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IMPROVING PATIENT CARE

Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional StudyVariation in Outpatient Antibiotic Prescribing for ARIs in Veterans

Barbara Ellen Jones, MD, MSc; Brian Sauer, PhD; Makoto M. Jones, MD, MSc; Jose Campo, MD; Kavitha Damal, PhD, CCRC; Tao He, MS; Jian Ying, PhD, MStat; Tom Greene, PhD; Matthew Bidwell Goetz, MD; Melinda M. Neuhauser, PharmD, MPH; Lauri A. Hicks, DO; and Matthew H. Samore, MD
[+] Article, Author, and Disclosure Information

From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention, or U.S. government.

Acknowledgment: The authors thank Saundra Duffy-Hawkins for administrative support, Jenny Teng for data collection and management, and Qing Zeng-Treitler and Douglas Redd for natural language processing.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1933.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Grant Support: From the U.S. Department of Veterans Affairs through the Informatics Decision Enhancement and Analytic Sciences 2.0 Center of Innovation (IDEAS 2.0: CIN 14-267) and the Centers for Disease Control and Prevention Get Smart Project (14FED1412883).

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Jones (e-mail, barbara.jones@hsc.utah.edu). Data set: Not available.

Requests for Single Reprints: Barbara Ellen Jones, MD, MSc, George E. Wahlen Department of Veterans Affairs Medical Center, Informatics, Decision-Enhancement and Analytic Sciences Center, 500 Foothill Boulevard, Mail Code 182, Salt Lake City, UT 84148; e-mail, barbara.jones@hsc.utah.edu.

Current Author Addresses: Drs. B.E. Jones, Sauer, M.M. Jones, and Samore and Mr. He: George E. Wahlen Department of Veterans Affairs Medical Center, Informatics, Decision-Enhancement and Analytic Sciences Center, 500 Foothill Boulevard, Mail Code 182, Salt Lake City, UT 84148.

Dr. Campo: Division of Infectious Disease, Knapp Medical Group, 2602 South Westgate Drive, Weslaco, TX 78596.

Dr. Damal: Kansas City Veterans Affairs Health Care System, 1490 Heritage Valley Drive, High Ridge, MO 63049.

Drs. Ying and Greene: Department of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108.

Dr. Goetz: Veterans Affairs Greater Los Angeles Healthcare, 11301 Willshire Boulevard, Room 4669, Los Angeles, CA 90073.

Ms. Neuhauser: Pharmacy Benefits Management, Veterans Affairs Hines, 1st Avenue, 1 Block North of Cermac Road, Building 37, Room 139, Hines, IL 60141.

Dr. Hicks: Division of Bacterial Disease, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop C25, Atlanta, GA 30329.

Author Contributions: Conception and design: B.E. Jones, B. Sauer, M.M. Jones, J. Campo, L.A. Hicks, M.H. Samore.

Analysis and interpretation of the data: B.E. Jones, B. Sauer, M.M. Jones, J. Campo, K. Damal, T. He, J. Ying, T. Greene, M.B. Goetz, L.A. Hicks, M.H. Samore.

Drafting of the article: B.E. Jones, B. Sauer, M.M. Jones, J. Campo, K. Damal, J. Ying, L.A. Hicks, M.H. Samore.

Critical revision of the article for important intellectual content: B. Sauer, M.M. Jones, J. Campo, J. Ying, M.B. Goetz, M.M. Neuhauser, L.A. Hicks, M.H. Samore.

Final approval of the article: B.E. Jones, B. Sauer, M.M. Jones, J. Campo, K. Damal, J. Ying, M.B. Goetz, M.M. Neuhauser, L.A. Hicks, M.H. Samore.

Provision of study materials or patients: B. Sauer.

Statistical expertise: B. Sauer, K. Damal, J. Ying, T. Greene.

Obtaining of funding: M.M. Jones, L.A. Hicks, M.H. Samore.

Administrative, technical, or logistic support: B. Sauer, J. Campo.

Collection and assembly of data: B.E. Jones, B. Sauer, M.M. Jones, J. Campo, K. Damal, T. He, M.H. Samore.


Ann Intern Med. 2015;163(2):73-80. doi:10.7326/M14-1933
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Background: Despite efforts to reduce antibiotic prescribing for acute respiratory infections (ARIs), information on factors that drive prescribing is limited.

Objective: To examine trends in antibiotic prescribing in the Veterans Affairs population over an 8-year period and to identify patient, provider, and setting sources of variation.

Design: Retrospective, cross-sectional study.

Setting: All emergency departments and primary and urgent care clinics in the Veterans Affairs health system.

Participants: All patient visits between 2005 and 2012 with primary diagnoses of ARIs that typically had low proportions of bacterial infection. Patients with infections or comorbid conditions that indicated antibiotic use were excluded.

Measurements: Overall antibiotic prescription; macrolide prescription; and patient, provider, and setting characteristics extracted from the electronic health record.

Results: The proportion of 1 million visits with ARI diagnoses that resulted in antibiotic prescriptions increased from 67.5% in 2005 to 69.2% in 2012 (P < 0.001). The proportion of macrolide antibiotics prescribed increased from 36.8% to 47.0% (P < 0.001). Antibiotic prescribing was highest for sinusitis (adjusted proportion, 86%) and bronchitis (85%) and varied little according to fever, age, setting, or comorbid conditions. Substantial variation was identified in prescribing at the provider level: The 10% of providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, and the 10% who prescribed the least did so during 40% or fewer of their ARI visits.

Limitation: Some clinical data that may have influenced the prescribing decision were missing.

Conclusion: Veterans with ARIs commonly receive antibiotics, regardless of patient, provider, or setting characteristics. Macrolide use has increased, and substantial variation was identified in antibiotic prescribing at the provider level.

Primary Funding Source: U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention.

Figures

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Figure 1.

Study flow diagram.

Visits could meet several exclusion criteria; therefore, the sum of visits meeting each exclusion criterion exceeds the total number of excluded visits.

ARI = acute respiratory infection; COPD = chronic obstructive pulmonary disease; ED = emergency department; VA = Veterans Affairs.

* There were 1 036 982 visits without missing values.

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Figure 2.

Trends in overall antibiotic prescribing.

The number of ARI-related visits per month and monthly proportion of visits resulting in an antibiotic prescription are depicted. ARI = acute respiratory infection.

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Appendix Figure 1.

Temporal trends in the proportion of all antibiotics prescribed for each antibiotic class.

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Appendix Figure 2.

Predictors of antibiotic prescribing.

The adjusted proportion of visits with antibiotics prescribed based on the marginal standardization model is shown for each subgroup. There were 1 036 982 total visits. The model also included the calendar month and year. Statistically significant predictors (P  < 0.001) included patient age, diagnosis, temperature, provider type, provider age, setting type, time of day, number of ARI visits per clinic per day, location type (CBOC vs. VAMC), and region, although the effect sizes were small. ARI = acute respiratory infection; CBOC = community-based outpatient clinic; ED = emergency department; URI = upper respiratory infection; VAMC = Veterans Affairs medical center.

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Appendix Figure 3.

Predictors of macrolide prescribing.

The adjusted proportion of antibiotic prescriptions that were macrolides is shown for each subgroup. There were 714 552 total visits. The model also included the calendar month and year. Statistically significant predictors ( P < 0.001) included patient sex, diagnosis, temperature, and number of comorbid conditions, although the effect sizes were small. ARI = acute respiratory infection; CBOC = community-based outpatient clinic; ED = emergency department; URI = upper respiratory infection; VAMC = Veterans Affairs medical center.

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Figure 3.

Variation in antibiotic prescribing.

ARI = acute respiratory infection; VAMC = Veterans Affairs medical center. Left. Variation among providers. The histogram shows the distribution of observed proportions of visits with an antibiotic prescription across 2594 providers with at least 100 ARI visits each (n = 480 875). The curve depicts the modeled distribution of antibiotic prescription across providers, after controls were set for the measured patient, provider, and setting characteristics listed in Appendix Figures 2 and 3. Right. Sources of variation. The solid, dashed, and dotted lines depict modeled distributions describing variation in proportion of antibiotic prescriptions attributable specifically to VAMCs, clinics, and providers, respectively, after controls were set for the measured patient, provider, and setting variables listed in Appendix Figures 2 and 3. The dashed-and-dotted line corresponds to the curve in the left panel and depicts overall modeled variation in antibiotic prescription across providers, including differences between providers at different clinics and VAMCs.

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Appendix Figure 4.

Conditional distribution of antibiotic prescribing.

Conditional density curves of antibiotic prescribing prevalence across providers within clinics (with prescription prevalence fixed at the 10th, 50th, and 90th percentiles of the distribution of antibiotic prescribing across clinics) and within VAMCs (with prescribing prevalence fixed at the 10th, 50th, and 90th percentiles of the distribution of antibiotic prescribing across VAMCs) are shown. VAMC = Veterans Affairs medical center.

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