By Brenda L. Mooney
SALT LAKE CITY — A study conducted in the VA health system uncovered a disturbing truth about overuse of antibiotics: A big contributor to the problem is that some clinicians prescribe the drugs to nearly every patient with a respiratory ailment.
A report published recently in the Annals of Internal Medicine notes that, over a seven-year period, 10% of medical providers in 130 VA medical centers (VAMCs) wrote an antibiotic prescription for 95% or more of patients diagnosed with a cold, bronchitis or other acute respiratory infection (ARI).1
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.
In fact, the study found 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, of the Salt Lake City VA. “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 healthcare 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 VA patient visits for ARIs at 990 clinics or EDs across the United States from 2005 to 2012. Over the eight-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.
Increase in Prescriptions
Results indicated that the proportion of 1 million visits with ARI diagnoses that resulted in antibiotic prescriptions increased from 67.5% in 2005 to 69.2% in 2012, while the proportion of macrolide antibiotics prescribed increased from 36.8% to 47.0%. Antibiotic prescribing was highest for sinusitis and bronchitis, varying little according to fever, age, setting or comorbid conditions.
The greater use occurred despite guidelines urging more judicious prescribing of antibiotics as well as recommendations against using macrolides as a first line of defense for most respiratory infections. The VA, for example, has an active antimicrobial stewardship program.
“Veterans with ARIs commonly receive antibiotics, regardless of patient, provider, or setting characteristics,” study authors wrote. “Macrolide use has increased, and substantial variation was identified in antibiotic prescribing at the provider level.”
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, of the University of Utah. “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.”
Why Does It Happen?
Why do clinicians at the VA and elsewhere persist with high prescribing rates for antibiotics, even while understanding the practice can feed growing problems with resistance?
In an effort to answer that question, researchers interviewed 30 physicians at two teaching hospitals — one a VAMC, the other on a university campus. Their study was published recently in the journal Infection Control and Hospital Epidemiology.2
“We wanted to better understand the culture among physicians in the hospital, the social and psychological factors that underlie excessive prescribing of antibiotics,” said Daniel Livorsi, MD, of the Richard L. Roudebush VA Medical Center.
Livorsi said in a recent VA Research Currents newsletters that, “in theory, prescribing should always be dictated strictly by evidence and information and be fully in line with clinical guidelines. But there are gray areas where physicians have to use their best judgment. And even in cases that are more black and white — where an antibiotic is clearly not indicated — there are still factors that may influence doctors’ prescribing decisions and lead them to write a prescription nonetheless and to justify it in their mind. Through the interviews, we wanted to get insight into this thought process.”
Results indicated that newer doctors are strongly influenced by their supervising physicians — whose careers may have begun at a time when s when over-prescribing of antibiotics was less of a concern.
“If they always do it [prescribe], then I feel the need to do it,” said one medical resident who was interviewed. Another said, “When we see broad-spectrum antibiotics being [prescribed] with relative ease, it gives us the confidence to do so, as well.”
The overuse of broad-spectrum antibiotics is a strong contributor to the spread of drug-resistant strains.
The survey also found that physicians were more worried about missing a possible infection in their patients than with exposing them to the harmful side effects of antibiotics or with contributing to the more abstract problem of antibiotic overuse.
“[The problem of antibiotic resistance] is always there at the back of your mind,” one resident told the researchers, “but … when you are faced with a particular situation, you’re stuck between trying [to think globally and] reduce broad-spectrum antibiotic use … versus trying to make sure you don’t miss a bug by going too narrow. ”
Physicians also expressed hesitancy to challenge their peers — even less so their supervisors — if they observed antibiotics being prescribed without clear justification.
“Avoiding confrontations and preserving strong working relationships were seen as higher priorities,” the researchers noted.
Livorsi and his co-authors offer a few possible solutions, including:
- Setting up regular forums in hospitals where doctors could discuss their antibiotic prescribing decisions, without risk of punitive measures for poor decisions.
- Having stewardship teams provide immediate feedback to providers on their prescribing decisions.
- Establishing performance measures that recognize good prescribing.
Technology also is providing some solutions. Livorsi notes that VAMCs regularly use diagnostic tests to guide antibiotic-prescribing decisions, but the tests have limitations.
“For one, test results may not be available for several days, so doctors initially make antibiotic-prescribing decisions based on their own clinical assessments,” he says. “In addition, there are several types of infections that cannot be diagnosed or ruled out with a simple diagnostic test, so the doctor’s judgment ultimately prevails.”
The authors of the Utah-based study, meanwhile, suggest electronic medical records could be used to urge high-prescribing prescribers of antibiotics to think again before writing a script.
- Jones BE, Sauer B, Jones MM, Campo J, Damal K, He T, Ying J, Greene T, Goetz MB, Neuhauser MM, Hicks LA, Samore MH. Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study. Ann Intern Med. 2015 Jul 21;163(2):73-80. doi:10.7326/M14-1933. PubMed PMID: 26192562.
- Livorsi D, Comer A, Matthias MS, Perencevich EN, Bair MJ. Factors Influencing Antibiotic-Prescribing Decisions Among Inpatient Physicians: A Qualitative
Investigation. Infect Control Hosp Epidemiol. 2015 Jun 16:1-8. [Epub ahead of
print] PubMed PMID: 26078017.