Original Article
Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections
Abstract
Objectives: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers’ adjusted prescribing rates and a number of patient outcomes.Methods: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011–2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic.
Results: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt.
Conclusions: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.
This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiotic-resistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis 2008;46:155-164.
2. Centers for Disease Control and Prevention. Office-related antibiotic prescribing for persons aged ≤ 14 years-United States, 1993-1994 to 2007-2008. MMWR Morb Mortal Wkly Rep 2011;60:1153-1156.
3. Pichichero ME. Dynamics of antibiotic prescribing for children. JAMA 2002;287:3133-3135.
4. Shapiro DJ, Hicks LA, Pavia AT, et al. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother 2014;69:234-240.
5. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med 2001;134:479-486.
6. Gonzales R, Malone DC, Maselli JH, et al. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis 2001;33:757-762.
7. Herz MJ. Antibiotics and the adult sore throat-an unnecessary ceremony. Fam Pract 1988;5:196-199.
8. Little P, Gould C, Williamson I, et al. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315:350-352.
9. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005;4:CD003539.
10. Barlam TF, Morgan JR, Wetzler LM, et al. Antibiotics for respiratory tract infections: a comparison of prescribing in an outpatient setting. Infect Control Hosp Epidemiol 2015;36:153-159.
11. 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.
12. Zhang Y, Steinman MA, Kaplan CM. Geographic variation in outpatient antibiotic prescribing among older adults. Arch Intern Med 2012;172:1465-1471.
13. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015;60:1308-1316.
14. Lee GC, Reveles KR, Attridge RT, et al. Outpatient antibiotic prescribing in the United States: 2000 to 2010. BMC Med 2014;12:96.
15. Angunawela II, Diwan VK, Tomson G. Experimental evaluation of the effects of drug information on antibiotic prescribing: a study in outpatient care in an area of Sri Lanka. Int J Epidemiol 1991;20:558-564.
16. Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based "detailing." N Engl J Med 1983;308:1457-1463.
17. Schaffner W, Ray WA, Federspiel CF, et al. Improving antibiotic prescribing in office practice. A controlled trial of three educational methods. JAMA 1983;250:1728-1732.
18. O'Connell DL, Henry D, Tomlins R. Randomised controlled trial of effect of feedback on general practitioners’ prescribing in Australia. BMJ 1999;318:507-511.
19. Rokstad K, Straand J, Fugelli P. Can drug treatment be improved by feedback on prescribing profiles combined with therapeutic recommendations? A prospective, controlled trial in general practice. J Clin Epidemiol 1995;48:1061-1068.
20. Hux JE, Melady MP, DeBoer D. Confidential prescriber feedback and education to improve antibiotic use in primary care: a controlled trial. CMAJ 1999;161:388-392.
21. Mainous AG, 3rd Hueston WJ, Love MM, et al. An evaluation of statewide strategies to reduce antibiotic overuse. Fam Med 2000;32:22-29.
22. McIsaac WJ, Goel V, To T, et al. Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study. J Fam Pract 2002;51:339-344.
23. Christakis DA, Zimmerman FJ, Wright JA, et al. A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. Pediatrics 2001;107:E15.
24. McConnell TS, Cushing AH, Bankhurst AD, et al. Physician behavior modification using claims data: tetracycline for upper respiratory infection. West J Med 1982;137:448-450.
25. Font M, Madridejos R, Catalan A, et al. Improving drug prescription in primary care: a controlled and randomized study of an educational method. Med Clin (Barc) 1991;96:201-205.
26. Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial. J Fam Pract 2002;51:324-328.
27. Dowell J, Pitkethly M, Bain J, et al. A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care. Br J Gen Pract 2001;51:200-205.
28. Little P, Gould C, Williamson I, et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 2001;322:336-342.
29. Finkelstein JA, Davis RL, Dowell SF, et al. Reducing antibiotic use in children: a randomized trial in 12 practices. Pediatrics 2001;108:1-7.
30. Hennessy TW, Petersen KM, Bruden D, et al. Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae : a controlled intervention trial in rural Alaska. Clin Infect Dis 2002;34:1543-1550.
31. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA 2002;287:3103-3109.
32. Gonzales R, Steiner JF, Lum A, et al. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA 1999;281:1512-1519.
33. Vervloet M, Meulepas MA, Cals JW, et al. Reducing antibiotic prescriptions for respiratory tract infections in family practice: results of a cluster randomized controlled trial evaluating a multifaceted peer-group-based intervention. NPJ Prim Care Respir Med 2016;26:15083.
34. Drekonja DM, Filice GA, Greer N, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015;36:142-152.
35. Meeker D, Linder JA, Fox CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016;315:562-570.
36. Dempsey PP, Businger AC, Whaley LE, et al. Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC Fam Pract 2014;15:194.
37. Weiss MC, Deave T, Peters TJ, et al. Perceptions of patient expectation for an antibiotic: a comparison of walk-in centre nurses and GPs. Fam Pract 2004;21:492-499.
38. Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations-a questionnaire study. BMJ 1997;315:520-523.
39. Welschen I, Kuyvenhoven M, Hoes A, et al. Antibiotics for acute respiratory tract symptoms: patients’ expectations, GPs’ management and patient satisfaction. Fam Pract 2004;21:234-237.
40. Gulliford MC, Moore MV, Little P, et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016;354:i3410.
