What Drives Variation in Antibiotic Prescribing for Acute Respiratory Infections?

Abstract

BACKGROUND: Acute respiratory infections are the most common symptomatic reason for seeking care among patients in the US, and account for the majority of all antibiotic prescribing, yet a large fraction of antibiotic prescriptions are inappropriate. OBJECTIVE: We sought to identify the underlying factors driving variation in antibiotic prescribing across clinicians and settings. DESIGN, PARTICIPANTS: Using electronic health data for adult ambulatory visits for acute respiratory infections to a retail clinic chain and primary care practices from an integrated healthcare system, we identified a random sample of clinicians for survey. MAIN MEASURES: We evaluated independent predictors of overall prescribing and imperfect antibiotic prescribing, controlling for clinician and site of care. We defined imperfect antibiotic prescribing as prescribing for nonantibiotic-appropriate diagnoses, failure to prescribe for an antibiotic-appropriate diagnosis, or prescribing a nonguideline-concordant antibiotic. KEY RESULTS: Response rates were 34 % for retail clinics and 24 % for physicians' offices (N = 187). Clinicians in physicians' offices prescribed antibiotics less often than those in retail clinics (53 % versus 67 %; p < 0.01), but had a higher imperfect antibiotic prescribing rate (65 % versus 31 %; p < 0.01). Feeling rushed was associated with higher antibiotic prescribing (OR 1.34; 95 % CI 1.03, 1.75). Antibiotic prescribing was also associated with clinician disagreement that antibiotics are overused (OR 1.60, 95 % CI, 1.16, 2.20). Imperfect antibiotic prescribing was associated with receiving antibiotic prescribing feedback (OR 1.35, 95 % CI 1.04, 1.75) and disagreement that patient demand was a problem (OR 1.66, 95 % CI 1.00, 2.73). Imperfect antibiotic prescribing was less common with clinicians who perceived that they prescribed antibiotics less often than their peers (OR 0.63, 95 % CI 0.46, 0.87). CONCLUSIONS: Poor-quality antibiotic prescribing was associated with feeling rushed, believing less strongly that antibiotics were overused, and believing that patient demand was not an issue, factors that can be assessed and addressed in future interventions.

Variability of Antibiotic Prescribing in a Large Healthcare Network Despite Adjusting for Patient-Mix: Reconsidering Targets for Improved Prescribing

“…For example, when controlling for patient characteristics, the odds of receiving an antibiotic prescription were approximately 10 times higher for patients who visited Clinic D compared with those who visited Clinic A. We considered whether encounter volume and time pressure within a clinic might influence prescribing decisions [26]; however, provider workload was not correlated with the decision to prescribe an antibiotic. Studies have noted that cultural factors (such as patient attitudes) and other external forces (such as insurance type, accessibility and price of antibiotics, or public opinion) may influence the prescribing of antibiotics [7, 26–29].…”

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

“…However, they did not assess the differences between high and low prescribers regarding these issues. Prior surveys, [15][16][17] which were not based on qualitative interviews, also did not consider the prescribing rates of the respondents. One study of emergency physicians found that high prescribers tended to see antibiotic prescribing as an opportunity to shorten infection at no cost, whereas low prescribers appreciated the potential harms of antibiotics.…”

“…Questions relating to clinical factors that might influence antibiotic prescribing were based on existing guidelines for antibiotics. 2,14 Based on prior studies, [15][16][17] we included questions that addressed nonclinical factors such as patients requesting antibiotics, concern for patient satisfaction, and time pressure. We also included questions probing selfreflection of prescribing patterns relative to their peers because interventions that provide physician with audit and feedback 6 have been shown to decrease inappropriate prescribing.…”

“…Survey Data. Using the findings from the qualitative interviews and previously published surveys, [15][16][17] we created an online survey (see Appendix). The survey included questions about the importance of patient satisfaction, complications, side effects, patient trust, patient insistence, and feeling rushed; response options ranged on a 4-point scale from Bnot important^to Bextremely important.^Standard demographic information was also collected.…”

Antimicrobial prescribing for children in primary care

“…Our results also validate previous reports on antibiotic use in Australian general practice, demonstrating a heavy reliance on broad‐spectrum antibiotics, seasonal variations in prescribing and reduction in the frequency of cefaclor and roxithromycin prescribing . Descriptions of broad‐spectrum antibiotic use, winter peaks in prescribing and inter‐practice variation are also reported in the international literature.…”