Coding Bias in Respiratory Tract Infections May Obscure Inappropriate Antibiotic Use

Martinez, Kathryn A.; Rood, Mark; Rothberg, Michael B.

doi:10.1007/s11606-018-4823-x

Cited by 13 publications

(9 citation statements)

References 7 publications

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“…For the purpose of comparing rates of antibiotic prescribing, we combined all the respiratory tract infection diagnoses to avoid biases relating to individual coding patterns. 12,18 Patients with history of COPD, immunocompromised status, or current use of immunosuppressant medications, for whom antibiotics may be appropriate, were excluded.…”

Section: Quantitative Studymentioning

confidence: 99%

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

et al. 2019

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Section: Quantitative Studymentioning

confidence: 99%

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

et al. 2019

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“…Yet, clinicians with higher antibiotic-prescribing rates were more likely to diagnose conditions where antibiotics may be indicated. This finding, echoed in prior work [ 36 ], implies that higher antibiotic-prescribing clinicians may choose to first prescribe antibiotics and then consciously or unconsciously choose a diagnosis to support that decision. If true, this pattern creates a challenge for measuring antibiotic appropriateness since the choice of diagnosis codes remains somewhat subjective.…”

Section: Discussionmentioning

confidence: 70%

Association of a Clinician’s Antibiotic-Prescribing Rate With Patients’ Future Likelihood of Seeking Care and Receipt of Antibiotics

Shi

Barnett

Jena

et al. 2020

Clinical Infectious Diseases

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Background One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients’ prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics when they have subsequent ARIs. Methods Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician’s antibiotic prescribing rate to the patients’ rates of ARI antibiotic receipt as well as their spouses’ rate of antibiotic receipt in the subsequent year. Results Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2-3.8, p<0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients’ spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6-7.7, p<0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits. Conclusions Receipt of antibiotics for an ARI increases the likelihood that patients and their family members will receive antibiotics for future ARIs.

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“…Our study relied on ICD-10 codes for diagnoses; thus, we were unable to verify the accuracy of the diagnoses or additional details related to diagnoses. Regional differences in coding practices could also account for some of these findings, as studies have shown that coding for ARIs may differ based on a clinician's status as a high or low prescriber [ 36 ]. Additionally, we used a lookback period of 12 months before the initial ARTI encounter to capture any documented comorbidities; however, it is possible that some comorbidities were undiagnosed, undocumented, or documented incorrectly and were therefore not counted in this study.…”

Section: Discussionmentioning

confidence: 99%

Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract Infections in a Commercially Insured Population, United States, 2017

Bizune

Tsay

Palms

et al. 2023

Open Forum Infectious Diseases

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Background Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population. Methods We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis. Results Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33–1.34). Conclusions It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing.

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Coding Bias in Respiratory Tract Infections May Obscure Inappropriate Antibiotic Use

Cited by 13 publications

References 7 publications

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

Association of a Clinician’s Antibiotic-Prescribing Rate With Patients’ Future Likelihood of Seeking Care and Receipt of Antibiotics

Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract Infections in a Commercially Insured Population, United States, 2017

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