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Patient presentation and physician management of upper respiratory tract infections: a retrospective review of over 5 million primary clinic consultations in Hong Kong

Patient presentation and physician management of upper respiratory tract infections: a... Background: Upper respiratory tract infection (URTI) has a significant healthcare burden worldwide. Considerable resources are consumed through health care consultations and prescribed treatment, despite evidence for little or no effect on recovery. Patterns of consultations and care including use of symptomatic medications and antibiotics for upper respiratory tract infections are poorly described. Methods: We performed a retrospective review of computerized clinical data on patients presenting to all public primary care clinics in Hong Kong with symptoms of respiratory tract infections. International Classification of Primary care (ICPC)codes used to identify patients included otitis media (H71), streptococcal pharyngitis (R72), acute URTI (R74), acute sinusitis (R75), acute tonsillitis (R76), acute laryngitis (R77), and influenza (R80). Sociodemographic variables such as gender, age, chronic illness status, attendance date, type and duration of drug prescribed were also collected. Results: Of the 5,529,755 primary care consultations for respiratory symptoms from 2005 to 2010, 98% resulted in a prescription. Prescription patterns of symptomatic medication were largely similar across the 5 years. In 2010 the mean number of drugs prescribed per consultation was 3.2, of which the commonly prescribed medication were sedating antihistamines (79.9%), analgesia (58.9%), throat lozenges (40.4%) and expectorant cough syrup (33.8%). During the study period, there was an overall decline in antibiotic prescription (8.1% to 5.1%). However, in consultations where the given diagnosis was otitis media (H71), streptococcal pharyngitis (R72), acute sinusitis (R75) or acute laryngitis (R76), over 90% resulted in antibiotic prescription. Conclusion: There was a decline in overall antibiotic prescription over the study period. However, the use of antibiotics was high in some conditions e.g. otitis media and acute laryngitis a. Multiple symptomatic medications were given for upper respiratory tract infections. Further research is needed to develop clinical and patients directed interventions to reduce the number of prescriptions of symptomatic medications and antibiotics that could reduce costs for health care services and iatrogenic risk to patients. Keywords: Upper respiratory tract infection, Primary care, Pharmacology * Correspondence: carmenwong@cuhk.edu.hk Division of Family Medicine, School of Public Health & Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong Jockey School of Public Health, Prince of Wales Hospital, Room 408, 32 Ngan Shing Street, Shatin, NT, Hong Kong Full list of author information is available at the end of the article © 2014 Kung et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kung et al. BMC Family Practice 2014, 15:95 Page 2 of 7 http://www.biomedcentral.com/1471-2296/15/95 Background  R77 – acute laryngitis Respiratory infections are the commonest health problem  R80 – influenza encountered in primary care worldwide [1-3], amounting to between 16% to over 60% of attendances depending on There are 74 PPCCs in Hong Kong covering the entire locality [4,5]. Upper respiratory tract infection (URTI) is population 7 million, with over 5 million attendances an- an important cause of reduced activity days, school and nually [17]. Consultations fees are subsidized for per- work loss, impaired school performance, and increased manent residents (patient pays USD5.8 per consultation, healthcare utilization [6], resulting in substantial economic inclusive of medications and investigations), while spe- burden. cific populations (government workers and those on fi- There is little data on actual prescribing practice for nancial assistance) receive free consultations. Existing URTI in Asia. Evidence shows that symptomatic medi- literature suggests that less than 100,000 attendances are cations including antibiotics are of marginal or no bene- made to local emergency departments for non-urgent fit [7-13]. However, there are widespread variations in respiratory tract infections annually [18,19], while 26% URTI management. A telephone survey of Auckland of private sector consultations (accounting for 50% of GPs found that 95% would, on occasions, prescribe as- Hong Kong’s primary care) are related to respiratory tract needed medications (instructions for patient to fill pre- infections [1]. scriptions if condition worsens), including antibiotics Data on gender, age, chronic illness status, attendance [14]. In a European study, the number of medication date, type and duration of drug prescribed for URTI were types per patient varied from 0.82 to 3.55 per patient extracted from the system-wide electronic record system per year [15]. Interestingly, the antibiotic prescription (Clinical Data Analysis & Reporting System [CDARS]). rate in this European study did not vary with the overall There is no information from CDARS for patients’ medication prescription rate. A study in Zimbabwe financial status; nevertheless, those requiring financial highlighted widespread non-evidence based prescribing assistance from the government can be identified separ- for URTI patients [16]. The actual prescribing practice ately from those paying the usual fee. Previous publica- among Chinese primary care physicians for URTI symp- tions using CDARS have demonstrated the accuracy and toms has not previously been investigated, although an- completeness of the data retrieved from this system [20]. ecdotal observations show that medications for We defined a repeat attendance for the same URTI symptomatic relief are commonly used. Understanding episode (which we considered as the same illness epi- the characteristics of patients who consult with URTI sode) as any attendances for URTI symptoms within symptoms and the prescribing practices of primary care 28 days of the previous URTI attendance. Medications clinicians could identify opportunities for intervention were grouped into specific drug classes, including anal- such as reducing unnecessary prescriptions of antibiotic gesia, antibiotics, antihistamines, cough syrup, mucolytic, and symptomatic medication and reallocating resources s α-agonists, β-agonists, theophylline and other including for other medical conditions in primary care such as throat lozenges, lysozyme. chronic disease management. All statistical analysis was performed using SPSS ver- We therefore reviewed the characteristics of patients sion 18.0 for Windows. Descriptive statistics were cal- attendingHongKong’s public primary care clinics (PPCCs) culated using mean and range. Chi-square test was used with URTI symptoms, and the types of medications clini- to compare categorical variables across the different cians prescribed for URTI symptoms. years. All p values <0.05 were regarded as statistically significant. Methods This study was approved by the Clinical Research Ethics We performed a retrospective review of computerized Committee of the Chinese University of Hong Kong and clinical data on patients presenting to PPCCs with upper New Territories East Cluster of the Hospital Authority. st respiratory tract symptoms between 1 January 2005 and st 31 December 2010. Upper respiratory tract symptoms Results were defined by specific ICPC (International Classification There were 5,529,755 attendances for RTIs from 2005 to of Primary Care) codes agreed upon by an expert panel of 2010. Patient demographics and the conditions diagnosed local primary care physicians including: are summarized in Table 1. H71 – otitis media Patient presentation R72 – streptococcal pharyngitis There were 5,529,755 consultations for URTI symptoms R74 – acute upper respiratory tract infection in the study period for the patient population of R75 – acute sinusitis 1,181,816 [21]. The distribution of annual attendances R76 – acute tonsillitis was similar across the six years with the majority Kung et al. BMC Family Practice 2014, 15:95 Page 3 of 7 http://www.biomedcentral.com/1471-2296/15/95 Table 1 Patient demographics and diagnosed conditions Year of attendance 2005 2006 2007 2008 2009 2010 Annual attendance for all 997768 937686 923504 966739 813874 895978 respiratory infections Distribution of annual attendances number (number of patients) 1 attendance 59.9% (319154) 59.7% (296239) 57.5% (269327) 56.7% (274308) 59.4% (253995) 57.8% (264110) 2-4 attendances 34.2% (181992) 34.0% (168824) 35.3% (165316) 35.9% (173343) 34.3% (146461) 35.3% (161307) 5-8 attendances 4.9% (26157) 5.2% (25765) 5.8% (27347) 6.1% (29305) 5.2% (22411) 5.8% (26308) >8 attendances 1.0% (5495) 1.1% (5359) 1.3% (6034) 1.3% (6517) 1.1% (4735) 1.2% (5549) Patient headcount 532798 496187 468024 483473 427602 457274 Mean attendance per patient per year 1.9 1.93 2.0 2.0 1.9 2.0 Mean age (years) 41.1 41.2 42.9 43.8 44.3 45.6 Gender Female 56.4% 56.1% 56.9% 57.0% 56.4% 57.0% On government subsidy 20.7% 20.4% 19.5% 21.0% 21.4% 21.0% Chronic illness Ischaemic heart disease 1.6% (8440) 1.5% (7578) 1.5% (7219) 1.6% (7594) 1.5% (6324) 1.5% (6729) Hypertension 22.8% (121304) 21.8% (108344) 23.2% (108397) 23.9% (115461) 23.9% (102066) 24.0% (109558) Stroke 1.6% (8290) 1.4% (7191) 1.5% (7151) 1.6% (7580) 1.4% (6128) 1.4% (6392) Prostatism 2.6% (13905) 2.7% (13160) 2.8% (13219) 2.9% (14072) 2.9% (12610) 2.9% (13374) Asthma 2.9% (15264) 3.0% (14904) 3.2% (14866) 3.1% (15146) 3.2% (13563) 2.9% (13358) COPD 1.5% (7797) 1.4% (7191) 1.4% (6679) 1.3% (6458) 1.3% (5595) 1.1% (5197) Coded conditions H71 (otitis media) 0.29% 0.34% 0.31% 0.33% 0.33% 0.33% R72 (streptococcal 0.02% 0.03% 0.02% 0.03% 0.04% 0.04% pharyngitis) 97.35% 96.99% 97.07% 96.30% 95.42% 94.25% R74 (acute URTI) 0.15% 0.17% 0.20% 0.21% 0.26% 0.25% R75 (acute sinusitis) 0.49% 0.53% 0.44% 0.67% 0.88% 1.02% R76 (acute tonsillitis) 0.04% 0.04% 0.03% 0.03% 0.04% 0.07% R77 (acute laryngitis) 0.26% 0.33% 0.29% 0.27% 0.69% 0.97% R80 (influenza) (approx 60%) of patients presenting once for symptoms Prescription of medication of upper respiratory tract infections. Over a third of the Of the 5,529,755 primary care consultations for URTI patients (approximately 35%) attended 2-4 times per symptoms from 2005 to 2010, 98% resulted in a pre- year. There was a 16% drop in attendances in 2009. scription of at least one medication (Table 2). Prescrip- Overall, there was a significant increase (p < 0.001) in tion patterns of symptomatic medication were largely the mean number of annual attendances per patient. similar across the 5 years, but there was a small but The mean age of presentation shows a steady increase significant rise in the number of drugs given per con- from 41.1 to 45.6 years from 2005 -2010. Patients were sultation (p < 0.001). The most commonly prescribed more likely to be female (approx 57%) and on average medications were sedating antihistamines (79.9%), anal- one fifth of those presenting were on government sub- gesia (58.9%), throat lozenges (40.4%) and expectorant sidy. Over 94% were coded as upper respiratory tract in- cough syrup (33.8%). During the study period, there was fection (R74). Over the 6 years, there was a significant a significant decline in antibiotic prescription from 8.1% increase (p < 0.001) in the number of patients coded with to 5.1% (p < 0.001). However, in consultations, where non-R74 conditions. the given diagnosis was otitis media (H71), streptococcal Kung et al. BMC Family Practice 2014, 15:95 Page 4 of 7 http://www.biomedcentral.com/1471-2296/15/95 Table 2 Details on drugs prescribed Year of attendance 2005 2006 2007 2008 2009 2010 Mean number of drugs 3.1 3.1 3.2 3.2 3.2 3.2 Number of drug items per prescription 0 2.7% 2.7% 2.3% 1.3% 1.3% 1.1% 1 5.7% 5.5% 5.1% 5.1% 5.5% 5.0% 2 21.2% 20.4% 19.6% 19.7% 19.8% 18.3% 3 34.6% 33.8% 33.3% 33.0% 32.4% 32.1% 4 27.8% 28.5% 29.7% 30.9% 31.0% 33.0% >4 8.1% 9.2% 10.0% 10.0% 10.0% 10.5% Proportion of prescriptions containing Current evidence Analgesics Paracetamol 58.3% 60.1% 59.8% 59.1% 58.7% 58.9% May reduce fever NSAIDs 3.0% 3.6% 4.2% 4.3% 4.5% 4.9% May reduce pain COX-II inhibitors 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% No evidence Antibiotics 8.1% 8.1% 6.8% 4.9% 4.4% 5.1% Antihistamines Sedating 81.1% 80.1% 82.3% 82.4% 80.8% 79.9% Ineffective Non-sedating 0.5% 0.3% 0.3% 0.3% 0.6% 1.2% Cough syrup Expectorant 36.8% 35.6% 36.3% 36.3% 34.0% 33.8% Not recommended in children Codeine 7.1% 6.9% 6.7% 6.5% 6.6% 6.3% Limited evidence Mucolytic 20.9% 22.2% 23.0% 24.0% 24.0% 25.0% May reduce symptoms Oral α-agonist 0.6% 0.4% 0.3% 0.2% 0.2% 0.2% Modest effect in adults Oral β-agonist 4.4% 4.7% 4.2% 4.1% 3.7% 4.1% No evidence Theophylline 1.1% 1.0% 1.0% 0.9% 0.8% 0.9% No evidence Others Throat lozenges 34.7% 34.9% 35.6% 37.5% 39.9% 40.4% No evidence Lysozyme 10.6% 11.8% 13.8% 14.5% 14.9% 15.6% No evidence Neozep 0.6% 0.3% 0.3% 0.2% 0.0% 0.1% pharyngitis (R72), acute sinusitis (R75) and acute laryn- Discussion gitis (R76), over 90% resulted in antibiotic prescription Main study findings (Table 3). Almost 50% of patients diagnosed with influenza Consultations for URTI symptoms account for almost were prescribed antibiotics. The proportion was much less 20% of attendances per year in Hong Kong’s public pri- among those coded with R74 (acute URTI). mary care (around 900,000 out of 5 million attendances Table 3 Proportion of antibiotic prescribed in different URTIs Condition Year H71 R72 R74 R75 R76 R77 R80 2005 94.4% (2816) 89.2% (213) 6.5% (957615) 90.7% (1523) 95.2% (4776) 23.9% (348) 54.0% (2556) 2006 95.4% (3135) 80.6% (294) 6.3% (897381) 86.1% (1529) 96.0% (4915) 25.4% (378) 52.8% (3087) 2007 95.2% (2798) 81.7% (164) 5.1% (889038) 85.0% (1788) 94.7% (4005) 26.9% (283) 50.6% (2669) 2008 94.1% (3179) 93.9% (245) 2.6% (937252) 91.6% (2024) 96.7% (6543) 59.1% (281) 47.0% (2623) 2009 94.4% (2683) 95.5% (352) 1.8% (782692) 92.0% (2138) 97.8% (7233) 68.6% (338) 43.1% (5697) 2010 94.4% (3044) 97.8% (320) 1.9% (858979) 91.3% (2317) 97.9% (9317) 73.6% (658) 48.2% (8882) Bracketed values indicate the number of attendances where the specified ICPC code was assigned. Kung et al. BMC Family Practice 2014, 15:95 Page 5 of 7 http://www.biomedcentral.com/1471-2296/15/95 annually [17]). There was a drop in attendances in 2009, rates did not vary with antibiotic prescription rate [15], which coincides with the swine flu outbreak that year, further research would be warranted in view of the overall where patients with influenza like illness were advised to low antibiotic prescription volume. go to designated fever clinics. There is an increasing A large variety of symptomatic medications were pre- mean age of patients presenting to primary care for scribed, including α and β-agonists, lysozyme and mu- upper respiratory tract infections which may reflect the colytics. There is little empirical evidence that these increasing age of the population and those presenting to medicines are effective for URTI [32-35]. Anecdotally, primary care. 98% of consultations were associated with it is not uncommon for patients to request a medica- a prescription, which on average included four drug clas- tion for each symptom they experience, which may help ses. Antibiotics were prescribed in 5% of consultations. explain why patients are prescribed antitussives, anti- histamines, mucolytics and throat lozenges. Among these Antibiotic prescribing prescriptions, 80% were on sedating antihistamines; 6% The overall antibiotic prescription rate observed in this were given opioid containing medications; and a minority study was much lower than in other countries [22-25]. was prescribed theophyllines, α-agonists or β-agonists. Although patients with uncomplicated URTIs (R74) com- There is a need for further research on the expectations prise the large majority of the population, it appears that of symptomatic medication prescriptions as recipients the overall volume of antibiotics prescribed remains low. of these medications included children, and patients However, nearly all those coded with H71 (otitis media), with chronic disease in which medication side effects R72 (streptococcal pharyngitis), R75 (acute sinusitis) and could be detrimental e.g. cardiac diseases, prostatic symp- R76 (acute tonsillitis) were almost always prescribed anti- toms or respiratory problems [36-39]. biotics, with an increasing trend among R72 and R77. Fur- thermore, around 50% of those diagnosed with influenza (R80) were also prescribed with antibiotics. Prescribing Implication for health service provision and future pressure [26] from patients may be an issue, especially research among those with more troubling symptoms. This could Compared with European countries [40-43], Hong Kong’s also reflect clinicians’‘coding creep’ or ‘diagnostic drift’ public primary care appears to exhibit low antibiotic pre- with the tendency to use non-R74 codes in consultations scribing behaviour for symptoms of upper respiratory tract where antibiotics were prescribed. Further education and infections. On the other hand, the prescription rate for training in terms of diagnosis, management and use of non-antibiotic medications is exceptionally high. It may correct coding may need to be instated. Whilst financial be that prescription of symptomatic medication has incentive is an important contributory factor for ‘coding managed to displace the expectation of antibiotic pre- creep’ in some countries [27-29], this is not an issue in scription. However, symptomatic drug prescription is Hong Kong where there is no pay-for-performance system high, and is estimated to cost the public healthcare in place. Further education of doctors in the appropriate system over 1.2 million US dollars per year. Other costs management of otitis media, streptococcal pharyngitic, including PPCCs’ facilities and human resources, as well acute sinusitis and acute tonsillitis may help to reduce as the societal impact of health services utilization for unnecessary antibiotic prescription. URTI have not been included. Previous studies have shown that a significant propor- Symptomatic drug utilization tion of primary care physicians believe patients should At least 3 medications are prescribed for each URTI epi- be empowered to self manage uncomplicated URTI [44]. sode. This is higher than the URTI drug prescription Nevertheless, many patients continue to consult doctors patterns of Dutch doctors, where a mean of 0.8 drugs within the first two days of their illnesses [30,31] despite were prescribed per patient. Possible explanations for a its self-limiting nature. Public health initiatives are there- higher prescription number may be related to the nature fore needed in order to promote self-management and of the Hong Kong healthcare system, where consultation appropriate indications for help seeking. The gap between fees in PPCCs are heavily subsidized and includes the clinical evidence for pharmacological intervention, doc- cost of medication, patients’ relatively low self medica- tors’ prescribing behavior and patient expectation must tion rate [30] and high expectations for receiving a pre- also be addressed in order to safeguard patient well- scription for medication during consultations [31]. The being and the appropriate use of health care resources. slight increase in the number of medications prescribed Primary care physicians can play an active role to em- coincided with an increase in annual attendances per pa- power patients to self-manage symptoms and in redu- tient for URTI, suggesting that this prescribing habit may cing the reliance on unnecessary medications whenever be encouraging patients to consult. Although one previous appropriate. Further studies looking into cultural differ- European study indicated that medication prescribing ences in expectations and management of URTI like Kung et al. BMC Family Practice 2014, 15:95 Page 6 of 7 http://www.biomedcentral.com/1471-2296/15/95 symptoms can better inform effective regional educational Competing interests The authors declare that they have no competing interests. interventions. Author contributions KK/CW conceptualised the whole study. KK researched data and wrote the Strengths and limitations of this study manuscript, with further analysis performed by CKYC. CW/SYSW/AL/SG/CCB This is the first study of patient characteristics and reviewed the manuscript. CCB contributed to discussion and reviewed the prescribed medication among patients presenting to manuscript. All authors declare that there are no financial relationships with any organisations that might have an interest in the submitted work, and public primary care clinics with URTIs in the South that no presentations have been made for this research. All authors read and China Region. The availability of electronic patient approved the final manuscript. data from all PPCCs in Hong Kong ensured coverage of all patients in the public primary care setting, allowing Acknowledgements an accurate analysis into the health services utilization This work was supported by the primary care team at the Chinese University of Hong Kong, without contribution from any external funding sources. related to URTIs. Internal audits within the Hospital Authority (unpublished data) have indicated that the Author details ICPC coding rate among PPCCs is generally over 90%. Division of Family Medicine, School of Public Health & Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong. Department of Family Two studies examining ICPC coding accuracy over the Medicine, the Hospital Authority, Kowloon, Hong Kong. Department of recent few years [45,46] have shown that 96% to 98% of 4 General Practice, Cardiff University, Cardiff, UK. Jockey School of Public cases are coded accurately, especially if the case is not Health, Prince of Wales Hospital, Room 408, 32 Ngan Shing Street, Shatin, NT, Hong Kong. complex. These imply that the data obtained for this study accurately reflects the public primary care situation Received: 13 January 2014 Accepted: 29 April 2014 in our locality. Published: 13 May 2014 Those who utilize public clinics in primary care are more likely to be of lower socio-economic status, elderly References 1. Lo Y, Lam C, Lam T, Lee R, Chiu B, Tang J, Chui B, Chao D, Lam A, Chan K: and individuals with chronic conditions [47], this is Hong Kong primary care morbidity survey 2007-2008. HK Pract 2010, reflected in our study where one fifth is on financial as- 32:17–26. sistance and the increasing age of presentation. How- 2. Hak E, Rovers M, Kuyvenhoven M, Schellevis F, Verheij T: Incidence of GP-diagnosed respiratory tract infections according to age, gender and ever, results do not include consultations in the private high-risk co-morbidity: the Second Dutch National Survey of General sector which is likely to see patients who are more afflu- Practice. Fam Pract 2006, 23(3):291–294. ent and younger. Meanwhile this study has important 3. Fleming D, Smith G, Charlton J, Charlton J, Nicoll A: Impact of infections on primary care - greater than expected. Commun Dis Public Health 2002, implications as older people are more prone to drug- 5(1):7–12. drug interactions and adverse events from the prescrip- 4. Lam W, Ho K, Kwok K, Tsang L: Morbidity pattern in four government tions of medications for URTI. Moreover, as there is a general practice clinics using the International Classification of Primary Care (Revised Edition) (ICPC-2) coding. HK Pract 2006, 28:363–375. high rate of ‘doctor shopping’ among patients in pri- 5. CDARS: Clinical Decision Analysis Reporting System. Hong Kong: Department mary care in Hong Kong, this pattern of high utilization of Family Medicine, New Territories East Cluster, Hospital Authority. Last of symptomatic prescriptions for URTI in Hong Kong is accessed 12 Jul 2011. 6. Nichol K, D’Heilly S, Ehlinger E: Burden of upper respiratory illnesses likely to be common among most patients consulting among college and university students: 2002-2003 and 2003-2004 primary care in Hong Kong, both in the private sector cohorts. Vaccine 2006, 24(44–46):6724–6725. and in government run clinics given similar expectations. 7. Taverner D, Latte J: Nasal decongestants for the common cold [update of Cochrane Review]. 2007, (1):CD001953. 8. Kernan W, Viscoli C, Brass L: Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med 2000, 343:1826–1832. Conclusions 9. Arroll B, Kenealy T: Are antibiotics effective for acute purulent rhinitis? Overall the rate of antibiotic prescription for patients Systematic review and meta-analysis of placebo controlled randomised attending Hong Kong’s public primary care is low, trials. BMJ 2007, 333:279. 10. Fahey T, Stocks N, Thomas T: Systematic review of the treatment of upper although the rate is high among those diagnosed with respiratory tract infection. Arch Dis Child 1998, 79:225–230. otitis media, pharyngitis, sinusitis and tonsillitis. On the 11. Sutter AI, Lemiengre M, Campbell H, Mackinnon HF: Antihistamines for the other hand, the number symptomatic medications pre- common cold. Cochrane Database Syst Rev 2009, (4):CD001267. 12. Yoder K, Shaffer M, La Tournous S: Child assessment of scribed is high, and its relationship with increasing doc- dextromethorphan, diphenhydramine, and placebo for nocturnal cough tor consultations and low overall antibiotic prescription due to upper respiratory infection. Clin Pediatr 2006, 45:633–640. need to be further explored. Gaps have been identified 13. Lam C: Rational prescribing for upper respiratory tract infections. HK Pract 2002, 24:298–304. between primary care practice and evidence based man- 14. Arroll B, Goodyear-Smith F: General practitioner management of upper agement of upper respiratory tract infections. There is a respiratory tract infections: when are antibiotics prescribed? NZJM 2000, huge potential to save resources on inappropriate anti- 493–496. 15. Rosman S, Le Vaillant M, Schellevis F, Clerc P, Verheij R, Pelletier-Fleury N: biotic use, unnecessary prescription of symptomatic medi- Prescribing patterns for upper respiratory tract infections in general cation and consultation appointments through doctor and practice in France and in the Netherlands. Eur J of Pub Health 2008, patient education. 18(3):312–316. Kung et al. BMC Family Practice 2014, 15:95 Page 7 of 7 http://www.biomedcentral.com/1471-2296/15/95 16. Trap B, Hansen E: Treatment of upper respiratory tract infections – a 40. Carrie AG, Zhanel GG: Antibacterial use in community practice: assessing comparative study of dispensing and non-dispensing doctors. J Clin quantity, indications and appropriateness, and relationship to the Pharma Therapeut 2002, 27:289–298. development of antibacterial resistance. Drugs 1999, 57(6):871–881. 17. Statistics & Workforce Planning Department, Strategy & Planning Division, 41. McGregor A, Dovey S, Tilyard M: Antibiotic use in upper respiratory tract Hospital Authority Head Office: GOP Service Portfolio 2012. Hong Kong infections in New Zealand. Fam Pract 1995, 12(2):166–170. Hospital Authority; 2012. 42. Fagnani F, German-Fattal M: Antibiotic prescribing patterns of French GPs 18. Lee A, Lau F, Hazelett C, Kam C, Wong P, Wong TW, Chow S: Morbidity for upper respiratory tract infections: impact of fusafungine on rates of patterns of non-urgent patients attending accident and emergency prescription of systemic antibiotics. Am J Respir Med 2003, 2(6):491–498. departments in Hong Kong: cross-sectional study. HKMJ 2001, 7:131–138. 43. Ashworth M, Cox K, Latinovic R, Charlton J, Gulliford M, Rowlands G: Why 19. Law C, Yip P: Acute care service utilisation and the possible impacts of a has antibiotic prescribing for respiratory illness declined in primary care? user-fee policy in Hong Kong. HKMJ 2002, 8:348–353. A longitudinal study using the General Practice Research Database. J Public Health 2004, 26(3):268–274. 20. Wong M, Jiang J, Tang J, Lam A, Fung H, Mercer S: Health services 44. Lam T, Lam K: Family doctors’ attitudes towards patient self- research in the public healthcare system in Hong Kong: An analysis of management of upper respiratory tract infections. Hong Kong Med J 2001, over 1 million antihypertensive prescriptions between 2004-2007 as an 7:146–149. example of the potential and pitfalls of using routinely collected elec- 45. Wong H, Chan E, Wong M, Liang J: Is the number of clinical problems per tronic patient data. BMC Health Serv Res 2008, 8:138. consultation correlated with poorer ICPC coding practices in primary 21. Census and Statistics Department: The Government of the Hong Kong Special care clinics? A pilot study in two distinct clinic settings. HK Pract 2009, Administration Region. Population Census; 2006. http://www.statistics.gov.hk/ 31:158–165. pub/B11200512006XXXXB0400.pdf. Last accessed 8 May 2014. 46. Wong L, Lee M, Mak H, Wong K, Chung K, Wong K, Tam S, Li H, Chan T, 22. Cheong L, Kwok C, Aljunid S, Cheah M: Antibiotic prescription in upper Kung K, Lam A, Li P: Accuracy and completeness of ICPC coding for respiratory tract infections. Asia Pacfici Family Medicine 2004, 3(1–2):38–45. chronic disease in general outpatient clinics. HK Pract 2010, 32:129–135. 23. Gonzales R, Steiner J, Sande M: Antibiotic prescribing for adults with 47. Wong S, Kung K, Griffiths S, Carthy T, Wong M, Lo S, Chung V, Goggins W, colds, upper respiratory tract infections, and bronchitis by ambulatory Starfield B: Comparison of primary care experiences among adults in general care physicians. JAMA 1997, 278(11):901–904. outpatient clinics and private general practice clinics in Hong Kong. BMC 24. Hui L, Li X, Zeng X, Dai Y: Patterns and determinants of use of antibiotics Public Health [Internet] 2010, 10:397. Available from: http://www.biomedcentral. for acute respiratory tract infection in children in China. Paed Infect Dis J com/1471-2458/10/397. 1997, 16(6):560–564. 25. Arustiyono: Promoting rational use of drugs at the community health centres in doi:10.1186/1471-2296-15-95 Indonesia. WHO World Bank Health Project IV; 1999. http://archives.who.int/ Cite this article as: Kung et al.: Patient presentation and physician prduc2004/Resource_Mats/Asia_papers/PROMOTING%20RATIONAL%20USE% management of upper respiratory tract infections: a retrospective 20OF%20DRUGS%20IN%20INDONESIA.htm. Last accessed 8 May 2014. review of over 5 million primary clinic consultations in Hong Kong. BMC 26. Stivers T: Prescribing under pressure: parent-physician conversations and Family Practice 2014 15:95. antibiotics. Oxford; New York: Oxford University Press; 2007:221. 27. Pongpirul K, Walker DG, Rahman H, Robinson C: DRG coding practice: a nationwide hospital survey in Thailand. BMC Health Serv Res 2011, 11(1):290. 28. Simborg DW: DRG Creep: A New Hospital-Acquired Disease. N Engl J Med 1981, 304(26):1602–1604. 29. Agrawal S: Educating Physicians About Responsible Management of Finite Resources. JAMA 2013, 309(11):1115. 30. Lee A, Siu S, Lam A, Tsang C, Kung K, Li P: The concepts of family doctor and the factors affecting choice of family doctors among Hong Kong people. Hong Kong Med J 2010, 16:18–25. 31. Chan C: What do patients expect from consultations for upper respiratory tract infections? Fam Pract 1996, 13:229–235. 32. Duijvestijn Y, Mourdi N, Smucny J, Pons G, Chalumeau M: Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochran Database Syst Rev 2009, 1:CD003124. 33. Smith S, Schroeder K, Fahey T: Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochran Database Syst Rev 2008, 1:CD001831. 34. Kim S, Chang Y, Cho H, Hwang Y, Moon Y: Non-steroidal anti- inflammatory drugs for the common cold. Cochran Database Syst Rev 2009, 3:CD006362. 35. Arroll B: Respiratory disorders (acute) - common cold. Clinical Evidence 2011, 03:1510. Submit your next manuscript to BioMed Central 36. Hong Kong Department of Health, Pharmaceutical Registration Section: Drug alert on the use of oral liquid cough medicines containing codeine. Hong and take full advantage of: Kong: Department of Health; 2010. 37. Church M, Maurer M, Simons F, Bindslev-Jensen C, van Cauwenberge P, • Convenient online submission Bousquet J, Holgate ST, Zuberbier T: Risk of first-generation H1- antihistamines: • Thorough peer review aGA2LEN position paper. Allergy 2010, 65:459–466. 38. Ng D: Prescription of codeine in young infants. Hong Kong Med J 2004, • No space constraints or color figure charges 10(6):439. • Immediate publication on acceptance 39. Medicines and Healthcare Products Regulatory Agency: Oral liquid cough • Inclusion in PubMed, CAS, Scopus and Google Scholar medicines containing codeine: should not be used in children and young people under 18 years. MHRA Public Assessment Report; 2010. http://www. • Research which is freely available for redistribution mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con096798. pdf. Last accessed 8 May 2014. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

Patient presentation and physician management of upper respiratory tract infections: a retrospective review of over 5 million primary clinic consultations in Hong Kong

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Copyright © 2014 by Kung et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Upper respiratory tract infection (URTI) has a significant healthcare burden worldwide. Considerable resources are consumed through health care consultations and prescribed treatment, despite evidence for little or no effect on recovery. Patterns of consultations and care including use of symptomatic medications and antibiotics for upper respiratory tract infections are poorly described. Methods: We performed a retrospective review of computerized clinical data on patients presenting to all public primary care clinics in Hong Kong with symptoms of respiratory tract infections. International Classification of Primary care (ICPC)codes used to identify patients included otitis media (H71), streptococcal pharyngitis (R72), acute URTI (R74), acute sinusitis (R75), acute tonsillitis (R76), acute laryngitis (R77), and influenza (R80). Sociodemographic variables such as gender, age, chronic illness status, attendance date, type and duration of drug prescribed were also collected. Results: Of the 5,529,755 primary care consultations for respiratory symptoms from 2005 to 2010, 98% resulted in a prescription. Prescription patterns of symptomatic medication were largely similar across the 5 years. In 2010 the mean number of drugs prescribed per consultation was 3.2, of which the commonly prescribed medication were sedating antihistamines (79.9%), analgesia (58.9%), throat lozenges (40.4%) and expectorant cough syrup (33.8%). During the study period, there was an overall decline in antibiotic prescription (8.1% to 5.1%). However, in consultations where the given diagnosis was otitis media (H71), streptococcal pharyngitis (R72), acute sinusitis (R75) or acute laryngitis (R76), over 90% resulted in antibiotic prescription. Conclusion: There was a decline in overall antibiotic prescription over the study period. However, the use of antibiotics was high in some conditions e.g. otitis media and acute laryngitis a. Multiple symptomatic medications were given for upper respiratory tract infections. Further research is needed to develop clinical and patients directed interventions to reduce the number of prescriptions of symptomatic medications and antibiotics that could reduce costs for health care services and iatrogenic risk to patients. Keywords: Upper respiratory tract infection, Primary care, Pharmacology * Correspondence: carmenwong@cuhk.edu.hk Division of Family Medicine, School of Public Health & Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong Jockey School of Public Health, Prince of Wales Hospital, Room 408, 32 Ngan Shing Street, Shatin, NT, Hong Kong Full list of author information is available at the end of the article © 2014 Kung et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kung et al. BMC Family Practice 2014, 15:95 Page 2 of 7 http://www.biomedcentral.com/1471-2296/15/95 Background  R77 – acute laryngitis Respiratory infections are the commonest health problem  R80 – influenza encountered in primary care worldwide [1-3], amounting to between 16% to over 60% of attendances depending on There are 74 PPCCs in Hong Kong covering the entire locality [4,5]. Upper respiratory tract infection (URTI) is population 7 million, with over 5 million attendances an- an important cause of reduced activity days, school and nually [17]. Consultations fees are subsidized for per- work loss, impaired school performance, and increased manent residents (patient pays USD5.8 per consultation, healthcare utilization [6], resulting in substantial economic inclusive of medications and investigations), while spe- burden. cific populations (government workers and those on fi- There is little data on actual prescribing practice for nancial assistance) receive free consultations. Existing URTI in Asia. Evidence shows that symptomatic medi- literature suggests that less than 100,000 attendances are cations including antibiotics are of marginal or no bene- made to local emergency departments for non-urgent fit [7-13]. However, there are widespread variations in respiratory tract infections annually [18,19], while 26% URTI management. A telephone survey of Auckland of private sector consultations (accounting for 50% of GPs found that 95% would, on occasions, prescribe as- Hong Kong’s primary care) are related to respiratory tract needed medications (instructions for patient to fill pre- infections [1]. scriptions if condition worsens), including antibiotics Data on gender, age, chronic illness status, attendance [14]. In a European study, the number of medication date, type and duration of drug prescribed for URTI were types per patient varied from 0.82 to 3.55 per patient extracted from the system-wide electronic record system per year [15]. Interestingly, the antibiotic prescription (Clinical Data Analysis & Reporting System [CDARS]). rate in this European study did not vary with the overall There is no information from CDARS for patients’ medication prescription rate. A study in Zimbabwe financial status; nevertheless, those requiring financial highlighted widespread non-evidence based prescribing assistance from the government can be identified separ- for URTI patients [16]. The actual prescribing practice ately from those paying the usual fee. Previous publica- among Chinese primary care physicians for URTI symp- tions using CDARS have demonstrated the accuracy and toms has not previously been investigated, although an- completeness of the data retrieved from this system [20]. ecdotal observations show that medications for We defined a repeat attendance for the same URTI symptomatic relief are commonly used. Understanding episode (which we considered as the same illness epi- the characteristics of patients who consult with URTI sode) as any attendances for URTI symptoms within symptoms and the prescribing practices of primary care 28 days of the previous URTI attendance. Medications clinicians could identify opportunities for intervention were grouped into specific drug classes, including anal- such as reducing unnecessary prescriptions of antibiotic gesia, antibiotics, antihistamines, cough syrup, mucolytic, and symptomatic medication and reallocating resources s α-agonists, β-agonists, theophylline and other including for other medical conditions in primary care such as throat lozenges, lysozyme. chronic disease management. All statistical analysis was performed using SPSS ver- We therefore reviewed the characteristics of patients sion 18.0 for Windows. Descriptive statistics were cal- attendingHongKong’s public primary care clinics (PPCCs) culated using mean and range. Chi-square test was used with URTI symptoms, and the types of medications clini- to compare categorical variables across the different cians prescribed for URTI symptoms. years. All p values <0.05 were regarded as statistically significant. Methods This study was approved by the Clinical Research Ethics We performed a retrospective review of computerized Committee of the Chinese University of Hong Kong and clinical data on patients presenting to PPCCs with upper New Territories East Cluster of the Hospital Authority. st respiratory tract symptoms between 1 January 2005 and st 31 December 2010. Upper respiratory tract symptoms Results were defined by specific ICPC (International Classification There were 5,529,755 attendances for RTIs from 2005 to of Primary Care) codes agreed upon by an expert panel of 2010. Patient demographics and the conditions diagnosed local primary care physicians including: are summarized in Table 1. H71 – otitis media Patient presentation R72 – streptococcal pharyngitis There were 5,529,755 consultations for URTI symptoms R74 – acute upper respiratory tract infection in the study period for the patient population of R75 – acute sinusitis 1,181,816 [21]. The distribution of annual attendances R76 – acute tonsillitis was similar across the six years with the majority Kung et al. BMC Family Practice 2014, 15:95 Page 3 of 7 http://www.biomedcentral.com/1471-2296/15/95 Table 1 Patient demographics and diagnosed conditions Year of attendance 2005 2006 2007 2008 2009 2010 Annual attendance for all 997768 937686 923504 966739 813874 895978 respiratory infections Distribution of annual attendances number (number of patients) 1 attendance 59.9% (319154) 59.7% (296239) 57.5% (269327) 56.7% (274308) 59.4% (253995) 57.8% (264110) 2-4 attendances 34.2% (181992) 34.0% (168824) 35.3% (165316) 35.9% (173343) 34.3% (146461) 35.3% (161307) 5-8 attendances 4.9% (26157) 5.2% (25765) 5.8% (27347) 6.1% (29305) 5.2% (22411) 5.8% (26308) >8 attendances 1.0% (5495) 1.1% (5359) 1.3% (6034) 1.3% (6517) 1.1% (4735) 1.2% (5549) Patient headcount 532798 496187 468024 483473 427602 457274 Mean attendance per patient per year 1.9 1.93 2.0 2.0 1.9 2.0 Mean age (years) 41.1 41.2 42.9 43.8 44.3 45.6 Gender Female 56.4% 56.1% 56.9% 57.0% 56.4% 57.0% On government subsidy 20.7% 20.4% 19.5% 21.0% 21.4% 21.0% Chronic illness Ischaemic heart disease 1.6% (8440) 1.5% (7578) 1.5% (7219) 1.6% (7594) 1.5% (6324) 1.5% (6729) Hypertension 22.8% (121304) 21.8% (108344) 23.2% (108397) 23.9% (115461) 23.9% (102066) 24.0% (109558) Stroke 1.6% (8290) 1.4% (7191) 1.5% (7151) 1.6% (7580) 1.4% (6128) 1.4% (6392) Prostatism 2.6% (13905) 2.7% (13160) 2.8% (13219) 2.9% (14072) 2.9% (12610) 2.9% (13374) Asthma 2.9% (15264) 3.0% (14904) 3.2% (14866) 3.1% (15146) 3.2% (13563) 2.9% (13358) COPD 1.5% (7797) 1.4% (7191) 1.4% (6679) 1.3% (6458) 1.3% (5595) 1.1% (5197) Coded conditions H71 (otitis media) 0.29% 0.34% 0.31% 0.33% 0.33% 0.33% R72 (streptococcal 0.02% 0.03% 0.02% 0.03% 0.04% 0.04% pharyngitis) 97.35% 96.99% 97.07% 96.30% 95.42% 94.25% R74 (acute URTI) 0.15% 0.17% 0.20% 0.21% 0.26% 0.25% R75 (acute sinusitis) 0.49% 0.53% 0.44% 0.67% 0.88% 1.02% R76 (acute tonsillitis) 0.04% 0.04% 0.03% 0.03% 0.04% 0.07% R77 (acute laryngitis) 0.26% 0.33% 0.29% 0.27% 0.69% 0.97% R80 (influenza) (approx 60%) of patients presenting once for symptoms Prescription of medication of upper respiratory tract infections. Over a third of the Of the 5,529,755 primary care consultations for URTI patients (approximately 35%) attended 2-4 times per symptoms from 2005 to 2010, 98% resulted in a pre- year. There was a 16% drop in attendances in 2009. scription of at least one medication (Table 2). Prescrip- Overall, there was a significant increase (p < 0.001) in tion patterns of symptomatic medication were largely the mean number of annual attendances per patient. similar across the 5 years, but there was a small but The mean age of presentation shows a steady increase significant rise in the number of drugs given per con- from 41.1 to 45.6 years from 2005 -2010. Patients were sultation (p < 0.001). The most commonly prescribed more likely to be female (approx 57%) and on average medications were sedating antihistamines (79.9%), anal- one fifth of those presenting were on government sub- gesia (58.9%), throat lozenges (40.4%) and expectorant sidy. Over 94% were coded as upper respiratory tract in- cough syrup (33.8%). During the study period, there was fection (R74). Over the 6 years, there was a significant a significant decline in antibiotic prescription from 8.1% increase (p < 0.001) in the number of patients coded with to 5.1% (p < 0.001). However, in consultations, where non-R74 conditions. the given diagnosis was otitis media (H71), streptococcal Kung et al. BMC Family Practice 2014, 15:95 Page 4 of 7 http://www.biomedcentral.com/1471-2296/15/95 Table 2 Details on drugs prescribed Year of attendance 2005 2006 2007 2008 2009 2010 Mean number of drugs 3.1 3.1 3.2 3.2 3.2 3.2 Number of drug items per prescription 0 2.7% 2.7% 2.3% 1.3% 1.3% 1.1% 1 5.7% 5.5% 5.1% 5.1% 5.5% 5.0% 2 21.2% 20.4% 19.6% 19.7% 19.8% 18.3% 3 34.6% 33.8% 33.3% 33.0% 32.4% 32.1% 4 27.8% 28.5% 29.7% 30.9% 31.0% 33.0% >4 8.1% 9.2% 10.0% 10.0% 10.0% 10.5% Proportion of prescriptions containing Current evidence Analgesics Paracetamol 58.3% 60.1% 59.8% 59.1% 58.7% 58.9% May reduce fever NSAIDs 3.0% 3.6% 4.2% 4.3% 4.5% 4.9% May reduce pain COX-II inhibitors 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% No evidence Antibiotics 8.1% 8.1% 6.8% 4.9% 4.4% 5.1% Antihistamines Sedating 81.1% 80.1% 82.3% 82.4% 80.8% 79.9% Ineffective Non-sedating 0.5% 0.3% 0.3% 0.3% 0.6% 1.2% Cough syrup Expectorant 36.8% 35.6% 36.3% 36.3% 34.0% 33.8% Not recommended in children Codeine 7.1% 6.9% 6.7% 6.5% 6.6% 6.3% Limited evidence Mucolytic 20.9% 22.2% 23.0% 24.0% 24.0% 25.0% May reduce symptoms Oral α-agonist 0.6% 0.4% 0.3% 0.2% 0.2% 0.2% Modest effect in adults Oral β-agonist 4.4% 4.7% 4.2% 4.1% 3.7% 4.1% No evidence Theophylline 1.1% 1.0% 1.0% 0.9% 0.8% 0.9% No evidence Others Throat lozenges 34.7% 34.9% 35.6% 37.5% 39.9% 40.4% No evidence Lysozyme 10.6% 11.8% 13.8% 14.5% 14.9% 15.6% No evidence Neozep 0.6% 0.3% 0.3% 0.2% 0.0% 0.1% pharyngitis (R72), acute sinusitis (R75) and acute laryn- Discussion gitis (R76), over 90% resulted in antibiotic prescription Main study findings (Table 3). Almost 50% of patients diagnosed with influenza Consultations for URTI symptoms account for almost were prescribed antibiotics. The proportion was much less 20% of attendances per year in Hong Kong’s public pri- among those coded with R74 (acute URTI). mary care (around 900,000 out of 5 million attendances Table 3 Proportion of antibiotic prescribed in different URTIs Condition Year H71 R72 R74 R75 R76 R77 R80 2005 94.4% (2816) 89.2% (213) 6.5% (957615) 90.7% (1523) 95.2% (4776) 23.9% (348) 54.0% (2556) 2006 95.4% (3135) 80.6% (294) 6.3% (897381) 86.1% (1529) 96.0% (4915) 25.4% (378) 52.8% (3087) 2007 95.2% (2798) 81.7% (164) 5.1% (889038) 85.0% (1788) 94.7% (4005) 26.9% (283) 50.6% (2669) 2008 94.1% (3179) 93.9% (245) 2.6% (937252) 91.6% (2024) 96.7% (6543) 59.1% (281) 47.0% (2623) 2009 94.4% (2683) 95.5% (352) 1.8% (782692) 92.0% (2138) 97.8% (7233) 68.6% (338) 43.1% (5697) 2010 94.4% (3044) 97.8% (320) 1.9% (858979) 91.3% (2317) 97.9% (9317) 73.6% (658) 48.2% (8882) Bracketed values indicate the number of attendances where the specified ICPC code was assigned. Kung et al. BMC Family Practice 2014, 15:95 Page 5 of 7 http://www.biomedcentral.com/1471-2296/15/95 annually [17]). There was a drop in attendances in 2009, rates did not vary with antibiotic prescription rate [15], which coincides with the swine flu outbreak that year, further research would be warranted in view of the overall where patients with influenza like illness were advised to low antibiotic prescription volume. go to designated fever clinics. There is an increasing A large variety of symptomatic medications were pre- mean age of patients presenting to primary care for scribed, including α and β-agonists, lysozyme and mu- upper respiratory tract infections which may reflect the colytics. There is little empirical evidence that these increasing age of the population and those presenting to medicines are effective for URTI [32-35]. Anecdotally, primary care. 98% of consultations were associated with it is not uncommon for patients to request a medica- a prescription, which on average included four drug clas- tion for each symptom they experience, which may help ses. Antibiotics were prescribed in 5% of consultations. explain why patients are prescribed antitussives, anti- histamines, mucolytics and throat lozenges. Among these Antibiotic prescribing prescriptions, 80% were on sedating antihistamines; 6% The overall antibiotic prescription rate observed in this were given opioid containing medications; and a minority study was much lower than in other countries [22-25]. was prescribed theophyllines, α-agonists or β-agonists. Although patients with uncomplicated URTIs (R74) com- There is a need for further research on the expectations prise the large majority of the population, it appears that of symptomatic medication prescriptions as recipients the overall volume of antibiotics prescribed remains low. of these medications included children, and patients However, nearly all those coded with H71 (otitis media), with chronic disease in which medication side effects R72 (streptococcal pharyngitis), R75 (acute sinusitis) and could be detrimental e.g. cardiac diseases, prostatic symp- R76 (acute tonsillitis) were almost always prescribed anti- toms or respiratory problems [36-39]. biotics, with an increasing trend among R72 and R77. Fur- thermore, around 50% of those diagnosed with influenza (R80) were also prescribed with antibiotics. Prescribing Implication for health service provision and future pressure [26] from patients may be an issue, especially research among those with more troubling symptoms. This could Compared with European countries [40-43], Hong Kong’s also reflect clinicians’‘coding creep’ or ‘diagnostic drift’ public primary care appears to exhibit low antibiotic pre- with the tendency to use non-R74 codes in consultations scribing behaviour for symptoms of upper respiratory tract where antibiotics were prescribed. Further education and infections. On the other hand, the prescription rate for training in terms of diagnosis, management and use of non-antibiotic medications is exceptionally high. It may correct coding may need to be instated. Whilst financial be that prescription of symptomatic medication has incentive is an important contributory factor for ‘coding managed to displace the expectation of antibiotic pre- creep’ in some countries [27-29], this is not an issue in scription. However, symptomatic drug prescription is Hong Kong where there is no pay-for-performance system high, and is estimated to cost the public healthcare in place. Further education of doctors in the appropriate system over 1.2 million US dollars per year. Other costs management of otitis media, streptococcal pharyngitic, including PPCCs’ facilities and human resources, as well acute sinusitis and acute tonsillitis may help to reduce as the societal impact of health services utilization for unnecessary antibiotic prescription. URTI have not been included. Previous studies have shown that a significant propor- Symptomatic drug utilization tion of primary care physicians believe patients should At least 3 medications are prescribed for each URTI epi- be empowered to self manage uncomplicated URTI [44]. sode. This is higher than the URTI drug prescription Nevertheless, many patients continue to consult doctors patterns of Dutch doctors, where a mean of 0.8 drugs within the first two days of their illnesses [30,31] despite were prescribed per patient. Possible explanations for a its self-limiting nature. Public health initiatives are there- higher prescription number may be related to the nature fore needed in order to promote self-management and of the Hong Kong healthcare system, where consultation appropriate indications for help seeking. The gap between fees in PPCCs are heavily subsidized and includes the clinical evidence for pharmacological intervention, doc- cost of medication, patients’ relatively low self medica- tors’ prescribing behavior and patient expectation must tion rate [30] and high expectations for receiving a pre- also be addressed in order to safeguard patient well- scription for medication during consultations [31]. The being and the appropriate use of health care resources. slight increase in the number of medications prescribed Primary care physicians can play an active role to em- coincided with an increase in annual attendances per pa- power patients to self-manage symptoms and in redu- tient for URTI, suggesting that this prescribing habit may cing the reliance on unnecessary medications whenever be encouraging patients to consult. Although one previous appropriate. Further studies looking into cultural differ- European study indicated that medication prescribing ences in expectations and management of URTI like Kung et al. BMC Family Practice 2014, 15:95 Page 6 of 7 http://www.biomedcentral.com/1471-2296/15/95 symptoms can better inform effective regional educational Competing interests The authors declare that they have no competing interests. interventions. Author contributions KK/CW conceptualised the whole study. KK researched data and wrote the Strengths and limitations of this study manuscript, with further analysis performed by CKYC. CW/SYSW/AL/SG/CCB This is the first study of patient characteristics and reviewed the manuscript. CCB contributed to discussion and reviewed the prescribed medication among patients presenting to manuscript. All authors declare that there are no financial relationships with any organisations that might have an interest in the submitted work, and public primary care clinics with URTIs in the South that no presentations have been made for this research. All authors read and China Region. The availability of electronic patient approved the final manuscript. data from all PPCCs in Hong Kong ensured coverage of all patients in the public primary care setting, allowing Acknowledgements an accurate analysis into the health services utilization This work was supported by the primary care team at the Chinese University of Hong Kong, without contribution from any external funding sources. related to URTIs. Internal audits within the Hospital Authority (unpublished data) have indicated that the Author details ICPC coding rate among PPCCs is generally over 90%. Division of Family Medicine, School of Public Health & Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong. Department of Family Two studies examining ICPC coding accuracy over the Medicine, the Hospital Authority, Kowloon, Hong Kong. Department of recent few years [45,46] have shown that 96% to 98% of 4 General Practice, Cardiff University, Cardiff, UK. Jockey School of Public cases are coded accurately, especially if the case is not Health, Prince of Wales Hospital, Room 408, 32 Ngan Shing Street, Shatin, NT, Hong Kong. complex. These imply that the data obtained for this study accurately reflects the public primary care situation Received: 13 January 2014 Accepted: 29 April 2014 in our locality. Published: 13 May 2014 Those who utilize public clinics in primary care are more likely to be of lower socio-economic status, elderly References 1. Lo Y, Lam C, Lam T, Lee R, Chiu B, Tang J, Chui B, Chao D, Lam A, Chan K: and individuals with chronic conditions [47], this is Hong Kong primary care morbidity survey 2007-2008. HK Pract 2010, reflected in our study where one fifth is on financial as- 32:17–26. sistance and the increasing age of presentation. How- 2. Hak E, Rovers M, Kuyvenhoven M, Schellevis F, Verheij T: Incidence of GP-diagnosed respiratory tract infections according to age, gender and ever, results do not include consultations in the private high-risk co-morbidity: the Second Dutch National Survey of General sector which is likely to see patients who are more afflu- Practice. Fam Pract 2006, 23(3):291–294. ent and younger. Meanwhile this study has important 3. Fleming D, Smith G, Charlton J, Charlton J, Nicoll A: Impact of infections on primary care - greater than expected. Commun Dis Public Health 2002, implications as older people are more prone to drug- 5(1):7–12. drug interactions and adverse events from the prescrip- 4. Lam W, Ho K, Kwok K, Tsang L: Morbidity pattern in four government tions of medications for URTI. Moreover, as there is a general practice clinics using the International Classification of Primary Care (Revised Edition) (ICPC-2) coding. HK Pract 2006, 28:363–375. high rate of ‘doctor shopping’ among patients in pri- 5. CDARS: Clinical Decision Analysis Reporting System. Hong Kong: Department mary care in Hong Kong, this pattern of high utilization of Family Medicine, New Territories East Cluster, Hospital Authority. Last of symptomatic prescriptions for URTI in Hong Kong is accessed 12 Jul 2011. 6. Nichol K, D’Heilly S, Ehlinger E: Burden of upper respiratory illnesses likely to be common among most patients consulting among college and university students: 2002-2003 and 2003-2004 primary care in Hong Kong, both in the private sector cohorts. Vaccine 2006, 24(44–46):6724–6725. and in government run clinics given similar expectations. 7. Taverner D, Latte J: Nasal decongestants for the common cold [update of Cochrane Review]. 2007, (1):CD001953. 8. Kernan W, Viscoli C, Brass L: Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med 2000, 343:1826–1832. Conclusions 9. Arroll B, Kenealy T: Are antibiotics effective for acute purulent rhinitis? Overall the rate of antibiotic prescription for patients Systematic review and meta-analysis of placebo controlled randomised attending Hong Kong’s public primary care is low, trials. BMJ 2007, 333:279. 10. Fahey T, Stocks N, Thomas T: Systematic review of the treatment of upper although the rate is high among those diagnosed with respiratory tract infection. Arch Dis Child 1998, 79:225–230. otitis media, pharyngitis, sinusitis and tonsillitis. On the 11. Sutter AI, Lemiengre M, Campbell H, Mackinnon HF: Antihistamines for the other hand, the number symptomatic medications pre- common cold. Cochrane Database Syst Rev 2009, (4):CD001267. 12. Yoder K, Shaffer M, La Tournous S: Child assessment of scribed is high, and its relationship with increasing doc- dextromethorphan, diphenhydramine, and placebo for nocturnal cough tor consultations and low overall antibiotic prescription due to upper respiratory infection. Clin Pediatr 2006, 45:633–640. need to be further explored. Gaps have been identified 13. Lam C: Rational prescribing for upper respiratory tract infections. HK Pract 2002, 24:298–304. between primary care practice and evidence based man- 14. Arroll B, Goodyear-Smith F: General practitioner management of upper agement of upper respiratory tract infections. There is a respiratory tract infections: when are antibiotics prescribed? NZJM 2000, huge potential to save resources on inappropriate anti- 493–496. 15. Rosman S, Le Vaillant M, Schellevis F, Clerc P, Verheij R, Pelletier-Fleury N: biotic use, unnecessary prescription of symptomatic medi- Prescribing patterns for upper respiratory tract infections in general cation and consultation appointments through doctor and practice in France and in the Netherlands. Eur J of Pub Health 2008, patient education. 18(3):312–316. Kung et al. BMC Family Practice 2014, 15:95 Page 7 of 7 http://www.biomedcentral.com/1471-2296/15/95 16. Trap B, Hansen E: Treatment of upper respiratory tract infections – a 40. Carrie AG, Zhanel GG: Antibacterial use in community practice: assessing comparative study of dispensing and non-dispensing doctors. J Clin quantity, indications and appropriateness, and relationship to the Pharma Therapeut 2002, 27:289–298. development of antibacterial resistance. Drugs 1999, 57(6):871–881. 17. Statistics & Workforce Planning Department, Strategy & Planning Division, 41. McGregor A, Dovey S, Tilyard M: Antibiotic use in upper respiratory tract Hospital Authority Head Office: GOP Service Portfolio 2012. Hong Kong infections in New Zealand. Fam Pract 1995, 12(2):166–170. Hospital Authority; 2012. 42. Fagnani F, German-Fattal M: Antibiotic prescribing patterns of French GPs 18. Lee A, Lau F, Hazelett C, Kam C, Wong P, Wong TW, Chow S: Morbidity for upper respiratory tract infections: impact of fusafungine on rates of patterns of non-urgent patients attending accident and emergency prescription of systemic antibiotics. Am J Respir Med 2003, 2(6):491–498. departments in Hong Kong: cross-sectional study. HKMJ 2001, 7:131–138. 43. Ashworth M, Cox K, Latinovic R, Charlton J, Gulliford M, Rowlands G: Why 19. Law C, Yip P: Acute care service utilisation and the possible impacts of a has antibiotic prescribing for respiratory illness declined in primary care? user-fee policy in Hong Kong. HKMJ 2002, 8:348–353. A longitudinal study using the General Practice Research Database. J Public Health 2004, 26(3):268–274. 20. Wong M, Jiang J, Tang J, Lam A, Fung H, Mercer S: Health services 44. Lam T, Lam K: Family doctors’ attitudes towards patient self- research in the public healthcare system in Hong Kong: An analysis of management of upper respiratory tract infections. Hong Kong Med J 2001, over 1 million antihypertensive prescriptions between 2004-2007 as an 7:146–149. example of the potential and pitfalls of using routinely collected elec- 45. Wong H, Chan E, Wong M, Liang J: Is the number of clinical problems per tronic patient data. BMC Health Serv Res 2008, 8:138. consultation correlated with poorer ICPC coding practices in primary 21. Census and Statistics Department: The Government of the Hong Kong Special care clinics? A pilot study in two distinct clinic settings. HK Pract 2009, Administration Region. Population Census; 2006. http://www.statistics.gov.hk/ 31:158–165. pub/B11200512006XXXXB0400.pdf. Last accessed 8 May 2014. 46. Wong L, Lee M, Mak H, Wong K, Chung K, Wong K, Tam S, Li H, Chan T, 22. Cheong L, Kwok C, Aljunid S, Cheah M: Antibiotic prescription in upper Kung K, Lam A, Li P: Accuracy and completeness of ICPC coding for respiratory tract infections. Asia Pacfici Family Medicine 2004, 3(1–2):38–45. chronic disease in general outpatient clinics. HK Pract 2010, 32:129–135. 23. Gonzales R, Steiner J, Sande M: Antibiotic prescribing for adults with 47. Wong S, Kung K, Griffiths S, Carthy T, Wong M, Lo S, Chung V, Goggins W, colds, upper respiratory tract infections, and bronchitis by ambulatory Starfield B: Comparison of primary care experiences among adults in general care physicians. JAMA 1997, 278(11):901–904. outpatient clinics and private general practice clinics in Hong Kong. BMC 24. Hui L, Li X, Zeng X, Dai Y: Patterns and determinants of use of antibiotics Public Health [Internet] 2010, 10:397. Available from: http://www.biomedcentral. for acute respiratory tract infection in children in China. Paed Infect Dis J com/1471-2458/10/397. 1997, 16(6):560–564. 25. Arustiyono: Promoting rational use of drugs at the community health centres in doi:10.1186/1471-2296-15-95 Indonesia. WHO World Bank Health Project IV; 1999. http://archives.who.int/ Cite this article as: Kung et al.: Patient presentation and physician prduc2004/Resource_Mats/Asia_papers/PROMOTING%20RATIONAL%20USE% management of upper respiratory tract infections: a retrospective 20OF%20DRUGS%20IN%20INDONESIA.htm. Last accessed 8 May 2014. review of over 5 million primary clinic consultations in Hong Kong. BMC 26. Stivers T: Prescribing under pressure: parent-physician conversations and Family Practice 2014 15:95. antibiotics. Oxford; New York: Oxford University Press; 2007:221. 27. Pongpirul K, Walker DG, Rahman H, Robinson C: DRG coding practice: a nationwide hospital survey in Thailand. BMC Health Serv Res 2011, 11(1):290. 28. Simborg DW: DRG Creep: A New Hospital-Acquired Disease. N Engl J Med 1981, 304(26):1602–1604. 29. Agrawal S: Educating Physicians About Responsible Management of Finite Resources. JAMA 2013, 309(11):1115. 30. Lee A, Siu S, Lam A, Tsang C, Kung K, Li P: The concepts of family doctor and the factors affecting choice of family doctors among Hong Kong people. Hong Kong Med J 2010, 16:18–25. 31. Chan C: What do patients expect from consultations for upper respiratory tract infections? Fam Pract 1996, 13:229–235. 32. Duijvestijn Y, Mourdi N, Smucny J, Pons G, Chalumeau M: Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochran Database Syst Rev 2009, 1:CD003124. 33. Smith S, Schroeder K, Fahey T: Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochran Database Syst Rev 2008, 1:CD001831. 34. Kim S, Chang Y, Cho H, Hwang Y, Moon Y: Non-steroidal anti- inflammatory drugs for the common cold. Cochran Database Syst Rev 2009, 3:CD006362. 35. Arroll B: Respiratory disorders (acute) - common cold. Clinical Evidence 2011, 03:1510. Submit your next manuscript to BioMed Central 36. Hong Kong Department of Health, Pharmaceutical Registration Section: Drug alert on the use of oral liquid cough medicines containing codeine. Hong and take full advantage of: Kong: Department of Health; 2010. 37. Church M, Maurer M, Simons F, Bindslev-Jensen C, van Cauwenberge P, • Convenient online submission Bousquet J, Holgate ST, Zuberbier T: Risk of first-generation H1- antihistamines: • Thorough peer review aGA2LEN position paper. Allergy 2010, 65:459–466. 38. Ng D: Prescription of codeine in young infants. Hong Kong Med J 2004, • No space constraints or color figure charges 10(6):439. • Immediate publication on acceptance 39. Medicines and Healthcare Products Regulatory Agency: Oral liquid cough • Inclusion in PubMed, CAS, Scopus and Google Scholar medicines containing codeine: should not be used in children and young people under 18 years. MHRA Public Assessment Report; 2010. http://www. • Research which is freely available for redistribution mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con096798. pdf. Last accessed 8 May 2014. Submit your manuscript at www.biomedcentral.com/submit

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BMC Family Practice – Springer Journals

Published: May 13, 2014

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