Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-23T11:54:10.191Z Has data issue: false hasContentIssue false
  • English
  • Français

Patient, Provider, and Practice Characteristics Associated with Inappropriate Antimicrobial Prescribing in Ambulatory Practices

Published online by Cambridge University Press:  30 January 2018

Monica L. Schmidt ,
Melanie D. Spencer  and
Lisa E. Davidson
Monica L. Schmidt*
Affiliation:
Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina
Melanie D. Spencer
Affiliation:
Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina
Lisa E. Davidson
Affiliation:
Division of Infectious Disease, Carolinas Medical Center, Carolinas HealthCare System, Charlotte, North Carolina
*
Address correspondence to Melanie D. Spencer, PhD, MBA, Center for Outcomes Research and Evaluation, 1540 Garden Terrace Suite 406, Carolinas HealthCare System, Charlotte, North Carolina 28203 ([email protected]).
Get access Rights & Permissions [Opens in a new window]

Abstract

OBJECTIVE

To reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.

DESIGN, SETTING, AND PARTICIPANTS

Data for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.

METHODS

Prescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.

RESULTS

The overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).

CONCLUSIONS

Our results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.

Infect Control Hosp Epidemiol 2018;39:307–315

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 3 , March 2018 , pp. 307 - 315
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Talkington, K, Hyun, D, Zetts, R, Kothari, P. Antibiotic use in outpatient settings. The Pew Charitable Trusts website. http://www.pewtrusts.org/~/media/assets/2016/05/antibioticuseinoutpatientsettings.pdf; Published May 2016. Accessed November 5, 2017.Google Scholar
2. Snow, V, Mottur-Pilson, C, Gonzales, R, et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults. Ann Intern Med 2001;134:487–489.CrossRefGoogle ScholarPubMed
3. Harris, AM, Hicks, LA, Qaseem, A, High Value Care Task Force of the American College of P, for the Centers for Disease C, Prevention. 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
4. Napolitano, LM. Emerging issues in the diagnosis and management of infections caused by multi-drug-resistant, gram-positive cocci. Surg Infect (Larchmt) 2005;6(Suppl 2):S5–S22.CrossRefGoogle ScholarPubMed
5. Branski, LK, Al-Mousawi, A, Rivero, H, Jeschke, MG, Sanford, AP, Herndon, DN. Emerging infections in burns. Surg Infect (Larchmt) 2009;10:389–397.CrossRefGoogle ScholarPubMed
6. Davoudi, A, Najafi, N, Alian, S, et al. Resistance pattern of antibiotics in patient underwent open heart surgery with nosocomial infection in north of Iran. Glob J Health Sci 2015;8:288–297.CrossRefGoogle ScholarPubMed
7. Bassetti, M, Carnelutti, A, Peghin, M. Patient specific risk stratification for antimicrobial resistance and possible treatment strategies in gram-negative bacterial infections. Expert Rev Anti Infect Ther 2017;15:55–65.CrossRefGoogle ScholarPubMed
8. National action plan for combating antibiotic-resistant bacteria. The White House website. https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Published 2015. Accessed October 20, 2016.Google Scholar
9. Sanchez, GV, Hersh, AL, Shapiro, DJ, Cawley, JF, Hicks, LA. Outpatient antibiotic prescribing among United States nurse practitioners and physician assistants. Open Forum Infect Dis 2016;3:ofw168.CrossRefGoogle ScholarPubMed
10. Roberts, RM, Hicks, LA, Bartoces, M. Variation in US outpatient antibiotic prescribing quality measures according to health plan and geography. Am J Manage Care 2016;22:519–523.Google ScholarPubMed
11. Shamsuddin, S, Akkawi, ME, Zaidi, ST, Ming, LC, Manan, MM. Antimicrobial drug use in primary healthcare clinics: a retrospective evaluation. Int J Infect Dis 2016;52:16–22.CrossRefGoogle ScholarPubMed
12. 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
13. Dyar, OJ, Beovic, B, Vlahovic-Palcevski, V, Verheij, T, Pulcini, C. How can we improve antibiotic prescribing in primary care? Expert Rev Anti-infect Ther 2016;14:403–413.CrossRefGoogle ScholarPubMed
14. Tamma, PD, Cosgrove, SE. Addressing the appropriateness of outpatient antibiotic prescribing in the United States: an important first step. JAMA 2016;315:1839–1841.CrossRefGoogle ScholarPubMed
15. American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics 2004;113:1412–1429.CrossRefGoogle Scholar
16. Ralston, SL, Lieberthal, AS, Meissner, HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. pediatrics. 2014;134:e1474–e1502. Pediatrics 2015;136:782.Google Scholar
17. Hersh, AL, Jackson, MA, Hicks, LA, American Academy of Pediatrics Committee on Infectious Diseases. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics 2013;132:1146–1154.CrossRefGoogle ScholarPubMed
18. Snow, V, Mottur-Pilson, C, Gonzales, R, et al. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med 2001;134:518–520.CrossRefGoogle ScholarPubMed
19. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128:595–610.CrossRefGoogle Scholar
20. 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
21. Cameron, AC, Pravin, K. Microeconomics Using Stata. College Station, TX: Stata Press; 2010.Google Scholar
22. Zou, GY, Donner, A. Extension of the modified Poisson regression model to prospective studies with correlated binary data. Statist Method Med Res 2013;22:661–670.CrossRefGoogle ScholarPubMed
23. Zou, G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004;159:702–706.CrossRefGoogle ScholarPubMed
24. McKay, R, Mah, A, Law, MR, McGrail, K, Patrick, DM. Systematic review of factors associated with antibiotic prescribing for respiratory tract infections. Antimicrob Agents Chemother 2016;60:4106–4118.CrossRefGoogle ScholarPubMed
25. Ivanovska, V, Hek, K, Mantel Teeuwisse, AK, Leufkens, HG, Nielen, MM, van Dijk, L. Antibiotic prescribing for children in primary care and adherence to treatment guidelines. J Antimicrob Chemother 2016;71:1707–1714.CrossRefGoogle ScholarPubMed
26. Ubhi, H, Patel, M, Ludwig, L. How well do outpatient prescriptions adhere to good antimicrobial stewardship? Arch Dis Child 2016;101:e2.CrossRefGoogle ScholarPubMed
27. Drekonja, DM, Filice, GA, Greer, N, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015;36:142–152.CrossRefGoogle ScholarPubMed
28. Sanchez, GV, Fleming-Dutra, KE, Roberts, RM, Hicks, LA. Core elements of outpatient antibiotic stewardship. MMWR 2016;65:1–12.Google ScholarPubMed
29. Dobson, EL, Klepser, ME, Pogue, JM, et al. Outpatient antibiotic stewardship: Interventions and opportunities. JAPhA 2017;57:464–473.Google ScholarPubMed
30. Drekonja, D, Filice, G, Greer, N, et al. Antimicrobial Stewardship Programs in Outpatient Settings: A Systematic Review. Washington, DC: Department of Veterans Affairs; 2014.Google ScholarPubMed
31. Pollack, LA, Srinivasan, A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014;59(Suppl 3):S97–S100.CrossRefGoogle ScholarPubMed
32. Centers for Disease Control and Prevention. Office-related antibiotic prescribing for persons aged ≤14 years—United States, 1993–1994 to 2007–2008. MMWR 2011;60:1153–1156.Google Scholar
33. Gangat, MA, Hsu, JL. Antibiotic stewardship: a focus on ambulatory care. S Dak Med 2015;Spec No:44–48.Google ScholarPubMed
34. Fleming-Dutra, KE, Demirjian, A, Bartoces, M, Roberts, RM, Taylor, TH Jr, Hicks, LA. Variations in antibiotic and azithromycin prescribing for children by geography and specialty—United States, 2013. Pediatr Infect Dis J 2017. PMID: 28746259; doi: 10.1097/INF.0000000000001708.CrossRefGoogle Scholar
35. Pinto, LA, Pitrez, PM, Luisi, F, et al. Azithromycin therapy in hospitalized infants with acute bronchiolitis is not associated with better clinical outcomes: a randomized, double-blinded, and placebo-controlled clinical trial. J Pediatr 2012;161:1104–1108.CrossRefGoogle Scholar
36. Kuzujanakis, M, Kleinman, K, Rifas-Shiman, S, Finkelstein, JA. Correlates of parental antibiotic knowledge, demand, and reported use. Ambul Pediatr 2003;3:203–210.2.0.CO;2>CrossRefGoogle ScholarPubMed
37. Altiner, A, Brockmann, S, Sielk, M, Wilm, S, Wegscheider, K, Abholz, HH. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother 2007;60:638–644.CrossRefGoogle ScholarPubMed
38. Holmes, JH, Metlay, J, Holmes, WC, Mikanatha, N. Developing a patient intervention to reduce antibiotic overuse. AMIA Annu Symp Proc 2003:864.Google ScholarPubMed
39. Pechere, JC. Patients’ interviews and misuse of antibiotics. Clin Infect Dis 2001;33(Suppl 3):S170–S173.CrossRefGoogle ScholarPubMed
40. 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
41. Antibiotic prescription fill rates declining in the United States. In: The Health of America Report. BlueCross BlueShield website. https://www.bcbs.com/the-health-of-america/reports/antibiotic-prescription-rates-declining-in-the-US. Published August 2017. Accessed November 5, 2017.Google Scholar
42. Gerber, JS, Prasad, PA, Localio, AR, et al. Racial differences in antibiotic prescribing by primary care pediatricians. Pediatrics 2013;131:677–684.CrossRefGoogle ScholarPubMed
43. Gahbauer, AM, Gonzales, ML, Guglielmo, BJ. Patterns of antibacterial use and impact of age, race/ethnicity, and geographic region on antibacterial use in an outpatient medicaid cohort. Pharmacotherapy 2014;34:677–685.CrossRefGoogle Scholar
44. Mangione-Smith, R, Elliott, MN, Stivers, T, McDonald, L, Heritage, J, McGlynn, EA. Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns. Pediatrics 2004;113:e385–e394.CrossRefGoogle ScholarPubMed
45. Kornblith, AE, Fahimi, J, Kanzaria, HK, Wang, RC. Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics. Am J Emerg Med 2017 Jul 28. pii: S0735-6757(17)30632-0. doi: 10.1016/j.ajem.2017.07.081.Google Scholar
46. Fleming-Dutra, KE, Shapiro, DJ, Hicks, LA, Gerber, JS, Hersh, AL. Race, otitis media, and antibiotic selection. Pediatrics 2014;134:1059–1066.CrossRefGoogle ScholarPubMed
47. Watson, JR, Wang, L, Klima, J, et al. Healthcare claims data: an underutilized tool for pediatric outpatient antimicrobial stewardship. Clin Infect Dis 2017;64:1479–1485.CrossRefGoogle ScholarPubMed
48. McCullough, AR, Pollack, AJ, Plejdrup Hansen, M, et al. Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations. Med J Aust 2017;207:65–69.CrossRefGoogle ScholarPubMed
49. 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
Supplementary material: PDF

Schmidt et al. supplementary material

Tables S1-S4

Download Schmidt et al. supplementary material(PDF)
PDF 39 KB