Two new studies indicate that a lack of thorough record-keeping in clinics and emergency departments could be hindering efforts to reduce the improper use of antibiotics. According to one of the studies, around 10% of children and 35% of adults who received a prescription for antibiotics during a visit to the office had no specific reason for the antibiotic recorded in their medical records.
According to one study, approximately 10% of children and 35% of adults who were given a prescription for antibiotics during a doctor’s visit had no specific reason documented for needing the antibiotics.
This type of prescribing is particularly prevalent among adults seen in emergency departments and clinics who are covered by Medicaid or have no insurance, the studies indicate. However, the issue also affects children.
Without the knowledge of what led to these inappropriate prescriptions, it will be even more challenging for clinics, hospitals, and health insurance companies to take action to ensure that antibiotics are only prescribed when necessary.The researchers emphasize the importance of only using antibiotics when necessary. Overuse and misuse of antibiotics can lead to bacteria developing resistance, making the drugs less effective. Inappropriate prescription of antibiotics can also have negative effects on patients. Dr. Joseph Ladines-Lim, the first author of the two new studies and a resident in internal medicine/pediatrics at Michigan Med, explained that the lack of documentation on why antibiotics are prescribed makes it hard to determine how many prescriptions are unnecessary and to focus on reducing inappropriate prescribing.
Ladines-Lim collaborated with U-M pediatrician and health care researcher Kao-Ping Chua, M.D., Ph.D., on the latest studies. The study on outpatient prescribing based on insurance status has been published in the Journal of General Internal Medicine, while the study on trends in emergency medicine is still pending. According to Ladines-Lim, “Our studies provide a context for the estimates of inappropriate prescribing that have been previously published. These estimates do not differentiate between antibiotic prescriptions that are considered inappropriate due to insufficient coding and those that are truly prescribed for a condition that they cannot treat.”
Department prescribing is in Antimicrobial Stewardship and Healthcare Epidemiology.
Building on previous research
Chua and colleagues recently conducted a study on inappropriate antibiotic prescribing in outpatients under the age of 65. They found that approximately 25% of antibiotic prescriptions were inappropriate. This includes prescriptions for conditions that do not require antibiotics, such as colds, as well as prescriptions that are not associated with any specific diagnoses that would warrant antibiotic treatment.
The new studies provide further insight into the issue of inappropriate antibiotic prescribing.
Upon closer examination of these two distinct types of inappropriate prescriptions, it was found that most efforts to promote responsible antibiotic usage have targeted the reduction of prescriptions for conditions that do not warrant antibiotic treatment, such as colds. Recent studies have revealed that these patients still make up a significant portion of all antibiotic prescriptions, ranging from 9% to 22%, depending on the demographic and clinical setting.
Due to the lack of a mandate for doctors and other prescribers to conduct bacterial infection tests or specify a diagnosis when prescribing antibiotics, symptoms serve as potential indicators.
It is unclear why some patients were prescribed antibiotics despite not having a clear infection-related diagnosis or symptoms recorded in their medical records. It is possible that some of these patients may have had a secondary bacterial infection that the clinician suspected based on symptoms, which could account for a portion of the cases.
However, it is difficult to determine the exact reasons for these prescriptions.
The researchers also suggest that clinicians may have omitted infection-related diagnoses or symptoms from the patient records, either unintentionally or deliberately, in order to avoid scrutiny from antibiotic monitoring organizations.
Speculate that the reason for the lower rate of diagnosis documentation in patients in the healthcare safety net may be related to the reimbursement system for healthcare organizations. Clinics and hospitals often receive a fixed amount from Medicaid to care for all their patients with that type of coverage, which means they are not motivated to create as detailed records as for privately insured patients who are reimbursed under a fee-for-service model. Ladines-L, a health equity advocate, suggests that this disparity in treatment may impact people with low incomes or no insurance when it comes to antibiotics.Ladines-Lim, who has studied antibiotic use in relation to immigrant and asylum-seeker health, and will soon start a fellowship in infectious diseases.
He suggested that private and public insurers, as well as health systems, might need to offer incentives for accurate diagnosis coding for antibiotic prescriptions — or at least make it simpler for providers to explain why they’re prescribing them.
This could involve steps such as requiring providers to document the reason for prescribing antibiotics before sending prescriptions to pharmacies via electronic health record systems.
According to Ladines-Lim, physicians often have to specify a diagnosis before prescribing antibiotics.The authors of the research articles recommend a similar approach to justify the prescription of antibiotics, as is done for ordering CT scans or x-rays. They emphasize the importance of addressing antibiotic resistance, which is a global concern for patients with antibiotic-susceptible conditions. The other authors of the articles include Michael A. Fischer, M.D., M.S. from Boston Medical Center and Boston University, and Jeffrey A. Linder, M.D., M.P.H. from Northwestern University Feinberg School of Medicine. The research was funded by a Resident Research Grant from the American Academy of Pediatrics and a Physician Investigator Award from Blue.The Cross Blue Shield Foundation of Michigan and the National Med-Peds Residents’ Association provided funding for this research project.
