The lack of detailed records in clinics and emergency departments may be hindering the reduction of inappropriate antibiotic use, a pair of new studies by a pair of University of Michigan doctors and their colleagues suggest.
In one of the studies, about 10% of children and 35% of adults who were prescribed an antibiotic during an office visit had no specific reason for the antibiotic in their record.
Studies show that the rate of this type of prescription is especially high in adults treated in emergency departments and in adults seen in clinics that are covered by Medicaid or are uninsured. But the problem also occurs in children.
Without information about what drove these inappropriate prescriptions, it will be even more difficult for clinics, hospitals and health insurers to take steps to ensure that antibiotics are prescribed only when they are truly needed, the researchers say.
Overuse and incorrect use of antibiotics increases the risk that bacteria will evolve to resist the drugs and make them less useful to everyone. Inappropriately prescribed antibiotics can also end up doing more harm than good to patients.
“When doctors don’t record why they prescribe antibiotics, it becomes difficult to estimate how many of those prescriptions are actually inappropriate and to focus on reducing inappropriate prescribing,” said Joseph Ladines-Lim, M.D., Ph.D., first author of the two new studies. and a combined internal medicine and pediatrics resident at Michigan Medicine, UM’s academic medical center.
“Our studies help contextualize previously published estimates of inappropriate prescribing,” he added. “Those estimates do not distinguish between antibiotic prescriptions that are considered inappropriate due to inadequate coding and antibiotic prescriptions actually prescribed for a condition they cannot treat.”
Ladines-Lim worked with UM pediatrician and healthcare researcher Kao-Ping Chua, M.D., Ph.D., on the new studies. The outpatient prescription due to insurance situation is in the Journal of General Internal Medicine and trends in emergency prescriptions are in Antimicrobial administration and health epidemiology.
Based on previous research
Chua and colleagues recently published findings on trends in inappropriate antibiotic prescribing in outpatients under 65 years of age, suggesting that about 25% were inappropriate. But that number includes antibiotic prescriptions written for infectious conditions that antibiotics don’t help, such as colds, and antibiotic prescriptions that are not associated with any diagnosis that could be a plausible indication for antibiotics.
The new studies add more nuance to that finding by taking a closer look at these two different types of inappropriate prescriptions.
Most antibiotic stewardship efforts to date have focused on reducing the use of the first type of inappropriate prescription: those written for infectious conditions but that do not require antibiotics, such as colds. New studies show that these patients still account for between 9% and 22% of all antibiotic prescriptions, depending on setting and age group.
But since doctors and other prescribers are not required to test for a bacterial infection or list a specific diagnosis to prescribe antibiotics, the symptoms provide potential clues as to why they might have prescribed antibiotics anyway.
So it’s possible that some of that 9% to 22% of all people who receive antibiotics also had a secondary bacterial infection that the doctor suspected based on the symptoms.
However, it is impossible to know.
As for those without infection-related diagnoses or symptoms in their records who received antibiotics, the researchers suggest that doctors may not have bothered to add these diagnoses or symptoms to the patient’s record inadvertently, or even deliberately, to try to avoid scrutiny. antibiotic surveillance.
But researchers also speculate that the lower rate of diagnosis documentation in patients in the healthcare safety net may also have to do with how healthcare organizations are reimbursed.
Clinics and hospitals often receive a set amount of Medicaid to care for all of their patients with that type of coverage. Therefore, they are not incentivized to create records as detailed as those of privately insured patients, whose care is traditionally reimbursed under a fee-for-service model.
“This could actually be a health equity issue if low-income or uninsured people are treated differently when it comes to antibiotics,” says Ladines-Lim, who has also studied HIV-related antibiotic use. health of immigrants and asylum seekers and will soon begin a fellowship in infectious diseases.
He said public and private insurers and health systems may need to incentivize accurate diagnosis coding for antibiotic prescriptions, or at least make it easier for providers to document why they administer them.
That could even include measures such as requiring providers to record the reason for prescribing antibiotics before prescriptions can be sent to pharmacies through electronic medical records systems.
After all, Ladines-Lim said, doctors often have to list a diagnosis that justifies the tests they order, such as CT scans or X-rays. Given that antibiotic resistance represents an international threat to patients suffering from antibiotic-susceptible diseases, similar measures could be advisable to justify the prescribing of antibiotics.
In addition to Ladines-Lim and Chua, the other authors of the two articles are Michael A. Fischer, MD, MS of Boston Medical Center and Boston University, and Jeffrey A. Linder, MD, MPH of the Feinberg School of Medicine at the Northwestern University.
The research was funded by a Resident Research Grant from the American Academy of Pediatrics, a Physician Investigator Award from the Blue Cross Blue Shield of Michigan Foundation, and a National Association of Med-Peds Resident Research Grant.