Abstract
Objectives
Collecting information on patterns of drug prescriptions and on factors influencing prescribing decisions is fundamental for supporting the rational use of drugs. This study was aimed at investigating patterns of drug prescription in paediatric outpatients and at evaluating determinants of prescriptions for respiratory tract infections (RTIs).
Methods
We conducted a national cross-sectional survey involving primary care paediatricians and parents. Diagnoses and prescriptions made at each consultation were described. Poisson regression models were used to analyse determinants of drug and antibiotic prescriptions for visits due to RTIs.
Results
A total of 4,302 physician and parent questionnaires were analysed. These corresponded to 2,151 visits, 792 of which were due to RTIs. Drugs were prescribed in 83.4% of RTI visits, while antibiotics were prescribed in 40.4%. According to paediatricians’ perceptions, 84.2% of parents of children with a RTI expected to receive a drug prescription. Paediatricians’ perception of parental expectations was the strongest determinant for prescription of drugs and specifically of antibiotics [adjusted relative risk (RR): 1.7 and 3.6, respectively; P < 0.001]. However, in 77.1% of RTI visits, paediatricians judged themselves as not being influenced at all by parents’ expectations in their decision to prescribe.
Conclusions
This study underscores that relational factors, in particular perceived parental expectations, are one of the leading factors of drug prescriptions in paediatric ambulatory care settings, reinforcing the opinion that communication between physicians and parents can affect prescription patterns.
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References
World Health Organization (2003) Introduction to drug utilization research
Murray B (1994) Can antibiotic resistance be controlled? N Engl J Med 330:1229–1230
Levin BR (2001) Minimizing potential resistance: a population dynamics view. Clin Infect Dis 33 (Suppl 3):S161–S169
Goossens H, Ferech M, Vander Stichele R, Elseviers M (2005) Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 365:579–587
Cockburn J, Pitt S (1997) Prescribing behavior in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 315:520–523
Britten N, Ukoumunne O (1997) The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey. BMJ 315:1506–1510
Himmel W, Lippert-Urbanke E, Kochen MM (1997) Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 15:118–122
Ramsden DJ, Quinn RF, Witham M (1998) Doctors are not pressured into giving prescriptions. BMJ 316:938
Webb S, Lloyd M (1994) Prescribing and referral in general practice: a study of patients’ expectations and doctors’ actions. Br J Gen Pract 44:165–169
Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M (2004) Importance of patient pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 328:444–446
Soumerai SB, Ross-Degnan DS (1990) Drug prescribing in pediatrics: challenges for quality improvement. Pediatrics 86:782–784
Otters HBM, van der Wouden JC, Schellevis FG, van Suijelekom-Smit LWA, Koes BW (2004) Trends in prescribing antibiotics for children in Dutch general practice. J Antimicrob Chemother 53(2):361–366
Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B (1999) Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs. Pediatrics 104:1251–1257
Finkelstein JA, Metlay JP, Davis RL, Rifas-Shiman SL, Dowell SF, Platt R (2000) Antimicrobial use in defined populations of infants and young children. Arch Pediatr Adolesc Med 154:395–400
Choonara I, Nunn AJ, Kearns G (eds) (2003) Introduction to pediatric and perinatal drug therapy. Nottingham University Press, Nottingham
del Torso S, Bussi R, DeWitt TG (1997) Primary care pediatrics in Italy: eighteen years of clinical care, research, and teaching under a national health service system. Pediatrics 99:E8
Nyquist A, Gonzales R, Steiner JF, Sande MA (1998) Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 279:875–877
Ciofi Degli Atti ML, Salmaso S, Bella A, Arigliani R, Gangemi M, Chiamenti G et al (2002) Pediatric sentinel surveillance of vaccine-preventable diseases in Italy. Pediatr Infect Dis J 21:763–768
World Health Organization Collaborating Centre for Drug Statistic Methodology (1999) Guidelines for ATC classification and DDD assignment. Oslo, Norway, World Health Organization. Available at: http://www.whocc.no/atcddd/atcsystem.html
Greenland S (2004) Model-based estimation of relative risks and other epidemiologic measures in studies of common outcomes and in case-control studies. Am J Epidemiol 160:301–305
Bronzwaer S, Cars O, Bucholz U, Molstad S et al (2002) A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 8(3):278–282
Boccia D, Spila Alegiani S, Pantosti A, Moro ML, Traversa G (2004) The geographic relationship between the use of antimicrobial drugs and the pattern of resistance for Streptococcus pneumoniae in Italy. Eur J Clin Pharmacol 60:115–119
McCaig L, Besser RE, Hughes JM (2002) Trends in antimicrobial prescribing rates for children and adolescents. JAMA 287:3096–3102
Bauchner H, Pelton SI, Klein JO (1999) Parents, physicians, and antibiotic use. Pediatrics 103:395–401
Mangione-Smith R, McGlynn EA, Elliot MN, Krogstad P, Brook RH (1999) The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 103:711–718
Mangione Smith R, McGlynn EA, Elliot MN, McDonald L, Franz CE, Kravits RL (2001) Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med 155:800–806
Thrane N, Olsen C, Schonheyder HC, Sorensen HT (2003) Socioeconomic factors and prescription of antibiotics in 0- to 2-year-old children. J Antimicrob Chemother 51:683–689
Huang N, Morlock L, Lee C, Chen L, Chou Y (2005) Antibiotic prescribing for children with nasopharyngitis (common colds), upper respiratory infections, and bronchitis who have health-professional parents. Pediatrics 116:826–832
Mangione-Smith R, Elliott MN, McDonald L, McGlynn EA (2002) An observational study on antibiotic prescribing behaviour and the Hawthorne effect. Health Serv Res 37:1603–1623
Clavenna A, Bonati M, Rossi E, Berti A, De Rosa M (2004) Il profilo prescrittivo della popolazione pediatrica italiana nelle cure primarie. Ric Prat 20:224–244
Istituto Nazionale di Statistica (2003) Rapporto annuale; la situazione del Paese nel 2002. Maggio
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Members of the SPES study group: Raffaele Arigliani, Guido Brusoni, Vincenzo Calia, Giampiero Chiamenti, Michele Gangemi, Stefano Del Torso, Milena Lo Giudice, Vitalia Murgia.
Appendix
Appendix
Paediatrician questionnaire variables
Paediatrician code:_ _ _
First three letters of patient’s name:_ _ _
First three letters of patient’s surname:_ _ _
Sex: ❑ M ❑ F
Age: _ _ _ years _ _ _ months (only if child is <1 year of age)
Date of consultation:_ _/_ _ /_ _ _ _
How long did the consultation last?
❑ Less than 15 min
❑ 15–30 min
❑ Over 30 min
Had this visit been scheduled for:
❑ Well child care consultation
❑ Vaccination for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
❑ Other
Main diagnosis:
❑ Acute otitis media
❑ Other upper respiratory tract infection
❑ Lower respiratory tract infection
❑ Gastroenteritis
❑ Other disorder of the gastrointestinal tract
❑ Asthma or other respiratory disease with bronchospasm
❑ Allergic disorders other than asthma
❑ Skin disorder
❑ Endocrinopathy
❑ Trauma/accident
❑ Blood disorder
❑ Insomnia or other sleep disorder
❑ Behaviour disorder
❑ Fever of unknown origin
❑ Other infectious or parasitic disease (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
❑ Non-classified signs/symptoms (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
❑ Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
❑ Follow-up visit (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Did the child have fever at the time of consultation?
❑ Yes
❑ No
❑ Don’t know
The main diagnosis was made on the basis of:
❑ Clinical features
❑ Clinical features plus laboratory findings and/or other exams
If the diagnosis was made solely on the basis of the clinical picture, were other tests requested to confirm the diagnosis?
❑ Yes
❑ No
If YES, which of the following were requested:
❑ Specialist consultation
❑ Follow-up examination
❑ Laboratory tests
❑ Other tests
Was the child seen by yourself or by a colleague in the last month for the same disorder?
❑ Yes
❑ No
❑ Don’t know
At the time of the visit was the child already taking any medicine/s for this disorder (including topical preparations, vitamins, homeopathic remedies, supplements or other non-conventional remedies)?
❑ Yes
❑ No
❑ Don’t know
If YES, specify commercial name/s_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
If YES, had the medications been:
❑ Prescribed by yourself
❑ Prescribed by another physician
❑ Recommended by a pharmacist
❑ Self-prescribed
❑ Don’t know
Were any medications prescribed during the consultation (including topical preparations, vitamins, homeopathic remedies, supplements or other non-conventional remedies)?
❑ Yes
❑ No
If YES, for each medicine indicate the commercial name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
With respect to the child’s current illness, the person accompanying the child was:
❑ Overly worried
❑ Justly worried
❑ Not adequately worried
In your opinion, how much did the person accompanying the child expect to receive a drug prescription?
❑ Very much
❑ Slightly
❑ Not at all
❑ Don’t know
In your opinion, how much, if at all, did the expectations of the person accompanying the child influence your choice of whether or not to prescribe a medicine?
❑ Very much
❑ Slightly
❑ Not at all
❑ Don’t know
Did the person accompanying the child suggest or explicitly ask you to prescribe a medicine/s?
❑ Yes
❑ No
Are you satisfied with the amount of time you allotted to the consultation?
❑ Yes, completely satisfied
❑ Sufficiently satisfied
❑ No, not satisfied
Parent questionnaire variables
Data regarding the child’s mother
Age (years): _ _ _
Nationality:
❑ Italian
❑ Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _
Educational level:
❑ Primary school (grades 1–5)
❑ Middle school (grades 6–8)
❑ High school (grades 9–13)
❑ University
Current work position:
❑ Does not work, stays at home
❑ Professional woman, manager, entrepreneur
❑ Office worker/teacher
❑ Skilled/unskilled worker/craftswoman
❑ Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _
Data regarding the child’s father
Age (years): _ _ _
Nationality:
❑ Italian
❑ Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _
Educational level:
❑ Primary school (grades 1–5)
❑ Middle school (grades 6–8)
❑ High school (grades 9–13)
❑ University
Current work position:
❑ Does not work, stays at home
❑ Professional man, manager, entrepreneur
❑ Office worker/teacher
❑ Skilled/unskilled worker/craftsman
❑ Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _
Data regarding the child
First three letters of child’s name: _ _ _
First three letters of child’s surname: _ _ _
Sex: ❑ M ❑ F
Date of birth: _ _/_ _ /_ _ _ _
Has the child any siblings?
❑ Yes
❑ No
If YES, how many?
❑ 1
❑ 2
❑ 3 or more
If YES, is the child a:
❑ First child
❑ Second child
❑ Third child or over
If the child is below 6 years of age indicate if he/she goes to day care or nursery school:
❑ Yes
❑ No
The person accompanying the child to the consultation is the child’s
❑ Mother
❑ Father
❑ Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _
Would you define your child’s clinical condition as being:
❑ Very worrisome
❑ Moderately worrisome
❑ Not worrisome
In your opinion, in order to resolve your child’s medical problem, a medicine is:
❑ Definitely necessary
❑ Probably necessary
❑ Probably not necessary
❑ Don’t know
To be completed only AFTER the medical examination:
In your opinion, the amount of time spent by the paediatrician for the consultation was:
❑ Good
❑ Sufficient
❑ Inadequate
Overall, are you satisfied with the consultation?
❑ Yes, very satisfied
❑ Yes, fairly satisfied
❑ No
Following the medical consultation, would you consider your child’s health status to be:
❑ Very worrisome
❑ Moderately worrisome
❑ Not worrisome
During the consultation did you ask the doctor to prescribe specific medicines for your child?
❑ Yes
❑ No
If YES, which medicine(s) did you request? _ _ _ _ _ _ _ _ _ _ _ _ _ _
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Ciofi degli Atti, M.L., Massari, M., Bella, A. et al. Clinical, social and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy. Eur J Clin Pharmacol 62, 1055–1064 (2006). https://doi.org/10.1007/s00228-006-0198-8
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DOI: https://doi.org/10.1007/s00228-006-0198-8