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The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness: A Cohort Study

Courtney Hebert, MD; Jennifer Beaumont, MS; Gene Schwartz, MD; and Ari Robicsek, MD
[+] Article, Author, and Disclosure Information

From The Ohio State University, Columbus, Ohio; Northwestern University, Feinberg School of Medicine, and University of Chicago Pritzker School of Medicine, Chicago, Illinois; and NorthShore University HealthSystem, Evanston, Illinois.

Disclaimer: Drs. Hebert and Robicsek had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Grant Support: Dr. Robicsek was supported by a NorthShore University HealthSystem Research Career Development Award.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2968.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Robicsek (e-mail, ARobicsek@northshore.org). Data set: Deidentified data set available from Dr. Robicsek (e-mail, ARobicsek@northshore.org).

Requests for Single Reprints: Courtney Hebert, MD, The Ohio State University Wexner Medical Center, Department of Biomedical Informatics, 3190 Graves Hall, 333 West Tenth Avenue, Columbus, OH 43210; e-mail, courtney.hebert@osumc.edu.

Current Author Addresses: Dr. Hebert: The Ohio State University Wexner Medical Center, Department of Biomedical Informatics, 3190 Graves Hall, 333 West Tenth Avenue, Columbus, OH 43210.

Ms. Beaumont: Northwestern University Feinberg School of Medicine, Department of Medical Social Sciences, 710 North Lakeshore Drive, 7th Floor, Chicago, IL 60611.

Dr. Schwartz: Department of Internal Medicine, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226.

Dr. Robicsek: NorthShore University HealthSystem, 2650 Ridge Avenue, Burch 124, Evanston, IL 60201.

Author Contributions: Conception and design: C. Hebert, A. Robicsek.

Analysis and interpretation of the data: C. Hebert, J. Beaumont, G. Schwartz, A. Robicsek.

Drafting of the article: C. Hebert, J. Beaumont, G. Schwartz, A. Robicsek.

Critical revision of the article for important intellectual content: C. Hebert, J. Beaumont, G. Schwartz, A. Robicsek.

Final approval of the article: C. Hebert, J. Beaumont, G. Schwartz, A. Robicsek.

Provision of study materials or patients: A. Robicsek.

Statistical expertise: J. Beaumont, A. Robicsek.

Obtaining of funding: A. Robicsek.

Administrative, technical, or logistic support: C. Hebert, A. Robicsek.

Collection and assembly of data: C. Hebert, G. Schwartz, A. Robicsek.

Ann Intern Med. 2012;157(3):160-169. doi:10.7326/0003-4819-157-3-201208070-00005
Text Size: A A A

Background: Little is known about the influence of contextual factors on a physician's likelihood to prescribe antimicrobials for febrile respiratory illness (FRI). Context includes epidemiologic context (for example, a pandemic period) and personal context (for example, recent exposure to other patients with FRI).

Objective: To examine the association between contextual factors and antimicrobial prescribing for FRI.

Design: 5.5-year retrospective cohort study.

Setting: A network of Midwestern primary care providers.

Patients: All patients presenting with FRI during influenza seasons between 2006 and 2011.

Measurements: Antimicrobial prescribing for FRI during pandemic and seasonal influenza periods.

Results: 28 301 unique patient encounters for FRI with 69 physicians in 26 practices were included. An antibiotic was prescribed in 12 795 (45.2%) cases. The range of prescribing among physicians was 17.9% to 83.7%. Antibiotics were prescribed in 47.5% of encounters during the seasonal period and 39.2% during the pandemic period (P < 0.001). After multivariable adjustment for patient and physician characteristics, antibiotic prescribing was lower in the pandemic period (odds ratio [OR], 0.72 [95% CI, 0.68 to 0.77]) than in the seasonal period. The likelihood of prescribing an antibiotic decreased as the number of FRI cases that a physician had seen in the previous week increased (OR, 0.93 [CI, 0.86 to 1.01] for 2 to 3 patients with FRI seen in the previous week; OR, 0.84 [CI, 0.77 to 0.91] for 4 to 6 patients; OR, 0.71 [CI, 0.64 to 0.78] for 7 to 11 patients; and OR, 0.57 [CI, 0.51 to 0.63] for ≥12 patients compared with the reference range of 0 to 1 patients). Pandemic season and recent personal context were also associated with antiviral prescribing.

Limitation: Retrospective study in a single geographic area.

Conclusion: Epidemiologic context and the number of cases of FRI that a physician had recently seen were associated with his or her likelihood to prescribe antimicrobials for FRI. Interventions that enhance a physician's contextual awareness may improve antimicrobial use.

Primary Funding Source: NorthShore University HealthSystem.


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Figure 1.

Study flow diagram.

FRI = febrile respiratory illness.

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Figure 2.

Percentage of all primary care outpatient visits for FRI during the study period.

FRI = febrile respiratory illness.

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Figure 3.

Antibiotic prescribing for FRI by eligible providers during seasonal influenza periods compared with change in prescribing during pandemic influenza periods.

FRI = febrile respiratory illness.

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Figure 4.

Percentage of patients with FRI who received antibiotics based on the number of patients with FRI seen by their physician in the previous week.

FRI = febrile respiratory illness.

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