July 29, 2015
Individual Prescriber Habits: Biggest Determinants of Antibiotic Overuse?

Salt Lake City, UT—What might have been clear to pharmacists for years is just now being documented by researchers: Some physicians prescribe antibiotics to nearly every patient with a respiratory ailment.

A study published recently in the Annals of Internal Medicine notes that 10% of medical providers in a large healthcare system wrote an antibiotic prescription for 95% or more of patients diagnosed with a cold, bronchitis, or other acute respiratory infection (ARI).

At the same time, another 10% of providers prescribe antibiotics during 40% or fewer patient visits with those diagnoses, according to the study led by researchers from the Veterans Affairs (VA) Salt Lake City Health Care System and the University of Utah and funded by the national Centers for Disease Control and Prevention.

In fact, the study finds that preferences of individual providers have a greater effect on antibiotic prescribing than patient characteristics, standards of practice at different hospitals, or clinical settings such as emergency department (ED), primary care or urgent care.

“We were able to see that even if Dr. A works just down the hall from Dr. B, they may practice medicine very differently,” said lead author Barbara Jones, MD, MS, in a University of Utah news release. “We all receive similar training, but we can practice differently. The extent of this variation has been hard to measure in the past.”

While the study found that 68% of all visits for ARI resulted in an antibiotic prescription at the VA—similar to other U.S. healthcare systems—the research was unique in describing the practice patterns of individual health care providers. That became possible by applying advanced statistical analysis to big data housed within the VA electronic health record.

For the study, researchers analyzed 1,044,523 patient visits for ARIs at 990 clinics or EDs at 130 VA medical centers (VAMCs) across the United States from 2005 to 2012. Over the 8-year period, the overall percentage visits in which providers prescribed antibiotics increased by 2%, with a 10% increase in the proportion of broad-spectrum antibiotics prescribed. The greater usage occurred despite guidelines urging more judicious prescribing of antibiotics in general as well as recommendations against using broad spectrum antibiotics as a first line of defense for most respiratory infections.

The analysis, which included 480,875 visits and 2,594 providers who treated at least 100 patients for ARI, indicated that 59% of the variation in how often antibiotics were prescribed was attributable to the habits of individual providers.

On the other hand, 28% of the variation was related to differences in practice among clinics, and 13% to differences in practice among hospital centers.

“One of the things that makes this work stand out is that we could discern three levels of variation in antibiotic prescribing—by provider, clinic, and VA medical center—in a large data set,” explained co-author Tom Greene, PhD. “This showed us the most striking result in this study, that the variation of prescribing practices between providers was quite large after accounting for patient characteristics.”

The authors suggest electronic medical records could be used to urge high-prescribers of antibiotics to think again before writing a scrip.

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