Provider Factors Tied to Unneeded Antibiotic Prescriptions

Marcia Frellick

January 31, 2018

Nurse practitioners (NPs) and physician assistants (PAs) are more likely than physicians to prescribe unneeded antibiotics for adult patients compared with physicians, a new study shows.

Monica L Schmidt, PhD, from the Center for Outcomes Research and Evaluation in Charlotte, North Carolina, and colleagues collected electronic medical record data from 448,990 outpatient visits between January 2014 and May 2016 for common upper respiratory conditions that should not need antibiotics. The visits spanned 898 providers and 246 practices in Carolinas HealthCare System urgent care, family medicine, internal medicine, and pediatric practices.

They focused on four conditions that do not usually require antibiotics: acute upper respiratory infection, acute bronchitis, bronchiolitis, and nonsuppurative otitis media. There was no overlap among acute bronchitis, bronchiolitis, and upper respiratory infection.

The overall prescribing rate for antibiotics in these nonindicated conditions was 407 per 1000 visits (95% confidence interval [CI], 405 - 408), the researchers report in an article published online January 30 in Infection Control & Hospital Epidemiology.

NPs, PAs More Likely to Prescribe

After adjusting for practice and patient characteristics, NPs and PAs were 15% more likely to prescribe antibiotics to adult patients compared with physicians (incident risk ratio, 1.15; 95% CI, 1.03 - 1.29). For pediatric patients, however, there was no difference in prescribing rates.

The authors note that their results are in line with previous studies. "Future national stewardship efforts should target education and antimicrobial stewardship interventions for [advance practice providers] as their role in patient care continues to grow," they write.

Among pediatric visits, older providers (aged 51 - 60 years) were 4 times more likely to prescribe an antibiotic than providers aged 30 years or younger (incident risk ratio, 4.21; 95% CI, 2.96 - 5.97). Moreover, when stratified by indication, the authors found that prescription rates went up with provider age up to age 61 years across all indications.

Patient Factors

The authors also found that patient factors affected the likelihood of prescription. For example, prescribing rates were 36% higher for adults in urban vs rural practice areas, after adjusting for practice and provider factors (incident risk ratio, 1.36; 95% CI, 1.15 - 1.61).

Acute bronchitis had the highest rate for inappropriate prescribing by any provider, at 703 prescriptions per 1000 visits (95% CI, 700 - 706).

Azithromycin was the most common drug prescribed for bronchitis in both adults and children.

"Previous studies and our results suggest that patient and provider education on appropriate prescribing for bronchitis, including guidance on correct use of azithromycin, may be an effective way to reduce prescribing rates," the authors write.

Also as reported in previous studies, the authors found that white patients were more likely to receive antibiotics vs patients of other ethnicities/races, and people in commercial care plans were more likely to receive them than were patients covered by Medicare or Medicaid.

Evidence for a Targeted Approach

The authors say the findings suggest a more targeted approach to stewardship practices and better supports in outpatient settings.

"At Carolinas HealthCare System, we've equipped our outpatient providers with scripts and educational materials to help guide conversations with patients about antibiotics," coauthor Lisa Davidson, MD, medical director for the Antimicrobial Support Network at Carolinas HealthCare System, said in a news release. "We've also given them checklists for over-the-counter medicines, which they can recommend to patients who have viral symptoms."

The results of the study could be key in reducing inappropriate prescriptions in a setting where they are comparatively high compared with inpatient settings.

"[N]ational data demonstrate that the volume of antibiotics used in the outpatient setting is much greater, with up to 30% of all outpatient antibiotic prescriptions deemed unnecessary and up to 50% inappropriate for the indication," the authors write.

The authors have disclosed no relevant financial relationships.

Infect Control Hosp Epidemiol. Published online January 30, 2018. Abstract

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