Antibiotic Overuse Highest in Urgent Care Clinics

Diana Phillips

July 16, 2018

Patients treated in urgent care clinics are far more likely than those treated in other ambulatory care settings to be prescribed antibiotics for conditions that don't require them, new research has shown.

Specifically, 45.7% of urgent care patients with an antibiotic-inappropriate respiratory diagnosis — such as allergies, influenza, or the common cold — received an antibiotic prescription, compared with 24.6% of those treated in an emergency department (ED), 17.0% in medical offices, and 14.4% in retail clinics. 

Danielle L. Palms, MPH, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues report the results of their retrospective cohort study in an article published online today in JAMA Internal Medicine.

Using data from the 2014 Truven Health MarketScan Commercial Claims and Encounters Database, the investigators analyzed outpatient claims with facility codes for urgent care center, retail clinic, hospital-based ED, or medical office in their analysis. The outcome of interest was the percentage of visits linked to the prescription of antibiotics, stratified by setting and diagnosis.

"We focused on antibiotic-inappropriate respiratory diagnoses (ie, diagnoses for which antibiotics are unnecessary based on clinical practice guidelines: viral upper respiratory infection, bronchitis/bronchiolitis, asthma/allergy, influenza, nonsuppurative otitis media, and viral pneumonia)," the authors explain.

The percentage of visits in which antibiotics were prescribed relative to all visits varied substantially by setting. Of 2.7 million urgent care center visits, 39.0% included antibiotic prescriptions (95% confidence interval [CI], 39.0% - 39.1%). The proportion was similar in retail clinics, at 36.4% of 58,206 visits (95% CI, 36.0% - 36.8%), but substantially lower in EDs and medical offices, at 13.8% of 4.8 million visits (95% CI, 13.8% - 13.8%) and 7.1% of 148.5 million visits (95% CI, 7.1% - 7.1%), respectively.

Patients with respiratory diagnoses that did not require antibiotics made up a larger proportion of visits at retail and urgent care clinics than of visits in other ambulatory settings. Specifically, the percentage of visits linked to antibiotic-inappropriate respiratory diagnoses was 17% (n = 10,009) for retail clinic visits, 16% (n = 441,605) for urgent care centers, 6% (n = 9,203,276) for medical offices, and 5% (n = 257,010) for EDs. As noted, antibiotics were prescribed for nearly half of urgent care center visits with an antibiotic-inappropriate respiratory diagnosis.

"These patterns suggest differences in case mix and evidence of antibiotic overuse, especially in urgent care centers. This finding is important because urgent care and retail clinic markets are growing," Palms and colleagues write.

The findings also suggest that previous estimates of unnecessary antibiotic prescriptions based on data from EDs and medical practices may underestimate the scope of the problem, they note.

In an invited commentary,  Michael A. Incze, MD, a resident in the Department of Medicine at the University of California, San Francisco, and colleagues emphasize that the growth of the urgent care and retail clinic sector makes these findings all the more alarming. "The urgent care sector is growing at an astronomical rate, representing a $15 billion industry with more than 10 000 high-volume clinics nationwide," they write

Further, an unexpected consequence of the convenience, same-day access, and reduced costs of urgent and retail clinics might be patients' increased willingness to seek care for mild self-resolving illnesses that would be better treated with rest and symptom management at home. "Indeed, the authors found that a shocking percentage (54%) of visits to these sites were for upper respiratory tract conditions. Antibiotic prescriptions for this group were 2 to 3 times higher at urgent care centers than at other outpatient sites."

The editorialists also suggest that the business model that supports the creation of urgent care and retail care clinics may not align with incentive-based interventions to reduce inappropriate antibiotic prescribing. "Patients may seek care in one of these clinics specifically because they desire antibiotics, and clinicians may worry that patients will not return to urgent care in the future if their expectations are not met," they hypothesize.

Moreover, innovations that have proven effective in other settings, such as telephone-based triage consultations, would similarly conflict with business goals and perceived value of urgent care and retail clinics, which is to provide quick, convenient access to diagnoses and treatment of acute conditions, they write.

However, the study findings suggest that umbrella generalizations covering urgent care and retail clinics may be oversimplistic. "There are both differences and similarities between urgent care centers and retail clinics when it comes to antibiotic prescribing," according to study author David Y. Hyun, MD, an infectious disease specialist from the Pew Charitable Trusts, Washington, DC.

"When we looked at how much antibiotics are prescribed for conditions where antibiotics are not indicated, urgent care centers had by far the highest rates among the four outpatient settings while retail clinic had the lowest rates," he said. "However, for conditions where antibiotics are sometimes indicated, there is less variability, with retail clinics trending towards higher rates than the other outpatient settings." Examples of some of the latter conditions include sinusitis, acute otitis media, and pharyngitis.

"Our study underscores the need for antibiotic stewardship in all outpatient settings where antibiotics are being prescribed, including both urgent care centers and retail clinics, and that there is room for improvement across the board," Hyun told Medscape Medical News.

While the current study didn't investigate the potential drivers that could account for the prescribing patterns seen in urgent care centers and retail clinics, "other studies have shown that outpatient providers are significantly influenced by social drivers when it comes to antibiotic prescribing decisions, including patient pressure and demand," Hyun continued. "Successful outpatient antibiotic stewardship will require a better understanding of these social drivers specific to each outpatient setting and tailoring stewardship strategies accordingly that can help both providers and patients when it comes to antibiotic use."

The study was conducted as part of an ongoing collaboration between the Centers for Disease Control and Prevention and the Pew Charitable Trusts.  The authors of the study and accompanying editorial have disclosed no relevant financial relationships.

JAMA Intern Med. Published online July 16, 2018. Full text, Editorial

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