Impact of provider and patient characteristics on unnecessary antibiotic prescribing in The Emory Clinic outpatient setting, October 2015 – September 2017 Public

Abstract

Introduction: Within the outpatient setting, most of the antibiotics prescribed are for respiratory conditions, specifically acute respiratory infections (ARIs), but most ARIs are caused by viruses and antibiotics are not necessary. We analyzed provider specific antibiotic prescribing patterns as a step to improve prescribing practice and minimize unnecessary antibiotic use in an outpatient setting. 

Methods: A cross-sectional study was conducted on eligible encounters with a primary diagnosis of acute respiratory infection from October 2015 to September 2017 in The Emory Clinic (TEC) outpatient setting. Multivariable logistic regression analysis was performed to examine patient, provider, and setting characteristics impacts on antibiotic prescribing as well as analyze provider-specific prescribing rates.

Results: About half of the 9,600 encounters (53.4%) over the two-year study period resulted in an antibiotic prescription for an acute respiratory infection. Macrolides (40.3%) and broad-spectrum penicillins (21.4%) were the most frequent antibiotics prescribed. Prescribing rates between providers were highly variable (median: 43% antibiotics prescribed, interquartile range (IQR): 27%-60% antibiotics prescribed) and varied between the 8 clinic locations (median: 45% antibiotics prescribed, IQR: 39%-59% antibiotics prescribed). Odd of antibiotic prescriptions were independently associated with patient characteristics of white race (OR: 1.59, 95% CI: 1.47-1.73), age (51 to 64 years, OR: 1.32, 95% CI: 1.20-1.46; 65+ years, OR: 1.32, 95% CI: 1.20-1.46), and comorbid condition(s) presence (OR: 1.19, 95% CI: 1.09-1.30). Of the 109 providers, 60% (65) had an O:E ratio below 1.0 where 26% (28) were statistically significant; and, 38% (41) had an O:E ratio above 1.0 where 12% (13) were statistically significant.

Conclusion: Antibiotic prescription rates for ARIs is common within TEC outpatient settings with huge variation in prescribing rates despite a universal target of zero prescriptions. Even when accounting for patient characteristics associated with antibiotic receipt, about one-third of providers prescribe more than and should be targeted for practice improvements.

Table of Contents

BACKGROUND.................................................................................................... 1

Introduction............................................................................................................. 1

Consequences of unnecessary antibiotic use........................................................... 1

Contributing factors to antibiotic prescribing for ARIs.......................................... 2

METHODS............................................................................................................. 3

Study Design........................................................................................................... 3

Data source and study population........................................................................... 3

Covariate definitions............................................................................................... 4

Statistical analysis................................................................................................... 5

RESULTS............................................................................................................... 7

Study Population and Frequency of Antibiotic Prescribing.................................... 7

Encounter-level analysis......................................................................................... 7

Clinic-level and provider-level analysis.................................................................. 8

Standardized Prescribing Ratio............................................................................... 9

DISCUSSION....................................................................................................... 10

REFERENCES.................................................................................................... 12

TABLES............................................................................................................... 16

Table 1. Characteristics of eligible encounters with acute respiratory infections from The Emory Clinic locations, October 2015 to September 2017....................................................................................................................... 16

Table 2. Antibiotic prescribing during The Emory Clinic outpatient visits for acute respiratory infections, October 2015 and September 2017  18

Table 3. Multivariate model of antibiotic prescribing among The Emory Clinic encounters with acute respiratory infections      20

Table 4. Multivariable logistic regression models of antibiotic prescribing for acute respiratory infections among providers with ³ 10 encounters at The Emory Clinic.................................................................................................. 21

FIGURES............................................................................................................. 23

Figure 1. Histogram of total number of encounters overlaid by a trend line of unadjusted percent antibiotic prescribed by TEC locations between October 2015 and September 2017 (N = 9,600)................................................... 23

Figure 2. Stacked bar graph of total number of encounters and observed antibiotics prescribed overlaid by caterpillar plot of OE ratio of antibiotics prescribed by provider at TEC from October 2015 to September 2017............... 24

APPENDIX FIGURE AND TABLES............................................................... 25

Appendix Table 1................................................................................................ 25

Appendix Table 2................................................................................................ 26

Appendix Figure 1............................................................................................... 27

Appendix Figure 2............................................................................................... 28

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Mot-clé	outpatient settings unnecessary antibiotic prescribing acute respiratory infections antibiotic resistance
Committee Chair / Thesis Advisor	Fridkin, Scott, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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