Development and validation of antibiotic stewardship metrics for outpatient respiratory tract diagnoses and association of provider characteristics with inappropriate prescribing

Abstract

Objective: To determine metrics and provider characteristics associated with inappropriate antibiotic prescribing for respiratory tract diagnoses (RTDs).

Design: Retrospective cohort study.

Setting: Primary care practices in a university health system.

Participants: Patients seen by an attending physician or advanced practice provider (APP) at their primary care office visit with International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM)-coded RTDs.

Methods: Medical records were reviewed for 1,200 randomly selected office visits in which an antibiotic was prescribed to determine appropriateness. Based on this gold standard, metrics and provider characteristics associated with inappropriate antibiotic prescribing were determined.

Results: Overall, 69% of antibiotics were inappropriate. Metrics utilizing prespecified RTDs most strongly associated with inappropriate prescribing were (1) proportion prescribing for RTDs for which antibiotics are almost never required (eg, bronchitis) and (2) proportion prescribing for any RTD. Provider characteristics associated with inappropriate antibiotic prescribing were APP versus physician (72% vs 58%; P = .02), family medicine versus internal medicine (76% vs 63%; P = .01), board certification 1997 or later versus board certification before 1997 (75% vs 63%; P = .02), nonteaching versus teaching practice (73% vs 51%; P < .01), and nonurban vs urban practice (77% vs 57%; P < .01).

Conclusions: Metrics utilizing proportion prescribing for RTDs for which antibiotics are almost never required and proportion prescribing for any RTD were most strongly associated with inappropriate prescribing. APPs and clinicians with family medicine training, with board certification 1997 or later, and who worked in nonteaching or nonurban practices had higher proportions of inappropriate prescribing. These findings could inform design of interventions to improve prescribing and could represent an efficient way to track inappropriate prescribing.

Fig. 1.

Methods of determining the association of appropriate antibiotic prescribing with respiratory tract diagnosis (RTD) metrics and provider demographic characteristics.

Fig. 2.

Proportion of antibiotic prescribing for respiratory tract diagnosis (RTD) metrics and total number of antibiotic prescriptions for RTDs by month.

Fig. 3.

Proportion of inappropriate prescribing and association with (A) percentage prescribing for tier 3 diagnosis visits and (B) percentage prescribing for all respiratory tract diagnosis (RTD) visits.