Many Antibiotics Prescribed Without Clinic Visit

Veronica Hackethal, MD

February 03, 2020

More than one quarter of outpatient prescriptions for antibiotics among Medicaid recipients may be written without a clinic visit, according to a study published online February 3 in Health Affairs.

The study included Medicaid claims data for approximately 53 million patients covering a 10-year period. Results also showed that some antibiotics were prescribed during a clinic visit but that the patient had not been diagnosed with an infection.

"It seems inappropriate that 17 percent of antibiotic prescriptions were given without an infection-related diagnosis, and it's concerning that nearly one in five antibiotics are prescribed without a clear rationale," senior author Jeffrey Linder, MD, MPH, said in a news release. Linder is chief of general internal medicine and geriatrics in the Department of Medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

The implication is that antibiotic stewardship efforts aimed at curbing inappropriate antibiotic prescribing may completely miss a large percentage of antibiotic prescriptions.

In the United States, the rate of antibiotic prescribing is about twice that in similar countries. The United States ranks as the third largest consumer of antibiotics in the world. Cutting down on inappropriate antibiotic use is important for patient safety to avoid adverse reactions such as rash, diarrhea, and Clostridium difficile infection, which can be life-threatening and may occur when antibiotics kill off normal bowel bacteria. Antibiotic overuse may also contribute to the development of antibiotic resistance. Each year, approximately 23,000 people in the United States die from drug-resistant bacteria, and roughly 2 million people are sickened by them.

"The prescription of antibiotics outside of clinic visits is a big area where it's really hard to assess patients fully and to be sure that we're doing the right thing for our patients," author Michael Fischer, MD, told Medscape Medical News. Fischer is an associate professor of medicine at Harvard Medical School, Boston, Massachusetts.

"As a community, we want to be thinking about how we can understand and make changes that might make prescribing better," he said.

Fischer acknowledged that the analysis used claims data and so has inherent limitations. Chiefly, researchers could not evaluate clinical decision making and the reasons why antibiotics were prescribed. Understanding the context in which these antibiotics were prescribed will be an important next step for efforts at antibiotic stewardship.

"We're not saying that every one of these antibiotic prescriptions is clinically inappropriate or problematic. We don't have definitive answers with this study. But we are saying that we all need to look carefully at what's going on. We need to figure out whether this could be contributing to overuse and the problems that result from overuse," he said.

Regarding the question of whether results apply to non-Medicaid patients, Fischer said the study sample was fairly representative nationally.

"Medicaid is by far the largest insurer in the country. If anything, non-Medicaid patients might have more access to emailing their doctor through patient portals and may be even more likely to get antibiotics outside of a visit, although of course we don't have a way to know that," he added.

The researchers used Medicaid claims data for all 50 states and the District of Columbia. The data covered the period 2004–2013. They evaluated whether outpatient antibiotic prescriptions were associated with a clinic visit during the last 7 days and whether they were associated with an infection diagnosis. The analysis included 298 million antibiotic prescriptions filled by 53 million Medicaid recipients.

Results showed that 28% of antibiotic prescriptions occurred without a clinic visit in the past 7 days. About half of these prescriptions were associated with laboratory testing or home care services.

Seventeen percent of antibiotic prescriptions were associated with clinic visits in which the patient was not diagnosed as having an infection. Fifty-five percent of antibiotic prescriptions associated with a clinic visit were linked to an infection diagnosis.

Children were prescribed antibiotics without a clinic visit less often than adults. Antibiotic prescriptions without a clinic visit occurred in 23.7% of cases involving patients aged 17 years and younger, compared with 34.1% of cases for those aged 18 to 64 years and 41% of cases for those aged 65 years or older.

People living in the West were prescribed antibiotics without a clinic visit more often than those in other US regions. Antibiotic prescriptions without a clinic visit occurred in 35.1% of those in the West, compared with 23.9% of those in the Midwest, 32% of those in the Northeast, and 25.1% of those in the South.

The authors acknowledge that the data used in this study were relatively old. However, they were the most recent Medicaid claims data that were available for analysis. Over time, the proportion of non-visit antibiotic prescriptions decreased slightly but remained over 20%. The percentage of prescriptions without an infection diagnosis remained about the same.

The authors have developed a publicly available comprehensive measure for evaluating the appropriateness of antibiotic prescribing.

The study was supported by grants from the Agency for Healthcare Research and Quality (AHRQ). Fischer serves as a medical consultant for the medical education nonprofit organization Alosa. One or more authors report receiving grants from one or more of the following: AHRQ, the Centers for Disease Control and Prevention, the National Association of County and City Health Officials, the National Institute on Aging, the National Institute on Drug Abuse, the Gordon and Betty Moore Foundation, and/or the Peterson Center on Healthcare. A complete list is available on the journal's website.

Health Aff. Published online February 3, 2020. Abstract

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