title: What Drives Variation in Antibiotic Prescribing for Acute Respiratory Infections?
abstract: Acute respiratory infections are the most common symptomatic reason for seeking care among patients in the US, and account for the majority of all antibiotic prescribing, yet a large fraction of antibiotic prescriptions are inappropriate.
  
  
  
  We sought to identify the underlying factors driving variation in antibiotic prescribing across clinicians and settings.
  
  
  
  Using electronic health data for adult ambulatory visits for acute respiratory infections to a retail clinic chain and primary care practices from an integrated healthcare system, we identified a random sample of clinicians for survey.
  
  
  
  We evaluated independent predictors of overall prescribing and imperfect antibiotic prescribing, controlling for clinician and site of care. We defined imperfect antibiotic prescribing as prescribing for non-antibiotic-appropriate diagnoses, failure to prescribe for an antibiotic-appropriate diagnosis, or prescribing a non-guideline-concordant antibiotic.
  
  
  
  Response rates were 34 % for retail clinics and 24 % for physicians' offices (N = 187). Clinicians in physicians' offices prescribed antibiotics less often than those in retail clinics (53 % versus 67 %; p < 0.01), but had a higher imperfect antibiotic prescribing rate (65 % versus 31 %; p < 0.01). Feeling rushed was associated with higher antibiotic prescribing (OR 1.34; 95 % CI 1.03, 1.75). Antibiotic prescribing was also associated with clinician disagreement that antibiotics are overused (OR 1.60, 95 % CI, 1.16, 2.20). Imperfect antibiotic prescribing was associated with receiving antibiotic prescribing feedback (OR 1.35, 95 % CI 1.04, 1.75) and disagreement that patient demand was a problem (OR 1.66, 95 % CI 1.00, 2.73). Imperfect antibiotic prescribing was less common with clinicians who perceived that they prescribed antibiotics less often than their peers (OR 0.63, 95 % CI 0.46, 0.87).
  
  
  
  Poor-quality antibiotic prescribing was associated with feeling rushed, believing less strongly that antibiotics were overused, and believing that patient demand was not an issue, factors that can be assessed and addressed in future interventions.
authors.affiliation: RAND Corporation, Boston, MA, USA. gidengil@rand.org.|Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA. gidengil@rand.org.
authors.forename: Courtney A
authors.initials: CA
authors.lastname: Gidengil
authors.affiliation: RAND Corporation, Boston, MA, USA.|Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.|Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Ateev
authors.initials: A
authors.lastname: Mehrotra
authors.affiliation: University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Beach
authors.affiliation: RAND Corporation, Pittsburgh, PA, USA.
authors.forename: Claude
authors.initials: C
authors.lastname: Setodji
authors.affiliation: RAND Corporation, Pittsburgh, PA, USA.
authors.forename: Gerald
authors.initials: G
authors.lastname: Hunter
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Linder
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000592:standards / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D011307:Drug Prescriptions / Q000592:standards; D057286:Electronic Health Records / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000188:drug therapy*; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: acute respiratory infections; antibiotics; overuse; prescribing