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Patient expectations of acute bronchitis not consistent with the best evidence

New research from the University of Georgia exposes a large discrepancy in the length of time patients expect an acute cough illness, also called acute bronchitis, to last and the reality of the illness. This mismatch may be a factor in the over-prescription of antibiotics.
Examining the gap in patient expectations and the actual length of time the body takes to rid itself of a chest cold, Dr. Mark Ebell, associate professor of epidemiology in the UGA College of Public Health, recently published an article in the Annals of Family Medicine. His results show that most patients expect to cough for seven to nine days. In reality, a bronchial illness takes closer to 18 days on average to run its course.

Ebell performed a meta-analysis by looking at 19 observational studies that each included between 23 and 1,230 patients and took place in the U.S., Europe, Russia and Kenya. He used the placebo or untreated control groups to determine that acute cough illness actually lasts an average of 17.8 days.

To gauge patient expectations, questions about the length of time a person thinks they should suffer with a cough were added to the bi-annual Georgia Poll, a random digit dialing survey of 500 Georgia residents from the UGA Survey Research Center. The results found people expected an illness to last only seven to nine days.

Ebell first realized disconnect in expectations and realities while working as a family practice physician. "There is a mismatch in what people believe and reality," Ebell said. "If someone gets acute bronchitis and isn't better after four to five days, they may think they need to see a doctor and get an antibiotic. And when the first one doesn't work, they come back four or five days later for another."

According to the Centers for Disease Control and Prevention, acute cough illness accounts for two to three percent of visits to outpatient physicians. Over half of these patients leave with a prescription for antibiotics. Ebell said this percentage should be much lower.

"We know from clinical trials there is very little, if any, benefit to antibiotic treatments for acute cough because most of these illnesses are caused by a virus," he said. "Among patients who receive antibiotics, about half of those will be very broad spectrum antibiotics that have the potential to increase antibiotic resistance. These are antibiotics that would be nice to still have around when we actually need them, like for someone who may have pneumonia."

Over-prescription of antibiotics leads to bacterial resistance and can severely limit the types of medicines physicians can prescribe when there's a serious health threat.

"We are already seeing types of infections that we don't have antibiotics for anymore," he said. "It is a real concern among public health officials that we will get to a point where we don't have antibiotics that work."

Ebell notes that besides antibiotic resistance, health care costs are another issue to be concerned about. Seeking medical attention can escalate the cost of a virus from $20 for an over-the-counter cough medicine and pain reliever to $200 for tests and prescriptions.

"We don't have an infinite amount of money in this country," he said. "We spend twice as much money per person as any other country on healthcare, but we don't achieve better outcomes overall. In fact, many of our outcomes are worse than other nations in Western Europe. We are spending a lot of money on things that don't make us healthier, and it is important to figure out what does work and what doesn't work."

Educating patients about the natural progression of illnesses will hopefully adjust their expectations, Ebell said.

Pulling data from the CDC, family physicians and local health departments, he is currently working on a Web portal that will advise people of their risk of certain illnesses. Using their symptoms to advise them whether to seek medical attention or not, Ebell said he hopes this effort will increase self-care and keep people from seeking unnecessary antibiotics.

Mark Ebell | EurekAlert!
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