Public acceptance of delayed prescribing in UK primary care: a choice experiment
Antimicrobial resistance is recognised as a global threat to public health, and there is a need for improved stewardship of existing medicines. One approach to reducing antibiotic consumption in primary care is delayed (or ‘back-up’) prescription. The clinician prescribes antibiotics, but the patient is advised to delay initiating treatment. This has shown to be effective in reducing consumption without increasing complication rates. However, despite its inclusion in guidelines since 2008, this strategy is not widely used in the UK. Although the prescribing decision is made by the GP, the expectations of the patient may influence that decision. Our work aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help improve implementation of this prescribing option.
We conducted an online choice experiment in two UK general population samples: adults, and parents of children under 18. We used the example of a respiratory tract infection (RTI) - a common reason for GP consultations and a major contributor to antibiotic prescribing. Respondents were presented with twelve scenarios in which they, or their child, might need antibiotics for an RTI, and asked to choose either immediate or delayed prescription. Scenarios were described by seven attributes (including symptoms, duration, and the format of the delayed prescription), allowing exploration of trade-offs between them. Preferences were modelled using mixed-effects logistic regression.
The survey was completed by 802 adults and 801 parents. In the adult sample the probability of choosing delayed prescription was 0.53 (95% CI 0.50-0.56) for a chesty cough and runny nose, compared to 0.30 (0.28-0.33) for a chesty cough with fever, 0.47 (0.44-0.50) for sore throat with swollen glands and 0.37 (0.34-0.39) for sore throat, swollen glands and fever. Probabilities were similar for parents considering treatment for a child.The most important determinant of choice was symptom severity, especially for cough-related symptoms. Respondents were less likely to choose delayed prescription with increasing duration of illness, and if they had to return to the practice to pick up the prescription. Parents differed from the adult sample in giving higher weighting to the duration of illness. Females were more likely to choose a delayed prescription than males, and were particularly likely to do so for minor cough symptoms. Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently, showed similar patterns of preferences.
Delayed prescription appears to be acceptable to patients. Certain groups appear to be more amenable to delayed prescription, suggesting opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses.