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The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness

The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness. A Cohort Study Annals of Internal Medicine 7 August, 2012 Volume 157 Number 3 Courtney Hebert, MD; Jennifer Beaumont, MS; Gere Schwartz, MD; and Ari Robicsek , MD. Danelle Blume

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The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness

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  1. The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness A Cohort Study Annals of Internal Medicine 7 August, 2012 Volume 157 Number 3 Courtney Hebert, MD; Jennifer Beaumont, MS; Gere Schwartz, MD; and Ari Robicsek, MD Danelle Blume University of Georgia College of Pharmacy 2013 Pharm.D. Candidate

  2. Background • Patient presentation is often ambiguous • Former studies have shown that antibiotic use peaks during the flu seasons, fall and spring • Epidemics such as the H1N1 pandemic can give clinicians a diagnostic cue which suggests viral illness • Decreases improper use of antibiotic therapy http://www.rodale.com/antibiotics-sinus-infection

  3. Funding • Research Career Development Award from NorthShore University HealthSystem to Dr. Robicsek, MD • Funding source had no role in the design, conduct, analysis, or decision to submit the study for publication

  4. Purpose • Large-scale, retrospective review of prescribing practices • Primary: Compare antibiotic and antiviral prescribing in the primary care setting for febrile respiratory illness (FRI) during a seasonal influenza period and a pandemic influenza period • Secondary: Examine the effect of patient and physician characteristics and of a physician’s personal context on the likelihood of antibiotic prescribing

  5. MethodsSetting/Inclusion • Setting: NorthShore University HealthSystem, an academic care system in metropolitan Chicago • Inclusion: Patients who presented to an eligible outpatient provider between January 1, 2006 and May 15, 2011 • Eligible outpatient providers: primary care, internal medicine, family practice, and pediatric physicians who worked within the NorthShore network and saw >100 outpatients with FRI during the study period

  6. MethodsData Collection • Encounter: chief symptom, diagnosis, or temperature measurement in the office consistent with fever and patient had chief symptom or diagnosis of respiratory illness including: cough, sore throat, or rhinorrhea • Provider Data: • Practice information (family practice, internal medicine, pediatric physician) • Medical school graduation date • Volume of patients seen during year of encounter • Number of patients with FRI seen in the week before a given visit • Quintiles: Based on volume physicians saw during study period

  7. Statistics • Estimated odds ratios (ORs) Definition: Probability of event occurring Probability of event not occurring Example : http://www.nutridesk.com.au/odds-ratio.phtml • The observed odds ratio = [40 x 3023] / [239 x 1287] = 0.39 • The 0.39 represents a 39% odds of a hip fracture occurring in a postmenopausal woman currently on HRT in comparison to a woman that has never used HRT or a former user of HRT.  • Another way of looking at the odds of 0.39 or 39% is to say that being a current user of HRT decreased the odds of a hip fracture by 61%

  8. ResultsBaseline Characteristics

  9. Results • Physician Characteristics: • Rate of antibiotic prescribing ranged from 17.9% to 83.7% • Individual physicians consistent from year to year • Individual physician factors (i.e. graduation date, volume of patient encounters, etc.) did not statistically influence primary outcome • Patient Characteristics: • Older age, body mass index (BMI) greater than 35 kg/m2, asthma, and chronic obstructive pulmonary disease (COPD) were associated with increased likelihood of antibiotic prescribing • Chief complaints of cough, ear, nose, sinus, and chest symptoms as well as fever in office associated with increased likelihood of antibiotic prescribing • Flu-like symptoms, gastrointestinal symptoms and headache associated with decreased likelihood

  10. Results

  11. Limitations • Retrospective • Nonrandomized • FRI cases differed in clinical presentation from one period to another • Design did not allow for the removal of cases of FRI for which antibiotics were clearly appropriate • Study included more pediatric patients than adults or elderly patients

  12. Conclusions • Overall rating IIIC • The context in which a patient presented was strongly associated with the likelihood that an antimicrobial agent would be prescribed • The presence of 1 or more medical comorbid conditions has been shown to be associated with antibiotic prescribing

  13. References • Herbert C, Beaumont J, Schwartz G, Robicsek A. The influence of context on antimicrobial prescribing for febrile respiratory illness. Annals of Internal Medicine. 2012;157:160-68.

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