With antibiotic resistance increasing across the globe, the need for antibiotic stewardship has never been more important. While there are multiple reasons for the increase, prescribing antibiotics for colds, flu, bronchitis, and other non-responsive illnesses contributes to the growing threat.
The Centers for Disease Control and Prevention (CDC) released a study last summer in the Journal of the American Medical Association Internal Medicine (JAMA IM) and found that when it comes to prescribing inappropriate antibiotics, urgent care is one of the biggest offenders.
To assess antibiotic prescribing patterns, researchers looked at 2014 data on outpatients in the U.S. under age 65 that visited urgent cares, retail clinics, emergency rooms, and medical offices. For urgent care, they examined outpatient claims data from more than 2.7 million patients. The study found that 39 percent of visits to urgent care clinics resulted in prescriptions for antibiotics, and that 45.7 percent of patients that visited urgent care for respiratory conditions for which antibiotics are inappropriate still received prescriptions for antibiotics.
With current urgent care data at our fingertips, we decided to study the same topic for this issue using data from July of 2017 through June of 2018. Our analysis found a few differences from those reported by JAMA IM.
In order to provide meaningful and current information, we looked at every urgent care visit that included an E/M code from July 1, 2017 through June 30, 2018—which excludes most non-urgent care visits like OccMed, sports physicals, and flu shot visits. Total visits represents the count of unique patient visit IDs.
*Differences in our dataset/methodology from that used by the CDC:
- Our dataset represents 6,081,686 visits versus 2,723,316 in the CDC study.
- Our data is more recent—looking at July 1, 2017 through June 30, 2018—compared to 2014 data used in the CDC study.
- We looked at prescriptions documented in the EMR, written for the particular visit where the diagnosis was documented. CDC data is based on outpatient pharmacy claims data within three days of a specific visit to determine the link between antibiotic use and outpatient visits.
- Our data includes all diagnoses for a single visit to see if an antibiotic prescription may have been appropriate for a secondary diagnosis, even if it was considered inappropriate for the primary diagnosis. The CDC data reflects only the primary diagnosis for each visit.
- We only included visits with an E/M code.
- The CDC study used data for patients under 65. Ours includes all patients, regardless of age.
ANTIBIOTIC USAGE STATISTICS
Based on unique patient visit IDs, we looked at a total of 6,081,686 urgent care visits from July 1, 2017 to June 30, 2018. Of these total visits, an antibiotic was prescribed in 3,170,037 visits—or 52.1 percent of total visits.
Figure A. Percent of Visits with Antibiotic Prescribed
In comparison, the CDC study reported that 39.0 percent of visits to urgent care centers resulted in antibiotic prescriptions, somewhat lower than what we found in our research.
This rate alone gives us no insight into the appropriateness of the written prescriptions. It offers instead an overview of the use of prescription antibiotics by urgent care providers.
APPROPRIATE VS. INAPPROPRIATE ANTIBIOTIC PRESCRIBING
How many of these 3 million plus antibiotic prescriptions were appropriate as defined by the CDC?
The CDC compiled a list of conditions for which antibiotics were an appropriate versus inappropriate treatment. This list was used in our analysis to screen ICD-10 codes for possible inappropriate prescriptions.
When we examined all visits, we found 1,157,432 visits with antibiotic-inappropriate conditions and with none of the antibiotic-appropriate conditions. Of these visits, antibiotics were prescribed at 375,025 visits, or at a rate of 32.4 percent. This is 13.3 percent lower than the inappropriate prescribing rate of 45.7 percent found in the CDC study.
Figure B. Percent of Inappropriate Antibiotic Prescribing
Looking at it in a slightly different way, out of 6,081,686 total visits, inappropriate antibiotics were inappropriately prescribed in 375,025 visits, or 6.1 percent of total urgent care visits.
ANTIBIOTIC-INAPPROPRIATE PRESCRIBING BASED ON RESPIRATORY CONDITION
We also looked at our data related to common conditions on the CDC Competing Conditions list. Our data was in alignment with the CDC’s findings even though our methodologies varied.
The numbers in [Figure C.] represent possible inappropriate antibiotic prescribing percentages by urgent care clinics for specific conditions based on DocuTAP’s methodology and the CDC’s.
Figure C. Possible Antibiotic-Inappropriate Prescribing Based on Respiratory Condition
ANTIBIOTIC PRESCRIBING BY REGION
We were interested in whether or not specific regions had higher or lower rates of antibiotic prescribing. There were no major differences between regions in the percentage of visits where an antibiotic was prescribed.
Figure D. Antibiotic Prescribing by Region
While our data showed a slightly lower incidence of inappropriate antibiotic prescribing in urgent cares than the CDC study, when compared against other market segments in that study, urgent care is still higher than retail health, medical offices, and emergency departments.
The CDC methodology used a 95 percent confidence interval which indicates they sampled data instead of looking at every claim. This has the potential to land their numbers in the upper bounds of the range, not the average. Would other specialties listed in the CDC study show lower (or higher) percentages of inappropriate prescribing with access to the same data and methodology we had with urgent care? Without access to the data, it’s impossible to say, but it’s worth considering as we look at the CDC’s report.
The most important thing about DocuTAP’s data is not how urgent care compares against other market segments, but what it tells us about urgent care specifically, and how we will respond and act on the data.
What’s an acceptable number to clinics? What do they tell us about our patients? How do we create and implement practical strategies to improve our processes and technology to lower the incidence of inappropriate antibiotic prescribing? DocuTAP is committed to being an active partner by improving our technology and providing the resources you need to best serve your patients, and move the urgent care industry into the future.
Looking at it in a slightly different way, out of 6,081,686 total visits, inappropriate antibiotics were prescribed in 375,025 visits, or 6.1 percent of total urgent care visits.
As on-demand healthcare becomes an increasingly important component of healthcare in America, urgent care organizations must continue to observe the treatments and trends that arise to improve patient care. While we all have work to do when it comes to antibiotic prescribing, this data confirms that the rate at which urgent cares are inappropriately prescribing antibiotics is in line with other segments of the healthcare market.
While patients regularly seek out urgent care for respiratory conditions and often expect an antibiotic prescription to help them feel better, practitioners have to be their own watchdogs, ensuring they’re committed to appropriate prescribing practices. Practitioners must be diligent in selecting ICD-10 codes consistent with clinical evaluation and diagnoses. And finally, educating patients and providing suggestions that help them through the discomfort of respiratory and other conditions will go a long way to improving antibiotic stewardship industry-wide.
At DocuTAP, our goal has always been to provide a better urgent care experience. We stand behind our software and services, but more importantly, are committed to urgent care clinics as a trusted business partner. By sharing urgent care data, we further our goal and support the goals of urgent care clinics nationwide—providing a better urgent care experience for patients, providers, and everyone in between.