Most antibiotic prescriptions written without visit or ID-related code, large study finds
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A study that assessed more than 22 million outpatient antibiotic prescriptions in the United States found that more than half were not associated with a clinician visit or an infection-related diagnosis, researchers reported.
“Antibiotic use is one of the most common outpatient medical interventions, with over 259 million outpatient antibiotic prescriptions dispensed in the United States in 2018,” Michael A. Fischer, MD, MS, who specializes in pharmacoepidemiology and pharmaeconomics at Brigham and Women’s Hospital and Harvard Medical School, and colleagues wrote, adding that clinicians prescribe antibiotics at 13% of ambulatory visits.
“Overuse of antibiotics, however, increases the risk of antibiotic resistance and adverse effects,” they wrote. “Moreover, every 1,000 outpatient antibiotic prescriptions result in one emergency department visit for an antibiotic-associated adverse drug event. Up to 50% of prescribed antibiotics may be unnecessary, meaning that patients do not even realize a clinical benefit in return for taking on the risk of adverse events.”
To assess ambulatory antibiotic prescribing in the U.S., Fischer and colleagues conducted an observational cohort study using data from a large private insurance plan on patients who received antibiotic prescriptions between April 1, 2016, and June 30, 2018. According to the study, they identified whether prescriptions were associated with a clinician visit and an infection-related diagnosis; associated with a clinician visit, but no infection-related diagnosis; or not associated with an in-person clinician visit in the 7 days before the prescription. They then assessed whether non-visit-based antibiotic prescriptions (NVBAP) differed from visit-based antibiotics by patient, clinician or antibiotic characteristics using multivariable models.
The study included 8.6 million people who filled 22.3 million antibiotic prescriptions.
According to Fischer and colleagues, 31% (6.9 million) of the antibiotic prescription fills were not associated with an office visit, and 22% (4.9 million) did not include an infection-related diagnosis code.
They found that NVBAP rates were lower for children than for adults, with children aged 0 to 17 years accounting for 16%, adults aged 18 to 64 years accounting for 33% and adults aged 65 years and older accounting for 34%. Additionally, among the most commonly prescribed antibiotic classes, NVBAP was highest for penicillins (36%) and lowest for cephalosporins (25%) and macrolides (25%). The study also showed that specialist physicians had the highest rate of NVBAP (38%), followed by internists (28%), family medicine physicians (20%) and pediatricians (10%).
“Our findings add to concerns about antibiotic overuse and the associated risks of adverse events and antibiotic resistance,” the authors wrote. “Prescriptions issued and filled in the absence of an in-person visit or without documentation of an infection raise particular problems, since antibiotic stewardship interventions may not reach the prescribing clinician at the time when a decision is being made.”
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