1029. Physicians’ Justifications for Prescribing Antibiotics to Patients with Acute Respiratory Infections
Session: Poster Abstract Session: Stewardship: Implementing Programs
Friday, October 4, 2013
Room: The Moscone Center: Poster Hall C
  • BEARI Justification poster smaller .pdf (452.5 kB)
  • Background: Acute respiratory infections (ARIs) account for most outpatient antibiotic prescriptions in the United States. Quality improvement initiatives aim to curtail inappropriate antibiotic prescribing for ARIs, but little is known about physician rationale for prescribing antibiotics against guidelines.

    Methods: From November 2011 to July 2012, we exposed 81 Boston-area primary care physicians to an electronic health record (EHR)-based “justification” intervention, which required them to type a free-text justification when electronically prescribing an antibiotic for non-specific upper respiratory infections (URIs), acute bronchitis, acute sinusitis, or acute pharyngitis. Prescribers’ written justifications then appeared as separate “Antibiotic Justification Notes” in the patient record viewable by other EHR users. Two physician reviewers independently coded each antibiotic prescribing justification as guideline-concordant (e.g., guideline says antibiotic can be used, or guideline does not apply) or discordant, resolving all disagreements by consensus.

    Results: The overall prescribing rate among ARI office visits was 17% (4% for URIs, 26% for acute bronchitis, 50% for acute sinusitis, and 20% for acute pharyngitis), yielding 1291 antibiotic prescriptions. Physicians wrote justifications for 95% of antibiotic prescriptions, and 64% of all prescriptions lacked a guideline-concordant justification (80% for URIs, 66% for bronchitis, 72% for sinusitis, 31% for pharyngitis). The most common discordant justifications were symptoms irrelevant to guidelines (e.g., color of nasal discharge; 18% of prescriptions), insufficient or irrelevant duration of symptoms (e.g., one week of “cold symptoms;” 12%), irrelevant worsening of symptoms (e.g., worsening fatigue; 8%), and prescribing with request to defer use (e.g., “use over weekend if not better;” 4%). Patient demand for antibiotics was mentioned in fewer than 2% of justifications.

    Conclusion: As reported by primary care physicians, most antibiotic prescriptions for ARIs lack guideline-concordant prescribing justifications. Educating physicians about irrelevant features of clinical presentation may have greater potential to reduce inappropriate prescribing than efforts to reduce patient demand for antibiotics.

    Mark Friedberg, MD, MPP1,2, Jeffrey Linder, MD, MPH, FACP1, Caroline Birks, MD3, Daniella Meeker, PhD4 and Jason Doctor, PhD5, (1)Brigham & Women's Hospital, Boston, MA, (2)RAND, Boston, MA, (3)Massachusetts General Hospital, Boston, MA, (4)RAND, Santa Monica, CA, (5)University of Southern California, Los Angeles, CA


    M. Friedberg, None

    J. Linder, None

    C. Birks, None

    D. Meeker, None

    J. Doctor, None

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