What Motivates Outpatient Providers to Write Unnecessary Prescriptions For Antibiotics?

Mike Kohut, PhD, qualitative researcher at the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine shares the results of his research that reveals providers are writing prescriptions for infections based largely on patient demand and not guideline recommendations.

Interview transcript (slightly modified for readability):

The interview itself was designed to help to evaluate the program and my main research questions were: ‘What are the forces that are driving prescribers to use unnecessary antibiotics?’ and ‘Is the program addressing those issues?’ Then there were other questions that were specifically asking, ‘How often are you prescribing unnecessary antibiotics?’ followed up with, ‘Why do you think that occurs?’”

“If you just asked them, what was causing the prescribing, the prescribers would say, ‘Well, it’s patient demand, it’s because the patients want them,’ but I wanted to follow up with that to see exactly what is it about that patient demand that forces the hand of these providers. To force the provider to abdicate the responsibility of prescribing over to the patients themselves.

After listening to those responses, there were a few themes that really emerged. One was patient satisfaction scores. In many cases, providers’ salaries are tied to their patient satisfaction scores, and so when they are looking through their scores at the end of the day and seeing that they were marked very low and they are seeing a comment, ‘I spent all this time waiting for an antibiotic and they wouldn’t give me one,’ that is something that the provider takes to heart, and that’s something that they worry about the next time that a patient wants an antibiotic.

Providers also talked about feeling obligated to patients. Patients would say, ‘I spent an hour waiting in the waiting room, I paid this huge copay, I took off work; all of this so that I could come here and get an antibiotic and you’re not giving me anything,’ In those cases, the provider felt guilty, and they felt like they needed to give something to this patient and oftentimes, that would be what they wanted—they would want those antibiotics.

The thing that surprised me the most was when providers would talk about feeling this need to give the patient something, and what they would do was sometimes prescribe them a Z-Pak, with the justification that, ‘antibiotic resistance has reached the point where this Z-Pak is ineffective anyway and so, I might as well give them a Z-Pak.’ That is interesting that in that case, antibiotics would be used as a placebo or just to satisfy the patient.”

The other thing that I noticed is that providers [would be worried that patients would be upset] and they would try to talk them out of [an antibiotic] and try to explain why they don’t really need antibiotics, but if the patient would not budge and they still continued to insist, they would talk about writing a prescription for the patient and saying, ‘I don’t recommend that you fill this, but it’s up to you.’ And [the provider] would say to me that was a weight off their conscience.

In that case, they were literally abdicating their responsibility as the prescriber to the patient.