Atlanta—More than 40% of all Medicare Part D antibiotic prescriptions were prescribed by 10% of prescribers, according to a new report from the CDC.

The article in the CDC's Morbidity & Mortality Weekly Report (MMWR) offers more proof of what has long been suspected: a small proportion of prescribers account for a disproportionately large percentage of dispensed antibiotics.

"Health care providers vary in their propensity to prescribe antibiotics," the authors wrote. "Peer comparison audit and feedback is an effective antibiotic stewardship intervention to improve antibiotic prescribing."

The researchers added that the highest 10% of antibiotic prescribers prescribed 41% of total antibiotic prescriptions for Medicare Part D beneficiaries in 2019. Furthermore, they advised, the antibiotic prescribing rate of the higher volume clinicians was 60% higher than that of the lower volume group.

Calling the situation "urgent," the MMWR pointed out that antibiotic prescribing can lead to adverse drug events and antibiotic resistance. Older adults that are aged 65 years and older receive the highest rates of outpatient antibiotic prescribing and also are at increased risk for antibiotic-related adverse events, including Clostridioides difficile, antibiotic-resistant infections, and related deaths, according to the report.

Part of the problem, according to the authors, is that variation in antibiotic prescribing usually is driven by prescribing patterns of individual healthcare providers who often do not consider patients' underlying comorbidities and diagnoses.

They suggest that "engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other healthcare providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale."

To reach those conclusions, the study analyzed data from the Centers for Medicare & Medicaid Services Part D Prescriber Public Use Files to describe higher volume antibiotic prescribers in outpatient settings compared with lower volume prescribers (the lower 90% of prescribers by antibiotic volume).

Results indicated that among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). "Public health organizations and healthcare systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes," the researchers suggested.

The CDC noted that about half (48%) of higher volume prescribers practiced in the South and prescribed 49% (12.3 million) of the total antibiotic prescriptions in that region, but differences were not explained by patients' underlying conditions. "Higher volume prescribers in the South also had the highest median antibiotic prescribing rate (696 antibiotic prescriptions per 1,000 beneficiaries) compared with higher volume prescribers in other regions (649 in the West) (P <.001)," the authors explained. "The most common specialties of higher volume prescribers were family practice and internal medicine, with 21% (19,213 of 89,759) and 20% (17,185 of 85,442) of prescribers, respectively, classified as higher volume prescribers."

The article points out that family practice and internal medicine higher volume prescribers accounted for approximately 60% of the antibiotics prescribed within their respective specialties and 22% of the total antibiotic volume overall.

Although urologists only contributed 1% of the total prescriber number during 2019, half of them were higher volume prescribers and prescribed 2.0 million antibiotic prescriptions—or 83% of urology-prescribed antibiotic volume. "Higher volume prescribers, as expected, had higher antibiotic prescribing rates within each specialty, with the highest rate among dentists," according to the report.

"This substantial difference in prescribing practices presents opportunities for improved prescribing through antibiotic stewardship activities focusing on these higher volume prescribers, independent of specialty," the CDC researchers wrote. "Total antibiotic volume is associated with unnecessary prescribing rates and might be a reasonable proxy for unnecessary prescribing in primary care settings."

The authors advise that primary care providers have varying prescribing rates, which offers opportunities for improvement in settings in which most antibiotics are prescribed. The same is true for urologists and dentists, they said, and those specialists should also be considered for antibiotic stewardship interventions.

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