Do patients get the best deal when antibiotics are prescribed out of hours?

Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department

Objective: The aim of this study was to compare the 30-day emergency department (ED) return rate between patients given a Take Home Medication pack (THM) versus a standard paper prescription (SPP) prior to discharge. Methods: This was an observational, prospective cohort study in an urban, university-affiliated, level I trauma center. Patients were identified through daily pharmacy reports. Consecutive adult patients discharged from the ED with either a THM or equivalent SPP were included. For each patient, baseline characteristics including age, gender, primary care provider (PCP), primary language, ethnicity, marital status, and insurance status were recorded from the electronic medical record (EMR). Review of the EMR was used to determine whether patients returned to the ED within 30 days and whether the return visit was for all-causes or for the same complaint targeted by the THM or SPP from the index visit. Similarly, visits to other providers in the health system within 30 days were recorded. Results: A total of 711 patients were included in the study, with 268 receiving a THM and 443 receiving a SPP. In comparison with the SPP group, the THM group was more likely to have an all-cause return (Relative Risk [RR] = 1.7, P < .01). Variables associated with increased odds of returning to the ED within 30 days included study group (adjusted Odds Ratio [aOR]: 1.7), male gender (aOR: 1.6), African American ethnicity (aOR: 3.0), public insurance (aOR: 3.3), and institutional financial assistance (aOR: 5.0). The difference between study groups for index visit complaint-specific returns was not significant. Conclusions: Patients receiving a THM demonstrated a higher all-cause return rate than patients receiving a SPP. A randomized study is needed evaluating the effect of THM on return ED visits.

The role of evidence in the decline of antibiotic use for common respiratory infections in primary care

Antibiotic prescribing in primary care for common respiratory infections increased steadily until the mid 1990s, when the trend reversed noticeably. During the subsequent decade, antibiotic prescribing reduced by up to one-third in some countries. Explanations for this reduction have focused on a decline in the incidence and severity of common respiratory infections, and on the resulting decrease in the number of patients seeking consultation. We argue that evidence from primary-care research had a central role in changing the practice of antibiotic prescribing, and discuss the concern that has arisen among some physicians around this issue. Targeted reductions in antibiotic prescribing constitute a balancing act between individual and societal concerns, pitting the expected gains in preserving the usefulness of an antibiotic against any given reduction in use. There may be unintended consequences for decreasing antibiotic use beyond a certain point without adequate supporting evidence. A new approach to antibiotic prescribing requires comprehensive research to answer why change is necessary, and how that change can be safely implemented. Future policies must move beyond a "one size fits all" mindset if public and provider behaviours are expected to become more congruent with the growing research evidence.

Self-reported antibiotic compliance: Emergency department to general practitioner follow up

BACKGROUND

General practitioner (GP) follow up is important in the management of patients who are discharged from an ED.

OBJECTIVES

To determine the antibiotic compliance and GP follow-up compliance rates in a population of patients seen and discharged from the ED with an antibiotic prescription. To test the hypothesis that the ability to nominate a GP is associated with improved antibiotic and GP follow-up compliance.

DESIGN

A prospective cohort study enrolling consecutive adults who were discharged from the ED with antibiotic prescriptions over a 3 month period. Patients were divided into those who nominated a GP at the time of ED presentation and those who did not. Two weeks after enrollment, patients were contacted and asked standardized questions regarding compliance.

RESULTS

In total, 123 patients were enrolled into the study. Of patients 76% were able to nominate a GP upon ED presentation. Analysis revealed that those patients who were able to nominate a GP had better compliance to follow up instructions (85 vs 44%, P < 0.01) and improved antibiotic compliance (99 vs 88%, P = 0.01).

CONCLUSION

The majority of patients who were seen and discharged from the ED with an antibiotic prescription were able to nominate a GP and this was associated with improved follow-up compliance and antibiotic compliance. Improving follow-up compliance and thus the quality of patient care would involve identifying those patients who present to the ED who are unable to nominate a GP.

The effect of ED prescription dispensing on patient compliance

The objective of this study was to evaluate whether dispensing prescriptions in the ED affects patient compliance and return visits to the hospital. Seventy-four patients who were deemed suitable candidates for outpatient therapy with a macrolide antibiotic were identified and prospectively randomized to receive either an entire course of azithromycin from the ED or a prescription for azithromycin to be filled at a local pharmacy free of charge. Pharmacy records and telephone interview were used to measure compliance with patients. Significantly fewer patients filled their prescription in the pharmacy group (74.2%) compared with the ED group, in which all patients received their medication. However, there was no difference in the self-reported compliance of completing the entire course of antibiotics between patients in the ED group (94.3%) and in the pharmacy group (96.8%). There was no significant difference between groups in return ED visits or hospital admissions. We conclude that delivery of prescriptions in the ED significantly increases the likelihood that the patient will obtain the medication prescribed. Whether the patients actually take the medication as directed is unknown. Patient's self-report did not accurately reflect true compliance and more objective means for measuring compliance is warranted.

Discharge planning in A & E: part 2

Discharge of patients from A & E was considered by both the 1992 and 1996 Audit Commission reports. The 1992 Commission recommended that unnecessary return attendance for follow-up care should be reduced to a minimum, those requiring to make a return visit falling within the range of 10-15% of first attendances. Other hospital specialties, GP services and self care were identified as appropriate follow-up treatment. This places more emphasis on appropriate discharge advice for those who do not need to reattend, and this is an aspect of health promotion which largely goes unrecognized. The second part of this study explores how effectively A & E departments perform the role of giving appropriate discharge advice. Part I of the study, published in October 1997, covered the comprehensive discharge planning required for patients who belong to vulnerable groups and who commonly reattend.