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Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

Published online by Cambridge University Press:  14 December 2020

James L. Lowery III ,
Bruce Alexander ,
Rajeshwari Nair ,
Brett H. Heintz  and
Daniel J. Livorsi Open the ORCID record for Daniel J. Livorsi [Opens in a new window]
James L. Lowery III
Affiliation:
Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
Bruce Alexander
Affiliation:
Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
Rajeshwari Nair
Affiliation:
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
Brett H. Heintz
Affiliation:
Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
Daniel J. Livorsi*
Affiliation:
Iowa City Veterans Affairs Health Care System, Iowa City, Iowa Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
*
Author for correspondence: Daniel Livorsi, E-mail: [email protected]
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Abstract

Objective:

Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs).

Design:

This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis.

Results:

There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001).

Conclusions:

Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 42 , Issue 6 , June 2021 , pp. 694 - 701
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Copyright
© The Author(s), 2020. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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Footnotes

PREVIOUS PRESENTATION: This work was presented at the Iowa Pharmacy Association’s Innovation and Research Forum conducted virtually in June 2020.

References

Antibiotic resistance threats in the United States. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Published 2019. Accessed July 3, 2020.Google Scholar
Suda, KJ, Hicks, LA, Roberts, RM, Hunkler, RJ, Matusiak, LM, Schumock, GT. Antibiotic expenditures by medication, class, and healthcare setting in the United States, 2010–2015. Clin Infect Dis 2018;66:185–190.CrossRefGoogle ScholarPubMed
National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf. Published 2017. Accessed July 3, 2020.Google Scholar
Dolan, S. How the growth of the urgent care industry business model is changing the healthcare market. Business Insider website. https://www.businessinsider.com/urgent-care-industry-trends. Published 2019. Accessed July 3, 2020.Google Scholar
Palms, DL, Hicks, LA, Bartoces, M, et al. Comparison of antibiotic prescribing in retail clinics, urgent care centers, emergency departments, and traditional ambulatory care settings in the United States. JAMA Intern Med 2018;178:1267–1269.CrossRefGoogle ScholarPubMed
Stenehjem, E, Wallin, AL, Fleming-Dutra, KE, et al. Antibiotic prescribing variability in a large urgent care network: a new target for outpatient stewardship. Clin Infect Dis 2020;70:1781–1787.CrossRefGoogle Scholar
May, L, Yadav, K, Gaona, SD, et al. MITIGATE antimicrobial stewardship toolkit: a guide for practical implementation in adult and pediatric emergency department and urgent care settings, 2018. Society for Healthcare Epidemiology of America website http://shea-online.org/images/priority-topics/MITIGATE_TOOLKIT_final.pdf. Published 2018. Accessed January 24, 2020.Google Scholar
Yadav, K, Meeker, D, Mistry, RD, et al. A multifaceted intervention improves prescribing for acute respiratory infection for adults and children in emergency department and urgent care settings. Acad Emerg Med 2019;26:719–731.CrossRefGoogle ScholarPubMed
Suda, KJ, Livorsi, DJ, Goto, M, et al. Research agenda for antimicrobial stewardship in the Veterans’ Health Administration. Infect Control Hosp Epidemiol 2018;39:196–201.CrossRefGoogle Scholar
Bohan, JG, Madaras-Kelly, K, Pontefract, B, et al. Evaluation of uncomplicated acute respiratory tract infection management in veterans: a national utilization review. Infect Control Hosp Epidemiol 2019;40:438–446.CrossRefGoogle ScholarPubMed
Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.CrossRefGoogle ScholarPubMed
National Healthcare Safety Network. Antimicrobial use and resistance module. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf. Accessed May 20, 2020.Google Scholar
Chua, KP, Fischer, MA, Linder, JA. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ 2019;364:k5092.CrossRefGoogle ScholarPubMed
Volgelmeir, C, Agusti, A, Anzueto, A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease website. https://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/pdf/GOLD_Report_2015_Apr2.pdf. Published 2015. Accessed July 6, 2020.Google Scholar
Shulman, ST, Bisno, AL, Clegg, HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:e86–e102.CrossRefGoogle Scholar
Mandell, LA, Wunderink, RG, Anzueto, A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 suppl 2:S27–S72.CrossRefGoogle Scholar
Chow, AW, Benninger, MS, Brook, I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72–e112.CrossRefGoogle ScholarPubMed
Harris, AM, Hicks, LA, Qaseem, A. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016;164:425–434.CrossRefGoogle ScholarPubMed
Hersh, AL, Fleming-Dutra, KE, Shapiro, DJ, Hyun, DY, Hicks, LA. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016;176:1870–1872.CrossRefGoogle ScholarPubMed
Jones, BE, Sauer, B, Jones, MM, et al. Variation in outpatient antibiotic prescribing for acute respiratory infections in the veteran population: a cross-sectional study. Ann Intern Med 2015;163:73–80.CrossRefGoogle ScholarPubMed
Donnelly, JP, Baddley, JW, Wang, HE. Antibiotic utilization for acute respiratory tract infections in US emergency departments. Antimicrob Agents Chemother 2014;58:1451–1457.CrossRefGoogle Scholar
Stoll, K, Feltz, E, Ebert, S. Pharmacist-driven implementation of outpatient antibiotic prescribing algorithms improves guideline adherence in the emergency department. J Pharm Pract 2020. doi: 10.1177/0897190020930979.CrossRefGoogle ScholarPubMed
Timbrook, TT, Caffrey, AR, Ovalle, A, et al. Assessments of opportunities to improve antibiotic prescribing in an emergency department: a period prevalence survey. Infect Dis Ther 2017;6:497–505.CrossRefGoogle Scholar
Kiel, A, Catalano, A, Clark, CM, et al. Antibiotic prescribing in the emergency department versus primary care: Implications for stewardship. J Am Pharm Assoc 2020. doi: 10.1016/j.japh.2020.03.016.CrossRefGoogle ScholarPubMed
Meyer, HE, Lund, BC, Heintz, BH, Alexander, B, Egge, JA, Livorsi, DJ. Identifying opportunities to improve guideline-concordant antibiotic prescribing in veterans with acute respiratory infections or cystitis. Infect Control Hosp Epidemiol 2017;38:724–728.CrossRefGoogle ScholarPubMed
Morris, AM, Calderwood, MS, Fridkin, SK, et al. Research needs in antibiotic stewardship. Infect Control Hosp Epidemiol 2019;40:1334–1343.CrossRefGoogle ScholarPubMed
Pulia, M, Redwood, R, May, L. Antimicrobial stewardship in the emergency department. Emerg Med Clin North Am 2018;36:853–872.CrossRefGoogle ScholarPubMed
Maselli, JH, Gonzales, R, Colorado Medical Society Joint Data Project. Measuring antibiotic prescribing practices among ambulatory physicians: accuracy of administrative claims data. J Clin Epidemiol 2001;54:196–201.CrossRefGoogle ScholarPubMed
Aronsky, D, Haug, PJ, Lagor, C, Dean, NC. Accuracy of administrative data for identifying patients with pneumonia. Am J Med Qual 2005;20:319–328.CrossRefGoogle ScholarPubMed
Ginde, AA, Tsai, CL, Blanc, PG, Camargo, CA Jr Positive predictive value of ICD-9-CM codes to detect acute exacerbation of COPD in the emergency department. Jt Comm J Qual Patient Saf 2008;34:678–680.Google ScholarPubMed
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