Wide Variation Documented Among VA Providers in Potential Overuse of Antibiotics for Acute Respiratory Infections
As the emergence of resistant pathogens outpaces our ability to develop new antibiotics, the problem of unnecessary antibiotic use – a primary cause of the development of resistant organisms – has become a major public health concern. Despite limited benefits, the majority of outpatient antibiotics are prescribed for acute respiratory infections (ARIs). While there has been a significant decline in overall antibiotic use for ARIs for children, the use of antibiotics among adults remains high, and recent studies show a dramatic increase in the use of broad-spectrum antibiotics, particularly macrolides. This study examined trends in antibiotic prescribing within the VA healthcare system over an 8-year period (January 2005 through December 2012) – and identified patient, provider, and setting sources of variation. Using VA data, investigators identified all patient visits with a primary diagnosis of ARI (n = 1,044,523), including nasopharyngitis, pharyngitis, sinusitis, acute bronchitis, upper respiratory tract infection, and other infections (i.e., laryngitis, tonsillitis). Veterans with comorbidities that increase the risk of bacterial infections (e.g., HIV, COPD) were excluded. Variables assessed included: patient demographics, diagnosis, distance from VAMCs, comorbidities, provider type (i.e., physician, mid-level provider, nurse), setting type (i.e., primary care clinic, urgent care clinic, ED), and region of the U.S.
- Over the 8-year study period, there was a persistently high prevalence of outpatient antibiotic prescriptions for ARIs among Veterans. Of more than one million ARI visits, the proportion resulting in antibiotic prescription increased from 67.5% in 2005 to 69.2% in 2012. Also, the proportion of antibiotic prescriptions that were macrolides increased from 37% to 47%.
- There was substantial variation in prescribing at the provider level. The 10% of VA providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, while the 10% who prescribed the least did so during <40% of their ARI visits. Mid-level providers prescribed antibiotics slightly more frequently than physicians (70% vs. 68%).
- Subgroups associated with higher prevalence of antibiotic prescribing included: diagnosis of sinusitis (86%) or bronchitis (85%), presence of a high fever (78%), occurrence in an urgent care setting (75%), and Southern and Central regions of the U.S. (both 71%).
- Investigators relied on VA administrative data and ICD-9 codes to identify patients.
- The variation analysis was limited to providers with at least 100 ARI visits during the study period.
- The study lacked additonal clinical and provider data contributing to the antibiotic decision, such as symptom duration, physical exam findings, and provider specialty.
Variation in ARI management seems to be strongly influenced by the prescribing patterns of individual providers. This is a ripe target for further research, quality improvement, and antibiotic stewardship interventions.
Jones B, Sauer B, Jones M, Campo J, Damal K, He T, Ying J, Greene T, Goetz M, Neuhauser M, Hicks L, and Samore M. Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population. Annals of Internal Medicine. July 21, 2015;163(2):73-80.