Original Research
21 July 2015

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

Publication: Annals of Internal Medicine
Volume 163, Number 2

Abstract

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.

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Supplemental Material

Supplement. Definitions of Inclusion, Exclusion Criteria, and Diagnostic Code Groupings

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 163Number 221 July 2015
Pages: 73 - 80

History

Published online: 21 July 2015
Published in issue: 21 July 2015

Keywords

Authors

Affiliations

Barbara Ellen Jones, MD, MSc
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.
Brian Sauer, PhD
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.
Makoto M. Jones, MD, MSc
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.
Jose Campo, MD
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.
Kavitha Damal, PhD, CCRC
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.
Tao He, MS
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.
Jian Ying, PhD, MStat
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.
Tom Greene, PhD
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.
Matthew Bidwell Goetz, MD
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.
Melinda M. Neuhauser, PharmD, MPH
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.
Lauri A. Hicks, DO
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.
Matthew H. Samore, MD
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, [email protected]). Data set: Not available.
Corresponding Author: 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, [email protected].
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.

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Barbara Ellen Jones, Brian Sauer, Makoto M. Jones, et al. Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study. Ann Intern Med.2015;163:73-80. [Epub 21 July 2015]. doi:10.7326/M14-1933

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