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Don’t Feed the Bears – Overprescribing Antibiotics and Downstream Healthcare Utilization

November 18, 2021

Written by Seth Walsh-Blackmore

Spoon Feed
In the year following an urgent care center (UCC) visit for acute respiratory illness (ARI), patients of providers in the top quartile of ARI antibiotic prescribing received more future antibiotics after the index visit than those of providers in the bottom quartile. This led to more future healthcare visits for ARI symptoms by both the patient and their spouses.

Why does this matter?
A reported 30% of outpatient antibiotic use is inappropriate, with ARIs accounting for most of those prescriptions. It is often faster and easier to write a script for ARIs in a busy clinic or ER, and providers may dismiss the contribution their individual prescribing practices have on this massive issue. Understanding the future impact of our current actions is needed to combat antibiotic resistance. This study suggests high prescribing providers are initiating a downstream effect of greater antibiotic and healthcare utilization for ARIs that extends beyond their individual practice.

Think hard about a soft script
This was an observational study of encounter data from patients insured by a private U.S. insurer seen at an UCC by either a physician, PA, or NP. A follow-up period began 21 days after the index visit and encompassed additional encounters, such as EDs and PCPs.  232,256 index visits to 9,577 providers at 736 UCCs were included.  Patients were grouped by the quartile of their index provider’s ARI antibiotic prescribing rate, regardless if the patient received antibiotics at the index visit.

The primary outcome was the rate of ARI antibiotic fills per 100 people in the year following the index visit. Relative to the lowest quartile (42.1% prescribing rate), the 2nd (58.4%) 3rd (69.6%) and 4th (80.8%) had an increase of 1.8, 2.6 and 3.0 fills per 100 patients, respectively. Secondary outcomes included fills of broad-spectrum ARI antibiotics, which increased by 0.8, 1.5, and 1.9 fills per 100, and ARI healthcare visits which increased by 2.0, 3.9 and 5.6 visits per 100 in the following year relative to the lowest quartile. A subgroup analysis found that ARI fills increased by 1.7, 1.6 and 3.5 fills per 100 people in the spouses of patients seen by providers in the 2nd, 3rd, and 4th quartile of prescribing rate, respectively. All differences were statistically significant (p <0.001).

If multidrug resistant organisms and side effects weren’t enough reason, these results reveal another adverse impact of unnecessary prescriptions for ARIs. The increase in fills after the index mirrors the increased additional visits for ARIs also observed in patients seen by higher prescribers. The authors hypothesize these visits are driving the fills vs a desire for antibiotics. It’s logical given that the likely alternative to a script is patient education about ARIs; thus, those seen by a higher prescribing provider would likely receive less education.  Without this education, patients may be less likely to tough out their next ARI or encourage their spouse to do the same. EM physicians accounted for over 60% of the index providers in each quartile, meaning this is very much a problem we can impact. By investing a little time to educate patients about the indications to receive antibiotics or seek medical attention for an ARI at the first visit, we may be saving a lot in the long run.

Association of a Clinician’s Antibiotic-Prescribing Rate With Patients’ Future Likelihood of Seeking Care and Receipt of Antibiotics. Clin Infect Dis. 2021 Oct 5;73(7):e1672-e1679. doi: 10.1093/cid/ciaa1173.

What are your thoughts?