Our study indicated that there were both pros and cons in antibiotic use by having a regular doctor. After controlling for the confounding factors of age, sex, education, income and private or public system attended, the respondents with a regular doctor only exhibited more positive results than other respondents in one aspect: more likely to report finishing the full course of antibiotics, which matched with our hypothesis 2. However, contrary to hypothesis 1, the respondents with a regular doctor were much more likely (OR = 1.76, 95 % CI:(1.27, 2.48)) to report using antibiotics in their last consultation for URTI. This finding did not echo the common belief that an established doctor-patient relationship in primary care would minimize inappropriate use of antibiotics [6, 13]. For hypothesis 3 that patients with a regular doctor had stronger intention to prevent antibiotic resistance, it was refuted after adjusting for confounding factors.
It is known that non-biomedical reasons can affect doctors’ antibiotic prescriptions for patients [3]. This study focused on the potential effect of having a regular doctor. Although we strongly acknowledge the benefits of continuity of care which enhances patient satisfaction and preventive care, [7, 9–11] our findings alert us to its potential drawbacks which might be neglected or under-reported in previous studies [24]. A recent qualitative study reported that primary care physicians felt easier to say “No” to long standing patients than to new patients when requests for antibiotics were made [6]. Accordingly, patients with regular doctors should be more likely to be refused when making improper request for antibiotics. However, the quantitative finding of this study showed the opposite, and this was consistent with our previous survey which found that patients who were attending doctors for follow-up consultations for infective illnesses were more likely to be prescribed antibiotics [25]. A possible explanation might be a concern that the unsatisfied patients would go elsewhere for future care, [1, 3, 5] which would have significant financial implications for the primary care physicians in a pluralistic healthcare system. Although we do not have clear evidence for the causes, our findings suggested a possible negative impact from the higher antibiotic prescription rate for URTI by regular doctors and it should be further studied in other countries. This may contribute to the global mission of reducing unnecessary antibiotic prescription in the primary care setting.
The proportion of respondents reporting use of antibiotics for URTIs in this study (17.0 %, Table 2) was slightly lower than the 23.7 % found in another local telephone survey conducted among the general public in 2008 [26]. Doctors in Hong Kong were getting increasingly cautious with the use of antibiotics [25]. In fact, among the respondents in the current survey who claimed that they did not ask for antibiotics during consultations, over 92 % of them considered “trust in the doctor” as the reason for not asking. In addition, a greater proportion of these respondents had regular doctors though the difference was of marginal statistical significance (OR = 1.59, 95 % CI:(1.01, 2.49)). Therefore, the doctors should value the patients’ trust and avoid over-perceiving their demand for antibiotics [1, 2].
Limitations of the study
Firstly, it is difficult to define without controversy what a “regular doctor” means. We used an intuitive definition in our questionnaire, “the doctor [whom] you see most of the time” to mean personal continuous care by a primary care physician. This definition is admittedly loose but probably most easily understood by the public in a telephone survey [19, 22]. A regular doctor was presumed to deliver continuous care instead of repeated episodic care. It is possible that patients having a regular doctor would still see other doctors on occasions (e.g. seeing the regular doctor for 80 % of the time but went elsewhere for the remaining 20 %).
Secondly, the study findings were based on self-reported data from the respondents. The findings were not validated with triangulation using actual clinical data. However, the potential recall bias should be small as the questions were asking about their usual practice or most recent experiences.
Thirdly, we assumed antibiotics were not needed for almost all cases of common cold/flu. Medical evidence suggests that antibiotics are not indicated for URTI except in the very rare cases like compromised immunity or for the very sick patients with serious comorbid diseases. Most URTIs among adults in the community are self-limited viral infections that can be treated without antibiotics [27]. The respondents of this study were from the ambient general population, hence the possibility of a medical indication for antibiotics for a URTI would be very rare.
Fourthly, this study focused on the impact of having a regular doctor. We used the multivariable logistic regression to adjust the effects of age, sex, education, income and type of healthcare system attended (private vs public). Nonetheless, we did not ask about the medical history of the respondents in the telephone survey. There was a possibility that the health status, URTI consultation rate of the respondents with a regular doctor were different from those without. If marked disparities did exist, the differences in antibiotic use observed between the two groups might not be due to having a regular doctor. It is worthwhile to conduct further studies in this respect. Finally, our findings in Hong Kong might not be generalizable to other countries.
