03 Mar More Physicians Per Capita Means More Prescriptions Per Capita
MedicalResearch.com Interview with:
Eili Y. Klein Ph.D. Assistant Professor
Department of Emergency Medicine
Johns Hopkins University
Baltimore, MD 21209
Medical Research: What is the background for this study? What are the main findings?
Dr. Klein: Antibiotic prescriptions rates vary widely across the country. We saw this at the state level, where rates in the highest prescribing states were as high as 1,200 prescriptions per 1,000 people to the lowest rates which were around 500 prescriptions per 1,000 people (see resistancemap.org). Europe has similar variation in prescribing rates across countries, and research there has documented a number of potential reasons for this such as education, access to health insurance, use of childcare centers, and cultural differences. However, the healthcare system in the US is structured differently than in Europe, so we set out to see if similar factors underlay differences in antibiotic prescribing in the US.
Understanding the drivers of differences in prescribing is important because it can help predict how future changes in demographics and socioeconomic characteristics will affect future antibiotic consumption. It also enables predictions in consumption as a result of interventions that target the healthcare delivery system, and also enables better targeting of information campaigns, such as the CDC’s Get Smart Program, on appropriate antibiotic prescribing to specific sub-populations. Finally, it allows providers to better understand how their practice is driven by external factors.
The results of the study found that a primary factor driving differences in prescribing was the density of physicians. In other words, the more physicians there are per capita, the more prescriptions per capita. This result could just be due to more physicians making it easier to access a doctor and thus people go to visit a physician more. However, it could also suggest that physicians are competing to attract or retain patients in some manner and this is driving up prescriptions. To try to understand which of these effects was dominating the change, we examined the role of retail and urgent care clinics.
Stand-alone urgent care clinics and clinics incorporated into the retail arm of a store (e.g., CVS minute clinic) are truly an American-style invention, and bear little similarity to how most Europeans receive healthcare. Over the last decade these establishments have exploded in popularity and greatly expanded their reach. Surprisingly what we found was that in low-income areas, a clinic increased the prescribing rate, but didn’t affect the rate that physicians were prescribing antibiotics. Thus, in these areas the story is all about access. Improving access to healthcare increases the likelihood that people will go to the doctor when they are sick and that increases the rate that people get prescribed antibiotics. This contrasted with wealthier areas, where we found that a clinic increased the rate of prescribing by physicians, which is likely due to competition. This competition can take multiple forms, from increasing the probability of getting an antibiotic as a physician is worried you won’t come back otherwise, to changes in how physician offices work so that it is easier to walk-in to your doctor or get a same-day appointment. Though we were not able to quantify which of these effects was dominant in this research.
Medical Research: What should clinicians and patients take away from your report?
Dr. Klein: The first thing I would say is that inappropriate antibiotic prescribing is a national problem, but that it is difficult to understand the consequences of any single prescription. For clinicians, this means trying to balance the question of whether the individual in front of them needs an antibiotic vs. the long-term utility of antibiotics. Many psychological studies have pointed out the difficulty this poses in all types of similar situations. However, this could push for a greater understanding of each physicians’ prescribing rate relative to their peers. If physicians understand that they are outliers, this might be enough to change behavior.
I would additionally say that urgent care clinics are not the problem here. Though they have probably increased prescribing rates in some areas because it is easier to go to the doctor, they have also made it easier to go to the doctor for people who lack access. This again requires balancing the benefits of increased access with additional antibiotic prescriptions. In this case, appropriate oversight and adherence to prescribing guidelines should be effective in dealing with issues of inappropriate prescribing.
Finally, I think patients should also understand that using antibiotics poses risks, both to the individual (there are more than 250,000 yearly emergency room visits for antibiotic medication problems such as C. diff and anaphylactic shock) as well as to the public. With estimates of more than 60% of prescriptions being inappropriate, we can assume that part of the issue is patient demand for antibiotics.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Klein: While our research was able to quantify some of the issues regarding the variation in prescribing rates, we still have some unaccounted variation to understand. Additional studies that look at cultural variation in prescribing, as well as laws and regulations will help us to better understand this issue. In addition, greater understanding is needed of the individual patient-doctor interaction to understand what motivates physicians to prescribe antibiotics even when the guidelines suggest it is not appropriate.
Citation:
Antimicrob. Chemother. first published online January 20, 2015 doi:10.1093/jac/dku563
MedicalResearch.com Interview with: Eili Y. Klein Ph.D. Assistant Professor (2015). More Physicians Per Capita Equals More Prescriptions Per Capita
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Last Updated on November 4, 2015 by Marie Benz MD FAAD