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Development and validation of antibiotic stewardship metrics for outpatient respiratory tract diagnoses and association of provider characteristics with inappropriate prescribing

Published online by Cambridge University Press:  02 June 2021

Kathleen O. Degnan ,
Valerie Cluzet ,
Michael Z. David ,
Lauren Dutcher ,
Leigh Cressman ,
Ebbing Lautenbach ,
Keith W. Hamilton Open the ORCID record for Keith W. Hamilton [Opens in a new window]  and
for the CDC Prevention Epicenters Program
Kathleen O. Degnan
Affiliation:
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Valerie Cluzet
Affiliation:
Health Quest Medical Practice, PC, Poughkeepsie, New York
Michael Z. David
Affiliation:
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
Lauren Dutcher
Affiliation:
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
Leigh Cressman
Affiliation:
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
Ebbing Lautenbach
Affiliation:
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
Keith W. Hamilton*
Affiliation:
Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
*
Author for correspondence: Keith W. Hamilton, E-mail: keith.hamilton@pennmedicine.upenn.edu
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Abstract

Objective:

To determine metrics and provider characteristics associated with inappropriate antibiotic prescribing for respiratory tract diagnoses (RTDs).

Design:

Retrospective cohort study.

Setting:

Primary care practices in a university health system.

Participants:

Patients seen by an attending physician or advanced practice provider (APP) at their primary care office visit with International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM)–coded RTDs.

Methods:

Medical records were reviewed for 1,200 randomly selected office visits in which an antibiotic was prescribed to determine appropriateness. Based on this gold standard, metrics and provider characteristics associated with inappropriate antibiotic prescribing were determined.

Results:

Overall, 69% of antibiotics were inappropriate. Metrics utilizing prespecified RTDs most strongly associated with inappropriate prescribing were (1) proportion prescribing for RTDs for which antibiotics are almost never required (eg, bronchitis) and (2) proportion prescribing for any RTD. Provider characteristics associated with inappropriate antibiotic prescribing were APP versus physician (72% vs 58%; P = .02), family medicine versus internal medicine (76% vs 63%; P = .01), board certification 1997 or later versus board certification before 1997 (75% vs 63%; P = .02), nonteaching versus teaching practice (73% vs 51%; P < .01), and nonurban vs urban practice (77% vs 57%; P < .01).

Conclusions:

Metrics utilizing proportion prescribing for RTDs for which antibiotics are almost never required and proportion prescribing for any RTD were most strongly associated with inappropriate prescribing. APPs and clinicians with family medicine training, with board certification 1997 or later, and who worked in nonteaching or nonurban practices had higher proportions of inappropriate prescribing. These findings could inform design of interventions to improve prescribing and could represent an efficient way to track inappropriate prescribing.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 1 , January 2022 , pp. 56 - 63
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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References

Centers for Disease Control and Prevention. 2019 Antimicrobial resistance threats report. https://www.cdc.gov/drugresistance/biggest-threats.html. Accessed September 24, 2020.Google Scholar
Suda, KJ, Hicks, LA, Roberts, RM, et al. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother 2013;68:715–718.CrossRefGoogle ScholarPubMed
Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.CrossRefGoogle ScholarPubMed
Gonzales, R, Malone, DC, Maselli, JH, Sande, MA. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis 2001;33:757–762.CrossRefGoogle ScholarPubMed
Sanchez, GV, Fleming-Dutra, KE, Roberts, RM, Hicks, LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65(RR-6):1–12.CrossRefGoogle ScholarPubMed
Mandell, LA, Wunderink, RG, Anzueto, A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 suppl 2:S27–S72.CrossRefGoogle Scholar
Chow, AW, Benninger, MS, Brook, I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54(8):e72–e112.CrossRefGoogle ScholarPubMed
Shulman, ST, Bisno, AL, Clegg, HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55(10):e86–e102.CrossRefGoogle Scholar
Lieberthal, AS, Carroll, AE, Chonmaitree, T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–e999.CrossRefGoogle ScholarPubMed
Pertussis (whooping cough) surveillance and reporting. Centers for Disease Control and Prevention website. http://www.cdc.gov/pertussis/surv-reporting.html. Accessed September 24, 2020.Google Scholar
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2018. Global Initiative for Chronic Obstructive Lung Disease (GOLD) website. https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf. Accessed September 24, 2020.Google Scholar
Harris, PA, Taylor, R, Thielke, R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–381.CrossRefGoogle ScholarPubMed
Quan, H, Sundararajan, V, Halfon, P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130–1139.CrossRefGoogle ScholarPubMed
Pouwels, KB, Dolk, CK, Smith, DRM, et al. Explaining variation in antibiotic prescribing between general practices in the UK. J Antimicrob Agents Chemother 2018;73:ii27–ii35.CrossRefGoogle ScholarPubMed
Calfee, DP, Brooks, J, Zirk, NM, et al. A pseudo-outbreak of nosocomial infections associated with the introduction of an antibiotic management programme. J Hosp Infect 2003;55:26–32.CrossRefGoogle ScholarPubMed
Ferech, M, Coenen, S, Malhotra-Kumar, S, et al. European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother 2006;58:401–407.CrossRefGoogle ScholarPubMed
Durkin, MJ, Jafarzadeh, SR, Hsueh, K, et al. Outpatient antibiotic prescription trends in the United States: a national cohort study. Infect Control Hosp Epidemiol 2018;39:584–589.CrossRefGoogle ScholarPubMed
Yan, J, Hawes, L, Turner, L, et al. Antimicrobial prescribing for children in primary care. J Paedriatr Child Health 2019;55:54–58.CrossRefGoogle ScholarPubMed
Curtis, HJ, Walker, AJ, Mahtani, KR, Goldacre, B. Time trends and geographical variation in prescribing of antibiotics in England 1998–2017. J Antimicrob Chemother 2019; 74:242–250.Google Scholar
Suda, KJ, Hicks, LA, Roberts, RM, et al. Trends and seasonal variation in outpatient antibiotic prescription rates in the United States, 2006 to 2010. Antimicrob Agents Chemother 2014;58:2763–2766.CrossRefGoogle ScholarPubMed
Saliba-Gustafsson, EA, Hampton, AD, Zarb, P, et al. Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta: a 1-year repeated cross-sectional surveillance study. BMJ Open 2019;9(12):e032704.CrossRefGoogle ScholarPubMed
Lee, TH, Wong, JG, Lye, DC, et al. Medical and psychosocial factors associated with antibiotic prescribing in primary care: survey questionnaire and factor analysis. Br J Gen Pract 2017;67:e168–e177.CrossRefGoogle ScholarPubMed
Schmidt, ML, Spender, MD, Davidson, LE. Patient, provider, and practice characteristics associated with inappropriate antimicrobial prescribing in ambulatory practices. Infect Control Hosp Epidemiol 2018;39:307–315.CrossRefGoogle ScholarPubMed
Li, D, Conson, M, Kim, N, et al. Patient and provider characteristics and outcomes associated with outpatient antibiotic overuse in acute adult bronchitis. Proc (Bayl Univ Med Cent) 2020;33:183–187.Google ScholarPubMed
Gonzales, R, Steiner, JF, Sande, MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901–904.CrossRefGoogle ScholarPubMed
Nyquist, AC, Gonzales, R, Steiner, JF, Sande, MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875–877.CrossRefGoogle ScholarPubMed
Katz, SE, Staub, M, Ouedraogo, Y, et al. Population-based assessment of patient and provider characteristics influencing pediatric outpatient antibiotic use in a high antibiotic-prescribing state. Infect Control Hosp Epidemiol 2020;41:331–336.CrossRefGoogle Scholar
Hicks, LA, Bartoces, MG, Roberts, RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015;60:1308–1316.Google ScholarPubMed
Fleming-Dutra, KE, Demirjian, A, Bartoces, M, et al. Variations in antibiotic and azithromycin prescribing for children by geography and specialty—United States, 2013. Pediatr Infect Dis J 2018;37:52–58.CrossRefGoogle ScholarPubMed
Kabbani, S, Palms, D, Bartoces, M, et al. Outpatient antibiotic prescribing for older adults in the United States: 2011 to 2014. J Am Geriatr Soc 2018;66:1998–2002.CrossRefGoogle ScholarPubMed
Staub, M, Ouedraogo, Y, Evans, CD, et al. Analysis of a high-prescribing state’s 2016 outpatient antibiotic prescriptions: implications for outpatient antimicrobial stewardship interventions. Infect Control Hosp Epidemiol 2020;41:135–142.Google ScholarPubMed
Frost, HM, McLean, HQ, Chow, BDW. Variability in antibiotic prescribing for upper respiratory illnesses by provider specialty. J Pediatr 2018;203:76–85.e8.CrossRefGoogle ScholarPubMed
Ference, EH, Min, JY, Chandra, RK, et al. Antibiotic prescribing by physicians versus nurse practitioners for pediatric upper respiratory infections. Ann Otol Rhinol Laryngol 2016;125:982–991.CrossRefGoogle ScholarPubMed
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