Written by Clay Smith
Spoon Feed
Physicians who wrote for the most antibiotics were also the ones who diagnosed sinusitis most often. To justify writing for an antibiotic, there was a coding bias to call it “sinusitis” when in fact, it probably was just a cold.
Why does this matter?
Antibiotic stewardship is critical in reducing resistance and adverse effects. Overuse of outpatient antibiotics is a major driver of inappropriate antibiotic use. Treating sinusitis appropriately is a key target to reduce prescribing.
If I call it sinusitis, that makes it true, right?
This was a group of about 13,025 telemedicine visits for respiratory tract infection (RTI) among 105 physicians. Nearly half (49%) of all encounters were coded as sinusitis. The highest quartile prescribers of antibiotics wrote for antibiotics 87% of the time (group 4 in the figure); the lowest, 40% (group 1). The lowest prescribers diagnosed sinusitis 35% of the time, and the highest prescribers 59% of the time. See figure from the cited article below. Patients were randomly assigned to physicians, so the types of RTI should have been evenly distributed among them. Meaning, physicians in the highest prescribing quartile were labeling “other RTI” (aka a cold) as “sinusitis” far more often than the lower prescribers. Of course, this was a telemedicine sample, which may not reflect other retail, urgent care, or ED settings. The take home point is this – clinicians who are prone to write prescriptions for antibiotics may justify their prescribing habits by coding for a diagnosis for which an antibiotic is appropriate, when in reality, the patient just has a cold. It’s important to be circumspect about our own prescribing habits and recognize these biases which impact our prescribing.
From cited article. RTI, respiratory tract infection
Source
Coding Bias in Respiratory Tract Infections May Obscure Inappropriate Antibiotic Use. J Gen Intern Med. 2019 Jun;34(6):806-808. doi: 10.1007/s11606-018-4823-x.
Open in Read by QxMD
Reviewed by Thomas Davis
" may justify their prescribing habits by coding for a diagnosis for which an antibiotic is appropriate"
Sinusitis, even if the correct diagnosis rarely indicates treatment with antibiotics. Guidelines put out by the american academy of otolaryngology stipulate that in general, a diagnosis of bacterial sinusitis should be made over viral sinusitis only in the case of symptoms >= 10 days or in the case of initially improving and then worsening symptoms.
If the patient doesn’t meet that criteria, but you absolutely need to give out a "goodie bag" to keep your patients happy, give them a nasal corticosteroid which has been shown to help with minimal side effects.
Good point. An antibiotic may be appropriate for sinusitis but is never appropriate for URI. I think that’s what leads to the coding bias.