title: Influence of patient symptoms and physical findings on general practitioners' treatment of respiratory tract infections: a direct observation study.
abstract: BACKGROUND
  The high rate of antibiotic prescriptions general practitioners (GPs) make for respiratory tract infections (RTI) are often explained by non-medical reasons e.g. an effort to meet patient expectations. Additionally, it is known that GPs to some extent believe in the necessity of antibiotic treatment in patients with assumed bacterial infections and therefore attempt to distinguish between viral and bacterial infections by history taking and physical examination. The influence of patient complaints and physical examination findings on GPs' prescribing behaviour was mostly investigated by indirect methods such as questionnaires.
  
  
  METHODS
  Direct, structured observation during a winter "cough an cold period" in 30 (single handed) general practices. All 273 patients with symptoms of RTI (age above 14, median 37 years, 51% female) were included.
  
  
  RESULTS
  The most frequent diagnoses were 'uncomplicated upper RTI/common cold' (43%) followed by 'bronchitis' (26%). On average, 1.8 (95%-confidence interval (CI): 1.7-2.0) medicines per patient were prescribed (cough-and-cold preparations in 88% of the patients, antibiotics in 49%). Medical predictors of antibiotic prescribing were pathological findings in physical examination such as coated tonsils (odds ratio (OR) 15.4, 95%-CI: 3.6-66.2) and unspecific symptoms like fatigue (OR 3.1, 95%-CI 1.4-6.7), fever (OR 2.2, 95%-CI: 1.1-4.5) and yellow sputum (OR 2.1, 95%-CI: 1.1-4.1). Analysed predictors explained 70% of the variance of antibiotic prescribing (R2 = 0,696). Efforts to reduce antibiotic prescribing, e.g. recommendations for self-medication, counselling on home remedies or delayed antibiotic prescribing were rare.
  
  
  CONCLUSIONS
  Patient complaints and pathological results in physical examination were strong predictors of antibiotic prescribing. Efforts to reduce antibiotic prescribing should account for GPs' beliefs in those (non evidence based) predictors. The method of direct observation was shown to be accepted both by patients and GPs and offered detailed insights into the GP-patient-interaction.
authors.affiliation: Department of General Practice, Georg-August-University, Goettingen, Germany. tfische@gwdg.de
authors.forename: Thomas
authors.initials: T
authors.lastname: Fischer
authors.forename: Susanne
authors.initials: S
authors.lastname: Fischer
authors.forename: Michael M
authors.initials: MM
authors.lastname: Kochen
authors.forename: Eva
authors.initials: E
authors.lastname: Hummers-Pradier
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D003139:Common Cold / Q000188:drug therapy / Q000503:physiopathology; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005194:Family Practice / Q000706:statistics & numerical data*; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D004366:Nonprescription Drugs / Q000627:therapeutic use; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012141:Respiratory Tract Infections / Q000145:classification / Q000188:drug therapy* / Q000503:physiopathology; D012651:Self Medication / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires
chemical_list: D000900:Anti-Bacterial Agents; D004366:Nonprescription Drugs