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Published on: August 30, 2018
Variation in Antibiotic Prescribing Across a Pediatric Primary Care Network
Jeffrey S Gerber1, Priya A Prasad2, A Russell Localio3
1Divisions of Infectious Diseases The Center for Pediatric Clinical Effectiveness Departments of Pediatrics Biostatistics and Epidemiology Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Insights
Antibiotic prescribing for pediatric respiratory infections varies widely between practices, even after accounting for patient factors. This highlights significant opportunities for improving antimicrobial stewardship in outpatient settings.
Area of Science:
- Pediatric infectious diseases
- Antimicrobial stewardship
- Health services research
Background:
- Outpatient respiratory tract infections are a leading cause of antibiotic prescriptions in children.
- Previous research indicates antibiotic overuse, but lacks detailed data on practice-level variability.
Purpose of the Study:
- To investigate the variability in antibiotic prescribing for pediatric acute respiratory tract infections across different outpatient practices.
- To identify potential determinants of this prescribing variability.
Main Methods:
- Retrospective cohort study of 399,793 acute visits to 25 pediatric practices (222 clinicians) in 2009.
- Data extracted from electronic health records, including diagnoses, medications, and patient demographics.
- Analysis adjusted for patient factors and clinician clustering to compare practice-level prescribing rates.
Main Results:
- 28% of acute visits resulted in antibiotic prescriptions.
- Antibiotic prescribing rates varied from 18% to 36% across practices, with broad-spectrum antibiotic use ranging from 15% to 58%.
- Significant practice-level variation was observed in diagnoses and broad-spectrum antibiotic prescribing for common infections like otitis media, sinusitis, pharyngitis, and pneumonia.
Conclusions:
- Substantial unexplained variability exists in antibiotic prescribing for common pediatric infections among outpatient practices.
- Patient-specific factors do not account for this observed prescribing variation.
- These findings underscore the need for targeted antimicrobial stewardship interventions in pediatric outpatient settings.
Background:
Outpatient respiratory tract infections are the most common reason for antibiotic prescribing to children. Although prior studies suggest that antibiotic overuse occurs, patient-specific data or data exploring the variability and determinants of variability across practices and practitioners is lacking.
Methods:
This study was conducted from a retrospective cohort of encounters to 25 diverse pediatric practices with 222 clinicians, from January 1 to December 31, 2009. Diagnoses, medications, comorbid conditions, antibiotic allergy, and demographic data were obtained from a shared electronic health record and validated by manual review. Practice-specific antibiotic prescription and acute respiratory tract infection diagnosis rates were calculated to assess across-practice differences after adjusting for patient demographics and clustering of encounters within clinicians.
Results:
A total of 102 102 (28%) of 399 793 acute visits by 208 015 patients resulted in antibiotic prescriptions. After adjusting for patient age, sex, race, and insurance type, and excluding encounters by patients with chronic conditions, antibiotic prescribing by practice ranged from 18% to 36% of acute visits, and the proportion of antibiotic prescriptions that were broad-spectrum ranged from 15% to 58% across practices, despite additional exclusion of patients with antibiotic allergies or prior antibiotic use. Diagnosis of (Dx) and broad-spectrum antibiotic prescribing (Broad) for acute otitis media (Dx: 8%-20%; Broad: 18%-60%), sinusitis (Dx: 0.5%-9%; Broad: 12%-78%), Streptococcal pharyngitis (Dx: 1.8%-6.4%; Broad: 2%-30%), and pneumonia (Dx: 0.4%-2%; Broad: 1%-70%) also varied by practice (P < 0.001 for all comparisons).
Conclusions:
Antibiotic prescribing for common pediatric infections varied substantially across practices. This variability could not be explained by patient-specific factors. These data suggest the need for and provide high-impact targets for outpatient antimicrobial stewardship interventions.
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