antibiotic overprescribing in urgent care vs in medical offices

And, one more article on antibiotic overprescribing, this one showing higher rates of overprescribing in urgent care centers and emergency departments (see antibiotic overprescribing in urgent care jamaintmed2018 in dropbox, or https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687524). Authors were affiliated with the CDC, Pediatric Infectious Disease at the University of Utah, and the Pew Charitable Trusts.

Details:
-- retrospective review of the 2014 Truven Health MarketScan Commercial Claims and Encounters Database, which has claims data on individuals younger than 65 who have employer-sponsored insurance.
-- outpatient claims had facility codes for urgent care center, retail clinic, hospital-based ED, or medical office
-- oral antibiotic prescriptions were linked to each enrollee's most recent outpatient visits, within the prior 3 days
-- the target diagnoses were: respiratory diagnoses of suppurative viral URIs, bronchitis/bronchiolitis, asthma/allergy, influenza, non-suppurative otitis media, and viral pneumonia

Results:
-- overall antibiotic prescriptions:
    -- urgent care: 39% of 2.7 million urgent care visits, n= 1,062,477
    -- retail clinic visits: 36% of 58,206, n= 58,206
    -- ED visits: 14% of 4.8 million visits, n= 660,450
    -- medical office visits: 7% of 148.5 million visits, n= 10,580,312
-- visits for antibiotic-inappropriate respiratory diagnoses:
    -- urgent care visits: 16%, n= 441,605
    -- retail clinic visits: 17%, n= 10,009
    -- ED visits: 5%, n= 257,010
    -- medical office visits: 6%, n= 9,203,276
-- % of visits for antibiotic-inappropriate respiratory diseases when antibiotics were prescribed:
    -- urgent care: 48%, n= 201,682
    -- retail clinic: 14%, n=1444
    -- ED: 25%, n= 63,189
    -- medical office: 17%, n= 1,563,573

Commentary:
-- 60% of outpatient antibiotic prescriptions in the US are written in traditional ambulatory care settings/medical offices and EDs. The other 40% are largely written in urgent care centers and retail clinics.
-- A potentially bright light in the above study is that inappropriate prescriptions in medical offices in particular as well as ED’s may be lower than prior estimates (around 30%, though other blogs suggest it might be much higher than that: seehttp://gmodestmedblogs.blogspot.com/2016/01/antibiotic-overprescribing-and-acute.html ). a recent clinical guideline on antibiotic overprescribing in acute respiratory infections noted that antibiotic prescription rates have decreased about 18% in people >5yo (see above blog)
-- But one concern is that the number of inappropriate prescriptions is much higher in urgent care centers. Not sure why the numbers were actually lower in retail clinics, since many of them are tied to pharmacies, though the number of patients seen there in this study was quite low as compared to the other sites. However, the concern is that the trend to utilize urgent care centers and retail clinics has been increasing dramatically.
-- The study, though of a large number of people, is somewhat limited in its generalizability, since it only includes younger, working people (a group with fewer comorbidities or disabilities than the average population); also I could not find the geographical distribution of the patients in the Truven Health system (now owned by IBM) to know whether their data is representative of the whole US.

So, a few points:
-- this study may reflect some positive change in prescribing patterns, especially in medical office visits. The prior blog cited above also suggests more recent decreases in inappropriate antibiotic prescriptions
-- however, to me, one of the big concerns about the results of the study is that it reflects the increasing fragmentation of primary care in the US. Primary care providers, who are well connected with their patients, are more likely to look at their care, and even episodic care such as for respiratory infections, in the context of the overall patient, and perhaps more likely to consider the larger community/social context of their prescribing. An increasing shift to urgent care centers, and retail centers often tied to pharmacies dispensing highly profitable drugs, may well lead to more uncoordinated care, with their goal being rapid diagnosis and treatment, and not, for example, treating the patient in the context of who they are (their comorbidities, social situation, cultural/psychological/educational/etc background) or, in this case, getting into detailed discussions with patients about the hazards of antibiotic overprescribing.

geoff​

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