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

Abstract

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.

Breaking the Ambulatory Antibiotic Prescribing Cycle with All-Antibiotic Stewardship, Patient Stewardship, and Visit Stewardship

“…However, collectively, prescriber-and visit-focused interventions have resulted in modest improvements in antibiotic prescribing, and only among children [30]. A deeper dive into the data presented by Shi and colleagues [20] in the context of other research suggests 3 broader approaches to stewardship that could be important in improving ambulatory antibiotic stewardship and breaking the antibiotic prescribing cycle: all-antibiotic stewardship, patient stewardship, and visit stewardship.…”

“…In a new Clinical Infectious Diseases manuscript, many of these same investigators applied the same longitudinal, quasirandom method to examine patient visits to urgent care clinicians and antibiotic prescribing [20]. At index acute respiratory infection visits-although there were no differences in expected antibiotic receipt by patient characteristics-the lowest quartile of antibiotic prescribers had an antibiotic prescribing rate of 42%, and the highest quartile of antibiotic prescribers had an antibiotic prescribing rate of 80%.…”

“…Initial, superficial reactions to the findings of Shi and colleagues [20] could lead one to focus on inappropriate antibiotic prescribing by high prescribers at acute respiratory infection visits. Indeed, ambulatory stewardship has focused on such prescribing.…”

“…Antibiotic prescribing measures that focus on specific diagnoses miss a large proportion of antibiotic prescribing. In the study by Shi and colleagues [20], looking across all locations, acute respiratory infections only accounted for about a quarter of all follow-up antibiotic prescribing. In the year after the index visit, the antibiotic prescribing rate for acute respiratory infections ranged from 20 to 24 prescriptions per 100 patients.…”

“…We previously found that decreasing proportions of antibiotics are being prescribed in physician offices, urgent care centers, emergency departments, outpatient surgery centers, home visits, and retail clinics [32]. In the study by Shi and colleagues [20], patients made an index acute respiratory infection visit to an urgent care center. However, in the subsequent year, fewer than 20% of follow-up visits were to the same urgent care center.…”