Antimicrobial stewardship programs tend to focus on prescribing decisions made when patients who may have an infection visit clinicians. But what happens when antibiotics are prescribed outside of clinician visits or without clear indications for use?
The investigators of a new study published in Health Affairs
analyzed data from 1 decade and determined that more than a quarter of prescriptions were not associated with a clinic visit. Additionally, nearly a fifth were associated with visits that did not have a documented infection-related diagnosis.
The study team used national Medicaid claims data collected from 2004 to 2013 taken from the Medicaid Analytic eXtract. Several antibiotics were excluded from the analysis, such as methenamine due to use in urinary tract infection prophylaxis. Other antibiotics excluded include non-oral antibiotics and non-absorbable oral antibiotics such as vancomycin.
Claims records were used to assess whether an antibiotic prescription had been preceded by any kind of clinical encounter. The investigators identified 298 million qualifying antibiotic prescriptions filed for 53 million patients over the study period.
The majority of antibiotics analyzed were prescribed to children, with more than one-third of all prescriptions being for children between the age of 0 to 5 years. More than 40% of antibiotic prescriptions were penicillins, accounting for more than double the prescription count for cephalosporins and macrolides.
The study authors noted that more than 40% of patients in the study cohort were located in the Southern United States, with the remaining patients spread near evenly across other regions. However, patients in the South and Midwest were less likely to have non-visit-based prescriptions and had more antibiotic fills associated with infection-related visits.
Ultimately, 28% of filled antibiotic prescriptions had no claims related to any clinician encounter in the previous 7 days. The study authors did note that around half of that 28% of patients had claims for medical services that did not involve a clinician encounter, such as laboratory testing or home care services by nurses or attendants.
In the remaining 72% of antibiotic prescriptions involving a clinician encounter, 55% included a diagnosis code for infection and 17% were not associated with an infection-related diagnosis.
While it may be inferred that a large proportion of the antibiotics prescribed without clinician encounters were for certain relevant chronic conditions, such prescriptions accounted for only 3% of antibiotics prescribed without an office visit.
Overall, the large numbers of antibiotics prescribed without a clinician visit present a sizable proportion of antibiotic use which would not be able to be evaluated by most existing antimicrobial stewardship programs.
“From a policy perspective, current antibiotic stewardship recommendations and programs are missing a huge proportion of antibiotic prescribing,” the study authors wrote.
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