Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract Infections in a Commercially Insured Population, United States, 2017

Abstract

Background Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population. Methods We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis. Results Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33–1.34). Conclusions It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing.

Prevalence, regional distribution, and trends of antimicrobial resistance among female outpatients with urine Klebsiella spp. isolates: a multicenter evaluation in the United States between 2011 and 2019

“…This finding supports previous observations of high AMR prevalence in US southern-border regions, which may be influenced by access to antimicrobials, and their overuse, without a prescription in Mexican pharmacies along the US-Mexico border [ 21 ]. Studies have also demonstrated higher outpatient antibiotic prescribing, including inappropriate prescribing, in Southern US states versus other US regions [ 1 , 22 ], which might reflect regional differences in antibiotic stewardship [ 1 , 22 ].…”

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

“…On the other hand, non-clinical factors such as demographic and socioeconomic differences [ 13 ], or differences in patient demand and prescription practices have been suggested to underlie regional variations [ 17 ], and the influence of patient demand on inappropriate antibiotic prescriptions is well documented [ 18 , 19 ]. Supporting small-area differences, calls have been made to take into account small-area regional factors in devising targeted interventions to support rational prescription practices [ 20 ].…”

Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid

“…Among commercially insured patients in 2017 with an acute respiratory tract infection, those living in the South were 34% more likely than those in the West to receive an antibiotic [ 20 ]. Similarly, examination of medical records from the National Ambulatory Medical Care Survey from 2012 to 2013 revealed that patients in the East South Central region (i.e., AL, KT, MS, TN) were more likely than those in Pacific states (CA, OR, WA) to be diagnosed with a condition where an antibiotic would be prescribed [ 21 ]. Kentucky had the highest prescription rates (1281 prescriptions per 1000 persons), which was about four-fold higher than Alaska (348 per 1000 persons) [ 17 ].…”

“…While regional and state-level disparities in antibiotic prescribing are well known [ 20 , 21 ], it is important to provide updated information to provide information on whether stewardship efforts have been successful in driving down these population-level differences. The low-income Medicaid population may face challenges that are different from those that are commercially insured.…”