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Running head: PROVIDER AWARENESS

Provider Awareness of the Patient Demand for Antibiotics


Antoinette M. Gamon
SUNY Polytechnic Institute
NUR 560

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ABSTRACT
Review of literature has suggested a strong connection between provider antimicrobial
prescribing patterns due to patient demand and antimicrobial overprescribing. The purpose of
this research is to investigate whether a patients desire for antibiotics and the providers
awareness of these expectations contribute to inappropriate antibiotic prescribing. A descriptive
correlation study design will be used with pre and post-test questionnaires among 10 providers
and 100 patients during a 3 month period. The setting will be based upon 4 private practices in
different geographical locations. Using a bivariate correlational analysis the results will identify a
positive or negative linear relationship regarding patient expectations, provider perception of
patient expectations and antimicrobial prescribing behavior. The results will be made available
for healthcare professionals and patients to assist in making educated decisions on whether
antibiotics are truly necessary.
BACKGROUND AND SIGNIFICANCE
Within the last decade, a movement towards patient centered care has induced a strong
effect on providers prescribing habits and philosophy. Due to a patient centered approach,
patients now appreciate strong communication with their provider and are involved in the
decision making regarding their care. A study addressing patient perceptions of patient
centeredness suggested patients who experience this approach were more likely to feel satisfied
regarding the care that was provided (Little et al, 2001). However, despite the benefits of a
strong relationship with the provider, this approach to medicine along with the general rise in
consumerism, may have unintentionally contributed to an increase in patient demand. Multiple
studies suggest the expectations and demands of patients have created a barrier in medicine and a
cause of irrational prescribing (Toska et al, 2015). Studies have shown that when a provider

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perceives a patient expectation for antibiotic treatment, they are more likely to inappropriately
prescribe antibiotics (Boxx, 2015). The irrational use of antibiotics is one of the most important
factors contributing to the development of antibiotic resistance and both providers and patients
should be aware of the public health implications of frequent antimicrobial use (Edgar et al,
2009). Antimicrobial resistance is a serious and extremely costly public health problem worldwide leading to treatment failure, morbidity and mortality. According to the CDC, healthcareassociated infections cost U.S. hospitals between $28.4 and $33.8 billion annually. Infectioncontrol initiatives could save up to $31.5 billion (Scott, 2009).
STATEMENT OF THE PROBLEM
The findings of multiple studies identify that patient pressure and demand appears to be
an important influence on the decision of whether or not to prescribe antibiotics. However, there
were few studies on why patients are so inclined to want an antibiotic. Understanding the
influence of patient expectations and actual requests for antibiotics and provider
acknowledgement of these are important in addressing irrational antibiotic prescribing. The
purpose of this research is to investigate whether a patients desire for antibiotics and the
providers awareness of these expectations contribute to inappropriate antibiotic prescribing.
REVIEW OF RELEVANT LITERATURE
According to the CDC approximately 10 million courses of antibiotics are prescribed by
general practitioners and approximately half of those are unnecessary. There is a rich body of
literature encompassing both theoretical modeling and empirical evidence which demonstrates a
wide practice of inappropriate antimicrobial prescribing not only in the US but other countries as
well. A study performed in a primary care setting in the United States identified that up to 75%
of adults with upper respiratory tract infections received antibiotics when only 20% actually

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required antimicrobial therapy due to high patient expectation (Britten, 1997). Smith et al (2014)
reported similar results indicating that 80% of bronchitis visits are treated with antibiotics due to
avoidance of patient dissatisfaction, although studies show they do not shorten the duration of
the illness. Toska et al (2015) assessed irrational prescribing in Greek pediatric hospitals and
67% of nurses found antimicrobials were prescribed due to patient and parent satisfaction. A
2013 study in Croatia noted that antibiotics were unnecessarily prescribed for tonsillopharyngitis
in 49.6% of the patients due to fear of patient dissatisfaction (Botica et al, 2013).
Multiple factors contribute to antibiotic resistance; however the majority of research is
linked to inappropriate prescribing, patient demand, and diagnostic uncertainty. External pressure
and patient demand is often imposed on providers as people have grown accustomed to feeling
entitled or may be dissatisfied leaving the office without a prescription of antibiotics (Oxford et
al, 2013). Patients also express the desire for a quick fix and fear of dissatisfaction leads to an
increased amount of unnecessary antibiotic prescriptions (Rodrigues et al, 2013). Fear of
diagnostic error, time constrains and a safety first approach in prescribing to prevent missing a
bacterial infection has also lead to inappropriate prescribing. Toska et al (2015) report that 56%
of registered nurses working along doctors believed uncertainty is the main cause of irrational
prescribing. Due to such short focused visits detailed explanations to patients as to why
prescribing antibiotics can be inappropriate has proven to be difficult for many providers since
they want to maintain a good relationship with their patients.
Lewin (1951) created a Three Step Change model that involves an arrangement of
organizational processes that occur over time. His theory suggests this process typically requires
three steps: unfreezing, moving, and refreezing. Unfreezing involves introducing new
information that points out flaws in the current situation and allowing letting go of an old pattern.

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Moving involves a process of change in thoughts, feeling, and behavior. Finally Refreezing
establishes the change of a new habit to become a standard (Lewin, 1951). The goals of this
model can be used to change the status quo regarding a patients comfort in requesting antibiotics
and to educate proper techniques to reduce overprescribing of antibiotics.
The strengths of the studies provided important insight into the provider prescribing
behaviors when faced with patient demands. The studies addressing the over prescription of
antibiotics defined the problems well, along with providing clear statistical evidence which
allowed for an objective perspective of the problem. However, the majority of studies were
heavily focused on the pediatric population followed by general family practice. Weaknesses of
the studies lacked reasoning behind why patients felt antibiotics needed to be prescribed. No
studies identify areas for changing or improving the antimicrobial prescribing patterns. Also
there was limited data regarding the experience level of the prescribers who were feeling
pressured to prescribe antibiotics. It would have been interesting to know if these providers were
new and felt uncomfortable saying no to patients or if the providers were seasoned and more
focused on patient satisfaction.
RESEARCH QUESTION
The research question for this proposal was: Do patient expectations of receiving
antibiotics and provider awareness of these expectations affect inappropriate antimicrobial
prescribing? Patient expectation can be theoretically defined as: Expectations, with reference to
healthcare, refer to the anticipation or the belief about what is to be encountered in a consultation
or in the healthcare system. It is the mental picture that patients or the public will have of the
process of interaction with the system (Lateef, 2011). Patient expectations were operationally
defined by the 5 point Likert scale. Theoretical definition of inappropriate antimicrobial

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prescribing is defined as prescribing antibiotics given for a viral infection. Operational definition
of inappropriate antimicrobial prescribing was defined by the Likert scale.
METHODS AND PROCEDURES
Research Design
A descriptive correlational study design will be used to examine the relationship between
patient expectations of receiving antibiotics and inappropriate antibiotic prescribing. Also the
relationship between provider awareness of patient expectations and inappropriate antibiotic
prescribing will be examined.
Setting
Two upstate New York private family practice offices will be chosen at a community
level. One practice will be located in an urban setting while the other practice will be located in a
rural setting. The goal is to attain an ethnically and geographically diverse population and
location for a broader sample.
Sample & Ethical Considerations
10 providers and 100 patients from the ages of 18-65 years during a 3 month period will
be used and chosen over a strict random selection. Initial interview data will be collected over
30 minutes and 10 patients will be seen per day by the researcher. The data will be then digitized
to a centralized data base. Patients will be screened for eligibility in the waiting room of the
private practices and will be asked to participate in the study if they meet a certain criteria. The
participants cannot be related to any family member or have any relationship to the other
participants to prevent a conflict of interest. Patients have to be able to read, speak English, be
of ages 18-65 years and present with a complaint of cough, congestion, or sinus pressure. A
proposal for research involving human subjects identifying the research intended the objectives,

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subjects, population, potential risks and measurements to take in protecting the subjects along
with the procedures and consent will be sent for review at SUNY POLY. IRB approval must be
obtained and consented from SUNY POLY regarding the methods being used. Patients will be
approached by the researcher and an oral explanation along with a written explanation will be
provided addressing the expectation of antibiotics. Confidentiality will be ensured if participating
in this study. After consent is obtained, then a questionnaire will be provided. Also when consent
is obtained from the providers, they will be asked to complete a post visit questionnaire
immediately after seeing the patient.
Measurements & Data Collection
To assess for reliability of the questionnaires, running a pilot test with a small set of
participants from the target population prior to the study may help in addressing the consistency
of the questionnaire. These participants will not be involved in the study otherwise. After
assessing the reliability, patients will be given a pre-visit questionnaire that includes questions
about their demographics, sex, age, education level, expectation of provider to prescribe
antibiotics and if they will ask for an antibiotic. A post visit questionnaire will also be
administered to patients after the visit addressing if their expectations were fulfilled, if they
received an antibiotic, and level of satisfaction of the visit. The provider will be given a post visit
questionnaire immediately after seeing the patient that will collect information of physical exam
findings supporting antibiotics, if antibiotics were prescribed, if the patient asked for antibiotics
and whether the doctor felt pressured to write an antibiotic prescription. The patients will be
asked to answer the antibiotic questions based on the 5 point Likert type scale. This scale will
determine the opinion of the subject and contains a number of declarative statements with a scale
after each statement. For example a question will ask Based on your symptoms do you think an

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antibiotic is necessary? Completely necessary (5) Somewhat necessary (4) Not sure (3)
Somewhat unnecessary (2) Unnecessary (1). Using the 5 point Likert type scale again for the
physician questionnaire will include questions such as The patient expected antibiotics to be
prescribed. Strongly agree (5) Agree (4) Not sure (3) Disagree (2) Strongly Disagree (1).
Data Analysis
A bivariate correlational analysis will be used. The variables on the x axis will be patient
expectation of antibiotics. The y axis will be if the antibiotic was inappropriately prescribed.
Another test will be the x axis provider perception of the patient expectations and y axis of
antibiotic inappropriately prescribed. Using this analysis will provide an accurate demonstration
of the linear relationship between these variables. It will be interesting to see if there is a positive
or negative linear relationship between patient expectation of antibiotics and inappropriate
antimicrobial prescribing. It will also be helpful in identifying a positive or negative linear
relationship regarding provider perception of patient expectations and antimicrobial prescribing
behavior.
Limitations
Possible limitations for this study in regards to the statistical tools used is assuming the
sample is representative of a much larger population and may not capture the full dynamic of the
variables. Ways to fix this could be sampling different locations. Other limitations could be in
regards to the providers. How conservative or lenient is the provider in prescribing antibiotics?
Also certain providers are more willing to prescribe antibiotics based on the familiarity of the
patient. Providers may have also been more cautious in prescribing antibiotics due to evaluation
apprehension. Possibly gathering information prior to the study on the amount of antibiotics that
were prescribed based on similar chief complaints of patients could have been a good indicator

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to how different the numbers were prior to the study vs during the study. There are not a lot of
supporting theories behind this type of research that could have improved the study. The change
management theory could help in slowly changing the views of patients regarding antibiotics and
the long term effects of antimicrobial overuse.
DISSEMINATION OF FINDINGS
The target audience for this completed research would benefit both patients and
providers. It would be important to make patients aware of the risks of overprescribing
antibiotics. Although a large part of the healthcare industry is based upon patient satisfaction,
using this study to reiterate the importance of providers using their scientific knowledge first in
making clinical judgements before trying to please the patient should be reinforced. A large
amount of evidence showed that patients were looking for strong communication with their
provider pertaining to their diagnosis (Lateef, 2011). I believe a simple discussion with
providers and patients would be beneficial. Using the evidence from the study to support the
facts will provide a convincing argument. If this was to include a peer reviewed option it would
be an honor to be included in the American Nurses Association. As a provider it is important to
maintain patient satisfaction and have a strong relationship with your patients but many studies
suggest that attempting to satisfy patients can contribute to antimicrobial resistance.

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