An observational study of antibiotic prescribing behavior and the Hawthorne effect.

OBJECTIVES To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing. DATA SOURCES/SETTING (1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96-3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96-3/97) and one year after (10/97-3/98) the observational study period. Ten pediatricians in two community practices were studied. STUDY DESIGN Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study. DATA COLLECTION/EXTRACTION METHODS For the observational study (10/96-2/97), diagnosis and treatment choices were obtained from questionnaires completed by physicians immediately following the visit. For the nonstudy encounters (10/96-3/97 and 10/97-3/98), data were abstracted from medical records one year after the observational study was completed. PRINCIPAL FINDINGS The proportion of viral cases in which an antibiotic was prescribed was 29 percentage points lower for the observational study compared to the retrospective analysis (p < .05). In one of two study sites, the proportion of cases assigned a bacterial diagnosis was 29 percentage points lower in the observational study period compared to the retrospective study (p <.05). CONCLUSIONS Observational study procedures including questionnaires and audio recording can affect antibiotic prescribing behavior. Future observational studies aimed at examining the frequency of inappropriate antibiotic prescribing should measure and adjust for the Hawthorne effect; without such adjustments, the results will likely underestimate the true degree of the problem. Future interventions aimed at decreasing inappropriate antibiotic prescribing should consider "harnessing" the Hawthorne effect through performance feedback to participating physicians.

[1]  M. Ebell,et al.  Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. An UPRNet study. Upper Peninsula Research Network. , 2000, The Journal of family practice.

[2]  A D Oxman,et al.  Changing physician performance. A systematic review of the effect of continuing medical education strategies. , 1995, JAMA.

[3]  N. Le Saux,et al.  Antimicrobial use in febrile children diagnosed with respiratory tract illness in an emergency department. , 1999, The Pediatric infectious disease journal.

[4]  S. Grufferman.  Complexity and the Hawthorne effect in community trials. , 1999, Epidemiology.

[5]  D. Vinson,et al.  The effect of parental expectations on treatment of children with a cough: a report from ASPN. , 1993, The Journal of family practice.

[6]  H. Carabin,et al.  Effectiveness of a training program in reducing infections in toddlers attending day care centers. , 1999, Epidemiology.

[7]  R. Pill,et al.  Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats , 1998, BMJ.

[8]  D De Amici,et al.  Impact of the Hawthorne effect in a longitudinal clinical study: the case of anesthesia. , 2000, Controlled clinical trials.

[9]  M. Sheridan,et al.  Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners. , 1997, The Pediatric infectious disease journal.

[10]  W A Watson,et al.  Hawthorne effect: implications for prehospital research. , 1995, Annals of emergency medicine.

[11]  A. Mainous,et al.  Antibiotics for colds in children: who are the high prescribers? , 1998, Archives of pediatrics & adolescent medicine.

[12]  F. J. Roethlisberger,et al.  Management and the Worker , 1941 .

[13]  Lohr Kn,et al.  Quality of care in the New Mexico Medicaid program (1971-1975) : the effect of the New Mexico Experimental Medical Care Review Organization on the use of antibiotics for common infectious diseases: , 1980 .

[14]  T Timpka,et al.  In what way may videotapes be used to get significant information about the patient-physician relationship? , 1990, Medical teacher.

[15]  F. J. Roethlisberger,et al.  Management and the Worker , 2003 .

[16]  J. Knottnerus,et al.  Fitting a routine health-care activity into a randomized trial: an experiment possible without informed consent? , 1997, Journal of clinical epidemiology.

[17]  M. Kolczak,et al.  Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs. , 1999, Pediatrics.

[18]  P. Dick,et al.  Self-reported prescribing of antibiotics for children with undifferentiated acute respiratory tract infections with cough. , 1998, The Pediatric infectious disease journal.

[19]  R H Brook,et al.  The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior , 1999, Pediatrics.

[20]  J. Steiner,et al.  Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. , 1999, JAMA.

[21]  S. Dowell,et al.  Current Attitudes Regarding Use of Antimicrobial Agents: Results from Physicians' and Parents' Focus Group Discussions , 1998, Clinical pediatrics.