Study spotlights inappropriate prescribing in urgent care

New research on antibiotic prescribing in outpatient settings indicates that the amount of inappropriate prescribing for coughs, colds, and other viral respiratory illnesses could be higher than previously thought.

In a study today in JAMA Internal Medicine, researchers with the Centers for Disease Control and Prevention (CDC), the University of Utah, and the Pew Charitable Trusts report that 45.7% of patients who visited urgent care centers in 2014 for respiratory illnesses that don't require antibiotics end up with prescriptions for those conditions, followed by 24.6% of patients treated in emergency departments (EDs), 17% of patients who went to medical offices, and 14.4% of patients who visited retail clinics. The findings are based on analyses of 2014 claims data from patients with employer-sponsored health insurance.

Previous estimates of outpatient antibiotic prescribing by some of the same researchers had pegged the amount of unnecessary prescribing at 30%, a number that some experts believe is conservative. Study coauthor David Hyun, MD, a senior officer with Pew's antibiotic resistance project, said the findings suggest that could very well be the case.

"The real number may very well be higher than 30% when it comes to inappropriate prescriptions," Hyun told CIDRAP News.

Growing use of urgent care, retail clinics

The researchers conducted the retrospective cohort study to get a fuller picture of prescribing practices in outpatient settings. Their previous analysis of outpatient prescribing, published in 2016, had looked at antibiotic prescribing in medical offices, emergency departments, and hospital clinics.

But these settings only account for about 60% of outpatient antibiotic prescriptions dispensed in the United States. Meanwhile, an increasing number of Americans are going to urgent care centers and retail clinics for minor ailments, some of which require antibiotics. An accompanying commentary notes that there are more than 10,000 of these high-volume clinics nationwide, with the rapid proliferation likely fueled by same-day access, proximity, and lower out-of-pocket costs than emergency departments.

"There's a significant proportion of outpatient prescribing that was not captured in the study we published 2 years ago," said Hyun, who was also a co-author on the previous study. "Urgent care centers and retail clinics are being viewed as a more accessible side of healthcare for some of these acute care conditions, for various reasons."

Because urgent care centers and retail clinics comprise a growing proportion of outpatient healthcare, he added, he and his colleagues felt it was necessary to look at claims data from these settings to gain a better idea of how often Americans are visiting them for minor viral illnesses like colds or other respiratory ailments, and how often they are being prescribed unnecessary antibiotics compared to other outpatient settings.

The analysis found that 39% of 2.7 million urgent care center visits and 36.4% of 58,206 visits to retail clinics were linked to antibiotic prescriptions, compared to 13.8% of 4.8 million ED visits and 7.1% of 148.5 million medical office visits. Visits for antibiotic inappropriate respiratory diagnoses—including viral upper respiratory infection, bronchitis, asthma, and influenza—accounted for 16% of trips to urgent care, 17% of trips to retail clinics, 6% of medical office visits, and 5% of ED visits.

The finding that inappropriate antibiotic prescribing for these conditions was two to three times higher in urgent care clinics than in other outpatient settings should send a message to all providers working in urgent care, said J.D. Zipkin, MD, associate medical director of Northwell Health-GoHealth Urgent Care, a network of urgent care centers in New York.

"The data, while imperfect, does certainly shine a light on the trends that are going on behind the scenes in this growing industry of urgent care," Zipkin said.

Stewardship message

Although Hyun and his colleagues did not examine what was behind the inappropriate prescribing at urgent care centers, he noted that previous research has identified patient pressure and demand as one of the primary drivers of inappropriate prescribing in doctor's offices and emergency departments. That pressure, he said, is likely present in all outpatient settings. Whether it's greater in urgent care centers is unclear.

"What may be helpful, as we think about stewardship across all these settings, is to gain a better understanding on whether there is variability in the amount or degree of patient pressure depending on the types of settings," Hyun said.

Another important factor, Zipkin explained, is that urgent care providers don't have the type of relationship with patients where they can take the time to explain why an antibiotic for a viral ailment isn't necessary. Moreover, some patients who go to urgent care don't have a primary care physician.

"When they go to an urgent care for the first time, they're just looking for the quick fix, and they don't necessarily realize there is no magic bullet," Zipkin said. "One of the skills that's so important in urgent care is the ability to connect with patients and have that amazing relationship with patients, but in a much smaller time frame than doctors have historically had."

While noting that Northwell Health-GoHealth places a high priority on antimicrobial stewardship and is "well ahead of the curve" on the issue, Zipkin said he believes that addressing inappropriate antibiotic prescribing across the urgent care industry will require a multifaceted solution involving patient and public education, better communication between urgent care providers and patients, buy-in from leadership, and robust tracking of prescribing habits.

 "We can do a better job, as an industry, with antimicrobial stewardship," Zipkin said. "It is absolutely the responsibility of leaders in the industry to take up the call to improve it."

See also:

Jul 16 JAMA Internal Med research letter

Jul 16 JAMA Internal Med commentary

May 4, 2016, CIDRAP News story "Study: 30% of outpatient antibiotic prescriptions unnecessary"

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