Delayed prescriptions are a recommended strategy for people presenting with upper respiratory tract infections (URTI). It involves giving a prescription to a patient with instructions to use it if symptoms persist or worsen. It appears to have clinical benefit, a Cochrane review of 11 randomised controlled trials reported a reduction in rates of immediate prescriptions compared to delayed prescriptions (93% vs 32%) (Spurling et al, 2017). Yet, despite this evidence and recommendations from the National Institute for Health and Care Excellence (NICE) (2008) advocating their use, there appears to be reticence in the prescribing community to regularly issue them. This research roundup will explore some of the evidence about prescribers' perceptions of delayed prescriptions for people presenting to primary care with URTIs. A search of the literature yielded five articles; four qualitative studies and one quantitative survey. Three of the studies explored views of UK-based prescribers, two were from Scandanavia and one from Australia.
Delayed antibiotic prescription for upper respiratory tract infections in children under primary care: physicians' views
This study was based in Denmark where antibiotic prescribing is the lowest in Europe, it explored GPs' (n=574) perceptions of delayed prescribing for children with respiratory tract infections (Flintholm Raft et al, 2017). Almost half of the respondents were supportive of the practice; however, only 7% frequently issued delayed prescriptions. Free text comments suggested that while doctors acknowledge the role of the parent in assessing the child's condition, others felt that the decision to start antibiotics rested with doctors rather than parents. A concern was raised that, although some parents would watchfully wait, others may give the antibiotics in the belief it may expedite recovery. An interesting observation was that GPs felt that since changes in out-of-hours service delivery in Denmark, and adoption of a more nurse-led service, the threshold for issuing antibiotics had dropped. This study therefore suggests that delayed prescribing is a one that has some support, is used by only a small proportion of prescribers and may result in inappropriate use of antibiotics.
Using theory to explore facilitators and barriers to delayed prescribing in Australia
This Australian qualitative study explored doctors', pharmacists' and patients' (n=42) views of delayed prescriptions (Sargent et al, 2017). Findings suggested that, although participants were aware of delayed prescribing, they did not commonly use it. Most respondents stated they would never use delayed prescriptions. Those who did, used it for very specific patient groups; the ‘well educated and sensible’ as there were concerns over inappropriate antibiotic use and subsequent antimicrobial resistance. An issue was also raised by some that clinical deterioration may be missed should the patient not return for review if their condition worsened. Factors that influenced giving a delayed prescription included how well clinicians trusted the patient, and the opportunity to provide reassurance to patients that anticipatory plans were in place should their condition worsen.
Delayed prescribing for upper respiratory tract infections: a qualitative study of GPs' views and experiences
This Norwegian qualitative study, conducted five focus groups with 33 GPs who regularly reviewed people with respiratory tract symptoms (Høye et al, 2010). It reported that although most were supportive of the concept, others were hesitant, only using delayed prescriptions when the patient demanded antibiotics. Many GPs reported a lower threshold for giving delayed prescriptions on a Friday to mitigate patients attending out-of-hours care over the weekend. They also reported issuing a delayed prescription provided an opportunity to educate the patient indications for antibiotic use in the presence of worsening symptoms. Similar to Sargent et al (2017), they were selective about who they gave a delayed prescriptions to, offering to those who were ‘knowledgable’ and understood the indications for antibiotic use and would most commonly use it when a patient presented with acute sinusitis.
Understanding the delayed prescribing of antibiotics for respiratory tract infection in primary care: a qualitative analysis
This was a UK study that purposively sampled doctors (n=33) from high prescribing and low prescribing general practitioners. The aim was to establish the GPs' views of delayed prescriptions (Ryves et al, 2016). Semi-structured interviews were conducted and thematically analysed. Findings were in-depth and comprehensive and suggested there was a lower threshold to issue delayed prescriptions for antibiotics to children, due to more serious adverse events and parental concerns. Most participants were positive about the use of delayed prescriptions, but some were hesitant due to diagnostic uncertainty, preferring to review the patients should symptoms worsen. The day of the week appeared to also influence the issuing of a delayed prescription, with more being issued on a Friday, thus avoiding the need to attend out-of-hours care. This article also reported reassurance that a delayed prescription offered to the patient that they had been listened and that it helped to establish patient–practitioner trust. Nonetheless, similar to the studies above, the decision to issue a delayed prescription was dependent on how ‘trustworthy’ a patient was. An additional finding not reported in the studies above was the need for support and training to develop delayed prescription practice. This included a desire by respondents to know statistics on the prevalence of filled delayed prescriptions and approaches to support shared decision-making with the patient on decisions not to prescribe, rather than issuing delayed prescriptions.
Managing self-limiting respiratory tract infections: a qualitative study of the usefulness of the delayed prescribing strategy
The final article used a mixed methods qualitative approach of one-to-one and focus group interviews with GPs, trainee GP and nurse prescribers (n=43), to explore the use, benefits and barriers of delayed prescriptions (Peters et al, 2011). Respondents reported infrequent use of delayed prescriptions and reasons such as managing clinical uncertainty and acknowledging it as a safety net in case symptoms had been missed. However, rather than issuing delayed prescriptions, many reported arranging a follow-up consultation to verify the condition of the patient and whether the antibiotics had been used. GPs appeared to adopt a paternalistic attitude with findings suggesting that patients were not well enough informed to make a decision about whether to take antibiotics or not. An interesting finding was the difference in attitudes of nurse and medical prescribers. For example, a driver for not issuing a delayed prescription for nurses was the concern over inappropriate antibiotic prescribing, whereas medics were more likely to issue a prescription due to diagnostic uncertainty and to ensure that the patient–clinician relationship was maintained. A final theme from this study was the perception that issuing a delayed prescription may give the patient a ‘mixed message’ about whether there was a need for antibiotics. Moreover, nurse prescribers appeared to be more comfortable with not issuing a prescription and instead, educating the patient why antibiotics were not indicated.
‘Delayed prescriptions are a recommended strategy for people presenting with upper respiratory tract infections’
Conclusion
These studies suggest that globally, delayed prescriptions are not frequently used in general practice. Qualitative research suggests that factors influencing issuing a delayed prescription include how well the prescriber trusts the patient to appropriately use the delayed prescription and clinicians preferring to review the patient if their condition was to worsen. Delayed prescriptions appeared to be more frequently used in practical situations, such as to avoid presenting to out-of-hours with worsening symptoms. Only one study obtained the views of nurses and, given the interprofessional nature of prescribing in the UK, it may be beneficial to explore barriers and facilitators of delayed prescriptions in a wider interprofessional group. This may be of particular interest given the reported differences in attitudes of nurse and GP prescribers by Peters et al (2011).