Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns

Interventions to improve treatment of respiratory infections in ambulatory managed-care patients

OBJECTIVE

To review the literature on managed-care initiatives to improve antimicrobial use in respiratory tract infections (RTIs) and examine whether efforts were successful in decreasing antibiotic prescribing when an antibiotic was not indicated or in increasing the frequency with which a preferred antimicrobial agent was chosen when an antibiotic was appropriate.

DATA SOURCES

A computerized search of Ovid MEDLINE was conducted for research articles published between 1966 and September 2004 using a key word search of MeSH subject headings and titles. Search terms included managed care or health maintenance organization and antibacterial agents or antibiotic or antimicrobial.

STUDY SELECTION AND DATA EXTRACTION

Studies evaluating initiatives in ambulatory managed-care environments and the effects of managed care on treatment of RTIs were chosen. Articles addressing both population and individual level tools were included.

DATA SYNTHESIS

Initiatives have been attempted in a variety of managed-care models. In some studies, multidimensional educational interventions were effective in decreasing antimicrobial prescribing rates for RTIs. However, in other studies, no decrease in antimicrobial prescribing after implementation of an evidence-based guideline or initiation of an educational intervention was observed. In one successful study, patient satisfaction was similar between groups. Each study had limitations in design or generalizability. Several studies had strengths, including using randomized groups or offering multidimensional educational efforts.

CONCLUSIONS

Randomized prospective studies of interventions to improve antimicrobial prescribing for RTIs in managed care have been variably successful. Because the topic is one of ongoing importance, it will continue to be an area of research.

Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance

This study draws on a database of 570 community-based acute pediatric encounters in the USA and uses conversation analysis as a methodology to identify two formats physicians use to recommend non-antibiotic treatment in acute pediatric care (using a subset of 309 cases): recommendations for particular treatment (e.g., "I'm gonna give her some cough medicine.") and recommendations against particular treatment (e.g., "She doesn't need any antibiotics."). The findings are that the presentation of a specific affirmative recommendation for treatment is less likely to engender parent resistance to a non-antibiotic treatment recommendation than a recommendation against particular treatment even if the physician later offers a recommendation for particular treatment. It is suggested that physicians who provide a specific positive treatment recommendation followed by a negative recommendation are most likely to attain parent alignment and acceptance when recommending a non-antibiotic treatment for a viral upper respiratory illness.

Parent resistance to physicians' treatment recommendations: one resource for initiating a negotiation of the treatment decision

This article examines pediatrician-parent interaction in the context of acute pediatric encounters for children with upper respiratory infections. Parents and physicians orient to treatment recommendations as normatively requiring parent acceptance for physicians to close the activity. Through acceptance, withholding of acceptance, or active resistance, parents have resources with which to negotiate for a treatment outcome that is in line with their own wants. This article offers evidence that even in acute care, shared decision making not only occurs but, through normative constraints, is mandated for parents and physicians to reach accord in the treatment decision.