Stewardship / Resistance Scan for Apr 22, 2019

Antibiotic prescribing in Ontario
Factors associated with prescribing

Study: High variability in prescribing by Canadian family physicians

A new study by Canadian researchers has found substantial inter-physician variability in antibiotic prescribing that was not explained at all by differences in patients. The findings appeared in the Journal of Antimicrobial Chemotherapy.

To describe predictors of overall antibiotic prescribing and inter-physician variability among family physicians in Ontario, researchers from Public Health Toronto looked at prescribing rates over 5 years and evaluated the association of patient-, physician-, and clinic-level characteristics with those rates. Using electronic medical records and linked databases containing demographic information on patients and physicians, they evaluated nearly 4 million physician-patient encounters, with 322,129 unique patients cared for by 313 physicians at 41 primary care clinics.

Overall, physicians prescribed a median of 54 antibiotics per 1,000 encounters. Patients' age and sex were highly correlated with antibiotic prescriptions, particularly in girls aged 3 to 5 years, who were associated with the highest antibiotic prescribing rates compared with males 65 years of age and older (odds ratio [OR], 4.01; 95% confidence interval [CI], 3.89 to 4.13). The only significant physician-level predictor was a median daily patient volume of more than 20 patients, compared with more than 10 (adjusted OR, 1.28; 95% CI, 1.06 to 1.55).

The analysis also found, however, that patient-level covariates had little impact on the variability of physician prescribing. The median ORs with and without patient characteristics were 1.68 and 1.69, respectively, which was interpreted as meaning that the odds of receiving an antibiotic prescription in the same patient randomly encountering two different physicians varied by 1.7-fold, simply by seeing different physicians. In addition, except among children ages 0 to 11, physician identifiers explained more of the antibiotic prescribing than all patient characteristics, including comorbidities and healthcare use.

The authors of the study say the findings provide supporting evidence that antibiotic prescribing rates don't need to be adjusted for patient characteristics when used for peer comparison of family physicians working in similar practice settings.
Apr 19 J Antimicrob Chemother study


Review highlights factors linked with prescribing in primary, dental care

In another study in the Journal of Antimicrobial Chemotherapy, a team of British researchers reviewed published literature and identified 30 factors associated with the decision to prescribe antibiotics to adults with acute conditions in primary care and primary dental care.

For the two-part review, the researchers identified 689 publications across primary care and 432 across dental care for review. Of these, nine and seven studies, respectively, were included in the final review. They covered 46 countries, of which 12 were low- and middle-income countries (LMICs).

A total of 30 modifiable and non-modifiable factors associated with prescribing were identified across both the umbrella review of primary care studies and the systematic review of primary dental studies. Among the 30 factors identified, the most frequent were "patient/condition characteristics," "patient influence," and "treatment skills." The two factors that were unique to dental studies were "procedure possible," and "treatment skills." None of the factors identified related only to LMICs.

The authors of the study say the identification of these factors should assist the theory-informed design of new interventions—and fine-tuning of existing interventions—aimed at helping clinicians in primary care and dental care optimize antibiotic prescribing.
Apr 19 J Antimicrob Chemother study

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