A new study in the Annals of Internal Medicine takes a detailed look at the huge problem of overprescribing antibiotics for outpatients with upper respiratory tract infections (URIs). Such acute respiratory infections (ARIs) are often viral in origin, and therefore won’t be helped by antibiotics. Instead, the overuse drives antibiotic resistance. Despite guidelines, most outpatient antibiotics are still prescribed for ARIs—bronchitis, sinusitis, laryngitis, “colds,” and ear infections.
A previous study estimated that antibiotics were prescribed in 10% of 95 million office visits. By 1999, 22% of adult and 14% of pediatric prescriptions for broad-spectrum antibiotics were for URIs, conditions which are largely viral. Similarly, a 2007-9 survey showed that more than 25% of prescriptions were for conditions not warranting antibiotics.
There are large geographic differences in prescribing not readily explained by patterns of disease. While some inappropriate antibiotic use has declined, sites with high-prescription rates had a higher proportion of antibiotic-resistant invasive pneumococcal infections, which are life threatening as well as far more costly to treat. This was especially true for overuse of cephalosporins and macrolides (e.g., azithromycin or clarithromycin).
In this study, researchers looked at differences in individual prescribing patterns, examining all VA outpatient records from 2005-12 for patients seen for ARIs. Importantly, they excluded patients who had underlying conditions (comorbidities) like diabetes or COPD that might have put them at higher risk for a serious bacterial infection. They also looked only at providers who had seen at least 100 patients with this condition.
Disappointingly, despite educational efforts to reduce antibiotic use over the past decade, the proportion of the 1 million ARI visits examined that led to antibiotic prescription increased from 67.5% to 69.2%. Macrolide prescriptions alone increased from 36.8 to 47%. The most interesting finding was the huge variation in prescribing patterns. Lead author Barbara Jones, M.D., M.S., assistant professor of internal medicine at the University of Utah and clinician at the VA Salt Lake City Health Care System, commented that she expected prescriptions in 10-40% of visits. Yet they found a higher rate—more than 20% higher—and this was driven by individual practitioner’s habits, rather than by differences in patients’ illness or underlying characteristics. Similarly, differences could not be explained by differences in standards of practice at different hospitals, or the type of clinical setting (emergency department, primary care, urgent care). “The 10% of providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, and the 10% who prescribed the least did so during 40% or fewer of their ARI visits.”
Surprisingly, prescribing from the Emergency Room was only slightly more common than from the clinic. Dr. Jones noted, “Within clinics, there were dramatic differences in prescribing patterns.” She suggests providing feedback to physicians by comparing them to their peers, as a way to modify their behavior. I don’t like this idea, and would prefer to have a decision tree or computer queries, if need be, to help guide decisions, based on patient characteristics and objective data. Dr. Jones later clarified that their aim was “not to develop performance measures or incentivize providers to practice one particular way.” She added, “We also have tools that incorporate best practice recommendations, offer alternative therapies to antibiotics (such as medications to control symptoms), and provide communication and education tips to enhance patient-provider communication.”
Guidelines are a double-edged sword. While generally useful, at least in suggesting factors that should be considered, my experience is that some guidelines—especially that for pneumonia—lead to considerable antibiotic overuse. I don’t like that algorithms have replaced thinking or experience, and that physicians are too often penalized for using their judgment by bean counters with little to no clinical experience and with no stake in the outcome.
Dr. Jones said they hope to look more carefully at the “positive deviants” to see what could be learned to help alter the other physicians’’ behavior. I look forward to seeing that, rather than just punitive actions against overprescribers.
Overprescribing is a problem, not just due to cost, but more importantly, due to increasing the emergence of resistant organisms which often lead to life-threatening infections. By comparing physicians at both ends of the prescribing spectrum, perhaps more effective strategies for education and limiting antibiotic use can be developed.
