Retail Clinicians Prescribe Antibiotics More Appropriately Than Primary Care Providers

The Society of General Internal Medicine recognizes that progress has recently stalled in antimicrobial stewardship. Prescribers continue to write scripts for antibiotics for viral infections and select broad-spectrum antibiotics where narrow therapies would be more apt.

The society’s recent study, published in theJournal of Internal Medicine, draws attention to the large disparity in antibiotic prescribing across different care settings—specifically, primary care providers’ offices and retail clinics. The study targeted the drivers of this variation by measuring the rates of antibiotic prescribing and imperfect antibiotic prescribing among clinicians in both retail and primary care clinics.

A large fraction of antibiotic prescribing for acute respiratory tract infections falls under the umbrella of “imperfect” prescribing:

1. Prescribing an antibiotic for a non—antibiotic-appropriate diagnosis (eg, upper respiratory infection, bronchitis, or non-streptococcal pharyngitis)
2. Failing to prescribe an antibiotic for an antibiotic-appropriate diagnosis (eg, sinusitis, pneumonia, streptococcal pharyngitis, otitis media)
3. Choosing a non—guideline-concordant antibiotic for an antibiotic-appropriate diagnosis (defined as an antibiotic other than amoxicillin-clavulanate or amoxicillin for sinusitis; a macrolide or doxycycline for pneumonia; amoxicillin or penicillin for streptococcal pharyngitis; and amoxicillin for otitis media)

Retail clinics—the convenient, walk-in health care stations in drug and grocery stores throughout the country—are primarily staffed by nurse practitioners and physician assistants. Patients often present with acute respiratory infections (eg, common cold, otitis, sinusitis, pharyngitis, acute bronchitis, and pneumonia), which appear to be the most common symptomatic reason for seeking care among patients in the United States, accounting for the majority of all antibiotic prescriptions.

In the study, clinicians in retail clinics prescribed significantly more antibiotics than primary care providers, but had a lower imperfect antibiotic prescribing rate. This supports prior work suggesting that retail clinic staff are more likely to provide guideline-concordant care.

One study limitation is that it only considered one chain of retail clinics across 19 states and collected prescribing data from ICD-9 codes that may not have been accurately matched with true practice.

Interestingly, clinicians in physicians’ offices who had higher rates of imperfect prescribing also had more years of practice and averaged more hours of practice each week compared to the nurse practioners and physician assistants in retail clinics. Survey-reported measures of knowledge, attitudes, and behaviors helped determine factors might lead to higher rates inappropriate prescribing.

Concern: Clinicians who felt rushed in patient visits were more likely to prescribe antibiotics.

Solution: Store brief “talking points” about antibiotics in your clinician arsenal.

Concern: Clinicians who felt less strongly that antibiotics were overused were more likely to prescribe antibiotics.

Solution: Refamiliarize yourself with the guidelines. Remain alert to when antibiotics are necessary and what spectrum of antibiotics may be appropriate.

Concern: Clinicians who didn’t believe patient demand was a problem in their practice were more likely to have imperfect antibiotic prescribing.

Solution: Create barriers for inappropriate prescribing by requiring justification in the electronic medical records for prescribing antibiotics. Educate patients in the waiting room with low-cost posters or pamphlets on antibiotic overuse and beliefs to only prescribe when appropriate.

In the interest of time and preventing patient conflict, clinicians may be tempted to take the path of least resistance. However, silencing patients with prescriptions that may be unnecessary contributes to the rising rate of inappropriate antibiotic use. It also puts patients at greater risk for resistance and unnecessary drug-related adverse effects. Determine alternative recommendations and educate and empower your patients when antibiotics aren’t needed.