LOS ANGELES Until recently, pediatricians readily prescribed antibiotics to children with inner ear infections. But with increasing bacterial resistance to infections like otitis media (OM), doctors in private practice as well as managed care are re-evaluating their prescribing practices.
In many situations, when a pediatrician is faced with whether or not to prescribe antibiotics for OM, it can be difficult to tell if the child is the minority requiring antibiotics or the majority needing no medication at all. Surprisingly, what almost always decides the issue for the pediatrician is not their diagnosis, but rather the parents intervention.
"[The parents] influence appears to be the primary reason for antibiotic overuse," said S. Michael Marcy, MD, of the University of Southern California Hospital and Kaiser Permanente Hospital in Los Angeles. "They have these expectations, or rather misconceptions, [about antibiotics] that we in the medical community have created. Parents dont want to send their children out into the world without some form of protection it can really frighten them."
But are the pressures on managed health care doctors to prescribe antibiotics for OM greater than on the pediatricians in private care? Peoples pre-conceived ideas are that private care pediatricians have all the time in the world to diagnose and will do exactly what they think is right without any outside pressure from parents, while the managed care pediatrician has a gun to his head to see patients every five minutes because his practice depends on insurance instead of out-of-pocket payments. The reality is that both areas are equally intense, said Marcy.
"There is a concern [among pediatricians] about economic loss that, well, if you dont give me what I want, Ill just go someplace else and pay them," said Marcy. "Litigation can also factor into a doctors prescribing habits because if the ear infection is not treated and the child contracts meningitis, the doctor could be held responsible. So, there is no question that pressures exist on physicians to be more productive."
But not all the worlds parents feel the need to demand antibiotics every time their child wakes up with a fever. In much of Europe, when children come in with an earache they are usually prescribed a pain medication because pediatricians are aware that the most infections get better without treatment. But expectations are far different in this country, where parents expect an antibiotic prescription.
Two focus groups conducted by researchers at the Centers for Disease Control and Prevention (CDC) also confirmed the problem of parental pressure. All the parental participants acknowledged that they overused prescription antibiotics. But the CDC researchers found that 90% of the parents interviewed said they would be satisfied with not getting antibiotics if the doctor or pediatrician simply took the time to explain why.
"We found a significant association between doctor and patient communication and the frequency of antibiotic prescribing," said Benjamin Schwartz, MD, chief of the Childhood and Respiratory Diseases Branch of the National Center for Infectious Disease at the CDC. "A lot of doctors told us they just did not have the time to go into detail with patients about other options. We have to remember that antibiotics are successful in treating only bacterial infections and not viral infections so sometimes its better not to treat at all."
There appears to be a real discrepancy between what the pediatrician believes is right for the child and what most parents want from the pediatrician. These problems are magnified when put into the context of managed health care settings, said Schwartz. Many organizations tend to judge pediatricians and tie their salaries to patient satisfaction. Sometimes, these pressures cause them to prescribe right away, which is neither the best medicine nor very cost-effective in the long or short term, Schwartz said.
"Many managed care doctors feel the patients expect antibiotics, so they prescribe them to keep them happy," he said. "But in some cases, parents only want their concerns addressed, which doesnt necessarily include having a prescription thrown at them. More diagnosing and less prescribing is the answer."
However, unlike their private care counterparts, managed care physicians can be at the mercy of patient evaluations and patient overloads. There is a concern among many in managed care that if they do not give patients what they expect (namely antibiotics) they will rate poorly. The pressure also increases when pediatricians are asked to see more patients in shorter periods.
It can be a Catch-22 for managed care pediatricians in the sense that giving good care may irritate the very people they want to help. But on the other hand, excessive antibiotic use leads to excessive return visits because resistance to the drugs causes therapeutic failure, said Marcy.
"Most physicians and pediatricians in managed care dont want to lose their jobs over not giving the patient what they want," he said. "But those doctors in managed health and private practice know what to do [when treating OM], but for one reason or another just dont do it. There not only has to be an education of the patient but of the pediatricians as well if we dont want to be overwhelmed by antimicrobial resistance in the not-too-distant future."
Editors note: At last November's Annual Infectious Diseases In Children Symposium in New York, we asked for a show of hands on who was treating otitis less frequently and for shorter periods. Among the 600 or so physicians in attendance, the show of hands was impressive. P. Brunell
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