Demographic, Clinical, and Socioeconomic Factors Associated with Antibiotic Prescribing Practices Among Veterans Using Non-VA Urgent Care Restricted; Files Only

Abstract

Background: Antibiotic resistance is a critical public health issue, driven in part by inappropriate prescribing practices that contribute to adverse outcomes. The Veterans Affairs (VA) introduced a benefit allowing Veterans to access urgent care in community clinics, raising concerns about antibiotic prescribing in settings with limited oversight and data coordination.

 

Methods: A retrospective cohort study was conducted among Veterans receiving antibiotics through non-VA urgent care. Patient characteristics were obtained from the VA Corporate Data Warehouse. Antibiotic prescriptions and associated ICD-10 codes documented during urgent care encounters were identified using the Community Care Reimbursement System. Prescriptions were classified into three tiers based on whether diagnoses were suggestive of infection or noninfectious conditions, and according to resistance risk using the WHO’s Access, Watch, Reserve classification. Multivariable logistic regression assessed associations between Veteran characteristics and two outcomes: 1) antibiotic prescribing without an associated infectious diagnosis and 2) prescribing high resistance risk antibiotics, adjusting for covariates and using multiple imputation for missing data.

 

Results: Among 108,081 Veterans receiving 155,550 non-VA urgent care antibiotic prescriptions, 79.2% (n=85,647) had prescriptions without documented infectious diagnoses, while 78.5% (n=84,883) received low resistance risk antibiotics. Adjusted analyses revealed higher odds of prescriptions with noninfectious diagnosis for Veterans ≥75 years [OR (95% CI): 1.07 (1.03–1.12)], Hispanic/Latino individuals [1.08 (1.03,1.13)], and those living in the West [1.12 (1.08,1.16)] or Northeast [1.08 (1.02,1.14)]. High resistance risk antibiotics were associated with higher odds with older age [65–74y: 1.08 (1.04,1.12); ≥75y: 1.07 (1.02,1.12)], rural residence [1.06 (1.03,1.08)], and neighborhood disadvantage [1.04 (1.01,1.07)].

 

Conclusion: This study of antibiotic prescribing practices found that age, race/ethnicity, and region were associated with potentially inappropriate antibiotic prescribing in non-VA urgent care, reflecting structural care access inequities and provider diagnostic uncertainty. However, claims data limitations—such as under-coding of infectious diagnoses and lack of direct prescription-diagnosis linkage— warrant caution in interpreting appropriateness. These findings underscore the need for enhanced clinical-claims data integration and stewardship partnerships between VA and community providers to ensure that prescribing aligns with patient needs.

Table of Contents

INTRODUCTION 1

METHODS 3

Study Design and Timeframe 3

Data Sources 3

Study Population 4

Evaluating Potentially Inappropriate Antibiotic Prescribing Practices 5

RESULTS 7

Primary Outcome (Diagnosis Tiers) 7

Secondary Outcome (Antibiotic Resistance Risk, Independent of Diagnosis) 8

DISCUSSION 9

REFERENCES 13

TABLES/FIGURES 15

Figure 1. Patient Cohort and Prescription Selection Criteria 15

Table 1. Non-VA Urgent Care Patient Demographic, Clinical, Socioeconomic Factors by Prescription Classifications 16

Table 2. Common Non-VA Urgent Care Antibiotics and Diagnoses by Classifications 18

Figure 2. Non-VA Urgent Care Prescription Rates Over Study Timeframe 19

Table 3. Logistic Regression: Factors Associated with Potentially Inappropriate Antibiotic Prescribing 20

APPENDIX 21

eTable 1. Selected Oral Antibiotics and Classification 21

eTable 2. Tiered Classification System for Infectious Syndromes and Corresponding ICD-10 Codes 22

eFigure 1. Directed Acyclic Graph (DAG) of Factors Associated with Potentially Inappropriate Antibiotic Prescribing 26

eTable 3. Model Assessment and Validation Results 27

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.S.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Pharmacy
Keyword	Urgent Care Veterans Antibiotic Prescribing
Committee Chair / Thesis Advisor	Walid Gellad, U.S. Department of Veterans Affairs Joshua D. Wallach, Emory University
Committee Members	Muriel L. Burk, U.S. Department of Veterans Affairs Francesca E. Cunningham, U.S. Department of Veterans Affairs

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