Later-Career Physicians Most Likely to Overprescribe Antibiotics

Jennifer Garcia

May 08, 2017

Almost half of elderly patients with nonbacterial acute upper respiratory infections (AURIs) received an antibiotic prescription, a new study has found. Later-career physicians and those from high-volume practices were more inclined to prescribe them.

"We found that nearly 1 in 2 elderly patients who visited a primary care physician for a nonbacterial AURI received an antibiotic prescription," and that "the greatest source of variability in prescribing rates was the provider," the authors write in an article published online May 8 in the Annals of Internal Medicine.

Michael Silverman, MD, from Schulich School of Medicine and Dentistry, St. Joseph's Health Care, London, Ontario, Canada, and colleagues evaluated records from patients who visited their primary care physician between January 1 and December 31, 2012.

The study included 185,014 patients aged 66 years or older who sought care for nonbacterial AURIs, including the common cold, acute bronchitis, acute sinusitis, or acute laryngitis. The study excluded patients with a diagnosed bacterial infection and high-risk patients, including those with immunosuppressive conditions, neoplasia, and those living in long-term care facilities. The majority of patients were managed by a single physician; the cohort included 8990 unique physicians.

Physicians prescribed antibiotics to 46.2% of patients. Patient characteristics were similar overall; however, those who received antibiotics were more likely to have acute bronchitis (45.3% vs 19.3%) or acute sinusitis (17.1% vs 10.6%) and had been prescribed antibiotics in the previous year (34.2% vs 27.7%).

Further, the researchers found that among physicians, prescribing rates were "highest among late-career physicians (median, 42.9%) and among physicians whose daily patient volume exceeded 45 patients per day (median, 47.7%)." Prescribing rates were lower among physicians with a hospital affiliation, as well as those who had received their medical training in Canada or the United States compared with those physicians who had trained abroad.

The authors note that although no causal inferences can be made on the basis of this study data, these findings are consistent with the finding of a recent systematic review that found that "physicians who have been practicing longer are less likely to adhere to new standards of care," Dr Silverman and colleagues write.

The researchers specifically note that broad spectrum antibiotics were the most commonly prescribed antibiotic type (69.9% of prescriptions), including macrolides (48.9%), cephalosporins (11.4%), and fluoroquinolones (9.6%). The use of broad spectrum antibiotics directly contradicts current clinical guidelines, which do not recommend the use of these antibiotics for any of the four conditions included in the study.

The authors acknowledge study limitations such as not knowing the rationale for specific antibiotic recommendations or the accuracy of the diagnostic data. The fact that only patients older than 65 years were included in the cohort also limits the generalizability of the findings.

"Our findings should be considered when planning interventions to reduce inappropriate prescribing," the authors write. "Because clinical guidelines and other approaches to behavioral change do not appear to have had the desired effect on practice, further research on alternative strategies to deter inappropriate antibiotic prescribing is needed," they conclude.

Funding for this study was provided by the Ontario Ministry of Health and Long-term Care, Academic Medical Organization of Southwestern Ontario, Schulich School of Medicine and Dentistry, Western University, and Lawson Health Research Institute. The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 8, 2017. Article

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