Hospitals, Pharma

Study finds inappropriate antibiotic use highest in urgent care clinics

Executive from urgent care-focused medical records firm says study numbers miss some of the nuances.

Misuse of antibiotics has long plagued healthcare, but a study published this week zeroes in on urgent care clinics as having a particular issue with inappropriate prescription of the antimicrobial medicines.

The study, published as a research letter in JAMA Internal Medicine, found that urgent care centers saw the highest percentage among outpatient settings of prescriptions of antibiotics during visits for respiratory diseases in which they are not indicated, 45.7 percent. That compared with 24.6 percent in emergency departments, 17 percent in medical offices and 14.4 percent in retail clinics. Data came from the 2014 Truven Health MarketScan Commercial Claims and Encounters Database. Antibiotic-inappropriate indications included in the study were viral upper respiratory infection, bronchitis/bronchiolitis, asthma/allergy, influenza, nonsuppurative otitis media and viral pneumonia.

“Overall, the findings underscore the need for antibiotic stewardship not only in doctors’ offices and emergency clinics, but in urgent care and retail clinics as well,” said study co-author Dr. David Hyun, a senior officer for the Pew Charitable Trusts’ Antibiotic Resistance Project, in a phone interview. Antibiotic stewardship refers to promoting appropriate use of the drugs to improve patient outcomes and reduce the risk of antibiotic-resistant bacteria.

Total inappropriate use of antibiotics may approach 50 percent of all prescriptions for the drugs in the outpatient setting, with at least 30 percent of courses prescribed being unnecessary, according to the Centers for Disease Control and Prevention, which sponsored the study. Indeed, resistance to antibiotics represents one of the most urgent threats to public health, and their overuse is a major cause of increases in drug-resistant bacteria.

Indeed, the interest is in looking at antibiotic prescribing across the outpatient practice spectrum and finding opportunities to improve antibiotic use throughout, said co-author Dr. Katherine Fleming-Dutra, deputy director of the CDC’s Office of Antibiotic Stewardship.

Hyun and Fleming-Dutra noted that the study didn’t go into potential drivers of the disparity in inappropriate antibiotic prescribing. It is known from medical literature that diagnostic uncertainty – in which the physician is uncertain whether an ailment is antibiotic-appropriate or not – is a factor, as is demand from patients, they said. “Patients want or demand antibiotics, so doctors are more likely to prescribe them when they think that’s what the patient expects,” Fleming-Dutra said, adding that this happens in all outpatient settings.

Limitations of the study included potential for misclassifications because the researchers could not clinically validate medical code diagnoses in claims data. Additionally, they used facility codes, but could not validate whether the medical facilities were actually urgent care centers.

However, another potential issue is that the study does not fully capture relative complexity of medical conditions that may compel somebody to go to an urgent care center versus a retail clinic, said Eric McDonald, CEO of DocuTAP, a Sioux Falls, South Dakota-based firm that provides electronic medical records services for urgent care centers. A patient with acute bronchitis walking into a retail clinic likely does not need an antibiotic, for example, whereas a patient with acute bronchitis who walks into an urgent care center may have a more complex condition that could make the provider more likely to prescribe one, he said. Generally, patients who use urgent care clinics have more complex conditions than those using retail clinics and doctor offices, he added.

DocuTAP plans to publish findings from its own data set in the next several weeks, McDonald said. Those data may provide a more accurate picture of antibiotic prescribing patterns in urgent care clinics, he said, adding that he had the sense the JAMA Internal Medicine study’s numbers were “a little inflated.”

Nevertheless, McDonald acknowledged that inappropriate antibiotics prescribing remains an issue overall. Ameliorating the issue may be more difficult at urgent care clinics than retail clinics given that the latter are mostly controlled by a handful of large companies, whereas the former is more decentralized, Hyun said. But McDonald pointed out that a majority of urgent care centers are already on the right path in terms of promoting antibiotic stewardship, notwithstanding some outliers. Indeed, it is being done already, Fleming-Dutra said, adding that their efforts align well with the CDC’s guidelines.

Photo: spawns, Getty Images

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