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A lack of detailed record-keeping in clinics and emergency departments may be contributing to the inappropriate use of antibiotics, according to two new studies led by University of Michigan physicians. The research, conducted by Joseph Ladines-Lim, M.D., Ph.D., and Kao-Ping Chua, M.D., Ph.D., underscores significant gaps in documentation that hinder efforts to curb unnecessary antibiotic prescriptions.
One study found that approximately 10% of children and 35% of adults who received an antibiotic prescription during an office visit had no specific reason recorded in their medical records. This issue is particularly prevalent among adults treated in emergency departments and clinics, especially those covered by Medicaid or lacking insurance. The problem also affects children, though to a lesser extent.
The absence of precise documentation complicates efforts by clinics, hospitals, and insurers to ensure antibiotics are prescribed only when necessary. Overuse and misuse of antibiotics can lead to bacterial resistance, reducing the effectiveness of these drugs and potentially causing harm to patients.
“When clinicians don’t record why they are prescribing antibiotics, it makes it difficult to estimate how many of those prescriptions are truly inappropriate, and to focus on reducing inappropriate prescribing,” said Ladines-Lim, the studies’ lead author and a resident at Michigan Medicine.
The studies offer a deeper context to previous estimates of inappropriate antibiotic prescribing. Earlier research suggested that about 25% of outpatient antibiotic prescriptions for those under 65 were inappropriate, including those for conditions that antibiotics cannot treat, such as colds, and prescriptions not linked to any plausible antibiotic indication. The new studies differentiate between these types of inappropriate prescriptions, revealing nuanced insights into prescribing behaviors.
Efforts to date have mainly targeted reducing antibiotics for conditions like colds, which do not benefit from such treatment. However, since prescribers are not required to run tests or list specific diagnoses to prescribe antibiotics, some prescriptions might be justified by symptoms indicative of secondary bacterial infections.
Nevertheless, the studies found that a significant number of antibiotic prescriptions were given without any infection-related diagnoses or symptoms in the records. This might be due to clinicians inadvertently or deliberately omitting such information to avoid scrutiny. The lower rate of documentation among Medicaid patients might also be linked to the reimbursement models, which differ from the fee-for-service model of private insurance.
“This could actually be a matter of health equity if people with low incomes or no insurance are being treated differently when it comes to antibiotics,” Ladines-Lim noted. He suggested that insurers and health systems may need to incentivize accurate diagnosis coding for antibiotic prescriptions or implement measures to make it easier for providers to document their reasons for prescribing.
Requiring providers to record justifications for antibiotic prescriptions in electronic health record systems before sending them to pharmacies might be one way to address the issue. This approach could mirror the current practice where physicians must justify diagnostic tests.
The research, published in the Journal of General Internal Medicine and Antimicrobial Stewardship and Healthcare Epidemiology, was supported by grants from the American Academy of Pediatrics, Blue Cross Blue Shield Foundation of Michigan, and the National Med-Peds Residents’ Association. The studies’ co-authors include Michael A. Fischer, M.D., M.S., of Boston Medical Center, and Jeffrey A. Linder, M.D., M.P.H., of Northwestern University Feinberg School of Medicine.
