A lack of detailed record-keeping in clinics and emergency departments may be hindering efforts to reduce the inappropriate use of antibiotics, according to two recent studies led by physicians from the University of Michigan and their colleagues.
One study found that approximately 10% of children and 35% of adults who received an antibiotic prescription during an office visit had no specific reason for the antibiotic documented in their medical records. The rate of this type of prescribing is particularly high among adults treated in emergency departments and those seen in clinics with Medicaid coverage or no insurance. However, this issue also affects children.
The absence of information on the reasons behind these inappropriate prescriptions makes it challenging for clinics, hospitals, and health insurers to ensure antibiotics are prescribed only when necessary, the researchers argue. Overuse and misuse of antibiotics increase the risk of bacteria evolving to resist the drugs, rendering them less effective. Inappropriately prescribed antibiotics can also cause more harm than benefit to patients.
"When clinicians don't record why they are prescribing antibiotics, it makes it difficult to estimate how many of those prescriptions are truly inappropriate, and to focus on reducing inappropriate prescribing," said Joseph Ladines-Lim, M.D., Ph.D., first author of both studies and a combined internal medicine/pediatrics resident at Michigan Medicine, U-M's academic medical center.
"Our studies help contextualize the estimates of inappropriate prescribing that have been published previously," Ladines-Lim added. "Those estimates don't distinguish between antibiotic prescriptions that are considered inappropriate due to inadequate coding and antibiotic prescriptions truly prescribed for a condition that they can't treat."
Ladines-Lim collaborated with U-M pediatrician and health care researcher Kao-Ping Chua, M.D., Ph.D., on the studies. The study on outpatient prescribing by insurance status is published in the Journal of General Internal Medicine, while the study on trends in emergency department prescribing is featured in Antimicrobial Stewardship and Healthcare Epidemiology.
Building on previous research, Chua and colleagues recently reported trends in inappropriate antibiotic prescribing in outpatients under age 65, suggesting that about 25% of such prescriptions were inappropriate. This figure includes antibiotic prescriptions for conditions that antibiotics do not help, such as colds, and prescriptions not associated with any diagnoses that could plausibly require antibiotics.
The new studies add nuance by examining two types of inappropriate prescriptions more closely. Most antibiotic stewardship efforts have focused on reducing prescriptions for infectious but antibiotic-inappropriate conditions like colds. The new studies show that such patients still account for 9% to 22% of all antibiotic prescriptions, depending on the setting and age group.
Doctors and other prescribers are not required to conduct tests for bacterial infections or list a specific diagnosis to prescribe antibiotics, which complicates the assessment of inappropriate prescriptions. Some patients may have had secondary bacterial infections suspected based on symptoms, but without proper documentation, it's impossible to know.
For patients with no infection-related diagnoses or symptoms recorded who received antibiotics, the researchers suggest that clinicians may have neglected to add these details to the patient record inadvertently or deliberately to avoid scrutiny from antibiotic watchdogs. Additionally, the lower rate of diagnosis documentation among patients in the healthcare safety net may relate to how healthcare organizations are reimbursed.
Often, clinics and hospitals receive a fixed amount from Medicaid to care for all their patients with that coverage, reducing the incentive to create detailed records compared to privately insured patients, whose care is reimbursed on a fee-for-service basis.
"This could actually be a matter of health equity if people with low incomes or no insurance are being treated differently when it comes to antibiotics," said Ladines-Lim, who has studied antibiotic use related to immigrant and asylum-seeker health and will soon begin a fellowship in infectious diseases.
Private and public insurers, and health systems, may need to incentivize accurate diagnosis coding for antibiotic prescriptions or make it easier for providers to document their reasons for prescribing antibiotics. Measures could include requiring providers to record the reason for antibiotic prescribing before sending prescriptions to pharmacies via electronic health record systems.
With antibiotic resistance posing an international threat, similar steps to justify antibiotic prescriptions might be advisable, Ladines-Lim suggested.
In addition to Ladines-Lim and Chua, other authors of the studies are Michael A. Fischer, M.D., M.S. of Boston Medical Center and Boston University, and Jeffrey A. Linder, M.D., M.P.H. of Northwestern University Feinberg School of Medicine. Chua is a member of the Susan B. Meister Child Health Evaluation and Research Center and the U-M Institute for Healthcare Policy and Innovation.
