Inappropriate prescribing in outpatient healthcare: an evaluation of respiratory infection visits among veterans in teaching versus non-teaching primary care clinics
© The Author(s). 2017
Received: 2 November 2016
Accepted: 17 March 2017
Published: 29 March 2017
A recent study led by the Centers for Disease Control and Prevention (CDC) revealed at least 30% of antibiotic prescriptions in the outpatient setting were inappropriate. In this study of all ages, among adult patients, results were similar to the overall population, with the majority of inappropriate prescribing relating to respiratory infections. We applied the same methodology to investigate rates of antibiotic prescribing for respiratory tract infections in outpatient primary care clinics at the Providence Veterans Affairs Medical Center. The results of our evaluation reflected comparable rates of inappropriate prescribing, but when stratified by teaching versus non-teaching primary care clinics, inappropriate prescribing was significantly higher in non-teaching clinics (17.6% vs 44.0%, p < .0001). Respiratory infection visits in non-teaching outpatient clinics may be a pragmatic target for antimicrobial stewardship programs.
KeywordsAntibiotic use Prescribing Outpatient Antimicrobial stewardship
We applaud Fleming-Dutra et al. on their recent analysis, which evaluated the rate of inappropriate outpatient antibiotic prescribing across several age groups and infectious diseases . They found at least 30% of outpatient antibiotics prescribed were inappropriate in the United States. Inappropriate prescribing among adults, excluding children, was slightly higher at 33%, with the majority of inappropriate prescription related to acute diagnoses of respiratory conditions including sinusitis, bronchitis, and pharyngitis.
Misuse of antibiotics has been associated with increased morbidity due to adverse drug reactions, increased healthcare costs, and antibiotic resistant bacteria . The Centers for Disease Control and Prevention and the White House, have declared the issue of antibiotic resistant bacteria a threat to the health of the public. As time and resources for antimicrobial stewardship programs (ASPs) are limited, outpatient ASPs need to evaluate which interventions will ensure appropriate prescribing . Currently, data on implementation and metrics of ASP initiatives in the outpatient setting are limited , including Veteran clinics . To characterize possible opportunities for an ASP initiative, we performed an evaluation of inappropriate antibiotic prescribing among patients with respiratory tract infections based on the high rate of inappropriate prescribing with these diagnoses described by Fleming-Dutra et al.
Rates of prescribing during respiratory infection visits
Fleming-Dutra et al.a
VA clinics total
VA teaching clinics
VA non-teaching clinics
Inappropriate prescribinga during respiratory infection visits
Fleming-Dutra et al.b
VA clinics total
VA teaching clinics
VA non-teaching clinics
Prescribing was lower among VA clinic visits (59.8%) compared to non-federal office-based physician visits (70.3%, p < .0001). However, when stratified by VA teaching versus VA non-teaching clinics, teaching clinics had markedly less prescribing (37.0% vs 65.9%, p < .0001), and non-teaching clinics had a rate similar to that of non-federal office visits (70.3%).
Rates of inappropriate prescribing among patients with respiratory infections were similar among non-federal office-based physician visits and VA clinic visits at 34.2% and 38.4%, respectively. However, VA teaching clinics had significantly lower rates of inappropriate prescribing compared with VA non-teaching clinics (17.6% vs 44.0%, p < .0001) and non-federal office visits (17.6% vs 34.2%, p < .0001). Our study had several limitations. As with any observational study, misclassification bias may have occurred due to diagnosis coding errors. Since we did not manually review patient electronic medical records and our reports provided limited information, we were not able to separate initial encounters from follow-up visits. It is not uncommon for a patient to be diagnosed and prescribed an antibiotic in the emergency room or hospitalized and upon discharge, follow up with their primary care provider. In addition, we were not able to observe whether patient’s had other co-morbidities that may have influenced the patient’s probability of getting an antibiotic or compare the patients among the different clinic types.
Nonetheless, our data offer insights into inappropriate outpatient prescribing among government clinics as those data were not available from the data source used in the Fleming-Dutra et al. study. While similar rates of inappropriate prescribing for acute respiratory tract infections have been described in two other VA health systems’ outpatient clinics , our findings are unique in suggesting that outpatient ASPs may benefit from focusing their efforts in non-teaching clinics, at least among VA clinics. In conclusion, while VA outpatient rates of inappropriate prescribing in respiratory infections were similar to those reported at non-federal office visits, inappropriate prescribing rates among VA teaching clinics were much lower than non-federal office visits. Non-teaching clinics therefore represent an important area of opportunity for ASPs.
Antimicrobial stewardship programs
The views expressed are those of the authors and do not necessarily reflect the position or policy of the United States Department of Veterans Affairs. Work supported, in part, by Dept. of VA.
Availability of data and materials
DMP, TTT, ARC, and KLL obtained and analyzed the data. DMP and TTT drafted the manuscript while critical revision was provided by ARC and KLL. All authors read and approved the final draft of the manuscript.
Diane M. Parente and Tristan T. Timbrook have no conflicts of interest to disclose. Aisling R. Caffrey has received research funding from Pfizer and Merck (Cubist). Kerry L. LaPlante has received research funding or acted as an advisor, or consultant for, Allergan, Cempra, Merck (Cubist), Davol/BARD, The Medicines Company, Ocean Spray, and Pfizer Inc.
Consent for publication
Ethics approval and consent to participate
A waiver of informed consent was obtained from the Providence Veterans Affairs Medical Center’s Institutional Review Board for this study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA. 2016;315:1864–73.View ArticlePubMedGoogle Scholar
- Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States. CDC, 2013. http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf. Accessed 15 Sept 2016.
- Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program. Clin Infect Dis. 2016;62:e51–77.View ArticlePubMedGoogle Scholar
- National Quality Forum. Antibiotic Stewardship Playbook. NQF, 2016. http://www.qualityforum.org/Publications/2016/05/Antibiotic_Stewardship_Playbook.aspx. Accessed 15 Sept 2016.
- Drekonja DM, Filice GA, Greer N, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol. 2015;36:142–52.View ArticlePubMedGoogle Scholar
- Morrill HJ, Caffrey AR, Gaitanis MM, LaPlante KL. Impact of a prospective audit and feedback antimicrobial stewardship program at a veterans affairs medical center: a six-point assessment. PLoS ONE. 2016;11:e0150795.View ArticlePubMedPubMed CentralGoogle Scholar
- Morrill HJ, Gaitanis MM, LaPlante KL. Antimicrobial stewardship program prompts increased and earlier infectious diseases consultation. Antimicrob Resist Infect Control. 2014;3:12.View ArticlePubMedPubMed CentralGoogle Scholar
- Morton JB, Curzake DJ, Morrill HJ, Parente DM, Gaitanis MM, LaPlante KL. Verbal communication with providers improves acceptance of antimicrobial stewardship interventions. Infect Control Hosp Epidemiol. 2016;37:740–2.View ArticlePubMedGoogle Scholar
- Rattinger GB, Mullins CD, Zuckerman IH, et al. A sustainable strategy to prevent misuse of antibiotics for acute respiratory infections. PLoS ONE. 2012;7:e51147.View ArticlePubMedPubMed CentralGoogle Scholar