Alarmingly high rate of antibiotics prescribed without evidence of office visit
A new study highlights a key area that might be missed by current efforts to ensure appropriate antibiotic use. A wide range of clinical policies aim to reduce the prescribing of antibiotics for illnesses that are not caused by a bacterial infection. These efforts are intended to help decrease the rate of antibiotic prescribing in the U.S., which is about double that of many other countries. However, such efforts may miss antibiotics that providers prescribe outside of clinical visits. Investigators from Brigham and Women's Hospital evaluated hundreds of millions of antibiotic prescriptions filled by Medicaid recipients over 10 years and found 28 percent were not associated with a clinic visit and another 17 percent were associated with visits with no documented infection-related diagnosis. Results are published in the February issue of Health Affairs.
"If we're thinking about how to improve antibiotic use, we need to understand the context in which antibiotics are being prescribed," said lead author Michael Fischer, MD, MS, a physician in the Brigham's Division of Pharmacoepidemiology and Pharmacoeconomics and an associate professor of Medicine at Harvard Medical School. "If prescribing is taking place outside of an office visit, most of the approaches we're taking to combat antibiotic overuse will miss those completely."
To capture these blind spots, Fischer and colleagues used national Medicaid claims data from 2004 to 2013. They identified 298 million antibiotic prescriptions that had been filled during this time for 53 million patients. The researchers used the Medicaid data to determine whether patients had made a clinic visit in the seven days prior to filling the antibiotic prescription and when there was a visit they checked whether the billing diagnosis specified an infection as the cause for the visit. The team found that 28 percent of the filled antibiotic prescriptions had no claims for a clinician encounter in the seven previous days and another 17 percent were not associated with a visit for an infection-related diagnosis.
"It seems inappropriate that 17 percent of antibiotic prescriptions were given without an infection-related diagnosis, and it's concerning that nearly one in five antibiotics are prescribed without a clear rationale," said senior study author Jeffrey Linder, MD, MPH, chief of general internal medicine and geriatrics in the department of medicine at Northwestern University Feinberg School of Medicine.
The authors acknowledge that a critical question remains: What occurred clinically in the many cases when antibiotic prescriptions were dispensed without an office visit?
"Since our analyses were based on claims data, we don't have access to medical records to determine what interactions took place between patients and prescribing clinicians. We assume that most of these prescriptions were associated with a telephone interaction, although some communication may have occurred over email, via web portals or in informal, uncaptured visits. Most of these encounters would be blind spots for the interventions designed to improve antibiotic use."
Fischer notes that it will be important for future research to use clinical data to examine outcomes for patients who are prescribed antibiotics outside of office visits, adding that future interventions to improve the quality of antibiotic care should be designed with the study's findings in mind so that this large proportion of prescriptions is not missed.
