119-125

Posted on RAND.org on December 31, 2009

by John Heritage, Marc N. Elliott, Tanya Stivers, Andrea Richardson, Rita Mangione-Smith

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Objective: This study investigates the relationship of 'online commentary' (contemporaneous physician comments about physical examination [PE] findings) with (i) parent questioning of the treatment recommendation and (ii) inappropriate antibiotic prescribing. Methods: A nested cross-sectional study of 522 encounters motivated by upper respiratory symptoms in 27 California pediatric practices (38 pediatricians). Physicians completed a post-visit survey regarding physical examination findings, diagnosis, treatment, and whether they perceived the parent as expecting an antibiotic. Taped encounters were coded for 'problem' online commentary (PE findings discussed as significant or clearly abnormal) and 'no problem' online commentary (PE findings discussed reassuringly as normal or insignificant). Results: Online commentary during the PE occurred in 73% of visits with viral diagnoses (n = 261). Compared to similar cases with 'no problem' online commentary, 'problem' comments were associated with a 13% greater probability of parents questioning a non-antibiotic treatment plan (95% CI 0-26%, p = .05,) and a 27% (95% CI: 2-52%, p < .05) greater probability of an inappropriate antibiotic prescription. Conclusion: With viral illnesses, problematic online comments are associated with more pediatrician-parent conflict over non-antibiotic treatment recommendations. This may increase inappropriate antibiotic prescribing. PRACTICE IMPLICATIONS: In viral cases, physicians should consider avoiding the use of problematic online commentary

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