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Survey highlights stewardship barriers in primary care
Filed Under:
Antimicrobial Stewardship
Chris Dall | News Reporter | CIDRAP News
| Aug 13, 2020
A new survey of US primary care physicians shows that a vast majority recognize that antibiotic resistance and inappropriate prescribing of antibiotics are problems in the nation's outpatient settings.
The issue is that far fewer see it as their problem.
In the survey of 1,500 primary care physicians, conducted by the Pew Charitable Trusts and the American Medical Association (AMA) from August 2018 through October 2018, 93% agreed that antibiotic resistance is a problem in the United States, and 91% agreed that inappropriate antibiotic prescribing is a problem in outpatient healthcare.
But only 55% of respondents agreed antibiotic resistance is a problem in their practice, and only 37% said overprescribing is a problem in their practice. Sixty percent said they believed their prescribing habits are better than those of their peers.
In addition, only 26% of internal medicine and family medicine physicians ranked antibiotic resistance as a top three public health issue, compared to 73% of pediatricians. Obesity and being overweight were the issues of highest concern.
The authors of the survey say the results show the potential barriers to implementing stewardship strategies in doctors' offices, urgent care clinics, and other outpatient settings.
"It really underscores the need for any strategies to improve antibiotic use in the outpatient setting to bridge that perception gap," said David Hyun, MD, of Pew's antibiotic resistance project.
Patient pressure cited as a problem
The goal of the survey, said Pew's Rachel Zetts, MPH, was to get a better view of how primary care physicians in the United States view antibiotic resistance and inappropriate antibiotic prescribing, as well as the need for antibiotic stewardship interventions within their practices. Although outpatient settings account for the vast majority of antibiotics used in healthcare, and nearly one in three antibiotic prescriptions issued in primary care settings are considered unnecessary, much of the stewardship focus to date has been in-hospital antibiotic use.
"While we've seen a real expansion of stewardship in hospitals, we haven't necessarily seen a national uptake of stewardship within outpatient practices, despite the fact that we know that inappropriate prescribing is occurring in outpatient practices in the US," said Zetts, who helped develop the survey with Hyun and researchers from the AMA, the University of Southern California, Children's Hospital of Philadelphia, and Northwestern University's Feinberg School of Medicine.
Ultimately, the hope is that the answers could provide a roadmap for how to design stewardship interventions that could help reduce inappropriate antibiotic prescribing in outpatient settings. But the responses to the survey questions indicate primary care physicians might not always be open to these efforts.
In the survey, 91% of the respondents—who included family and internal medicine physicians and pediatricians—said they believed that antibiotic stewardship programs are appropriate for office-based practices, and 78% said they believed that educating patients about antibiotic resistance and antibiotic use are essential to the success of any stewardship program.
But fewer primary care physicians were in favor of efforts to track and report antibiotic use. Half said they felt that tracking appropriate antibiotic use would be hard to do in a fair and accurate manner, and 52% said requiring practices to report their antibiotic use would be too onerous.
That skepticism toward efforts to track antibiotic prescribing, Zetts said, along with the belief that patient demand is a major driver of inappropriate prescribing, were some of the themes that emerged from a series of primary care physician focus groups that Pew and the AMA conducted in 2017, prior to the survey.
"It will not work unless you educate the population," a pediatrician in Birmingham, Alabama, said in one of the focus groups. "You cannot attack the doctors and curtail what they are doing until you educate patients that your doctor is doing the right thing."
Some participants in the focus groups expressed concern that not giving in to a patient's request for an antibiotic could lead to complaints or poor patient satisfaction scores, while others blamed other providers.
"A lot of us don't like to prescribe antibiotics, but they go to urgent cares and they go to…1 min clinics and they get prescribed antibiotics," a family and internal medicine physician in Los Angeles said.
Jeffery Linder, MD, MPH, a primary care physician at Northwestern's Feinberg School of Medicine who studies inappropriate antibiotic prescribing and helped design the survey, said he wasn't surprised by the focus on patient pressure. But he thinks that blaming patients is misguided, because research indicates that in a lot of cases, patients don't really want an antibiotic—physicians just think they do.
"Doctors are terrible at knowing which patients actually want antibiotics," Linder said. "Even operating from the assumption that the patients want antibiotics as a default, I actually don't think is correct. The vast majority just want to understand what's going on, get reassurance, and understand the course of the illness."
Linder said that the low percentage of respondents who see overprescribing as a problem in their practice is related, in part, to a well-known psychological phenomenon—the inclination for people to think they are better than average. But he also thinks that it's hard for primary care physicians, even if they think that unnecessary antibiotic use is a national problem, to recognize it in their own practice and individual patients, who may have specific issues that factor into the decision to prescribe an antibiotic.
"All of the mental defense mechanisms that allow you to prescribe antibiotics for an individual patient, you see that and you don't see the volume of antibiotics that you prescribe as a problem," he said.
Outside stakeholders could encourage stewardship
Nearly half of the survey participants (47%) also indicated that if they are going to implement stewardship strategies in their practices, they're going to need to help. But Hyun and Zetts said they were encouraged by responses to questions about what type of efforts by external organizations would spur primary care providers to implement stewardship interventions. The answers suggest state and local health departments and insurers could play a significant role.
More than 80% said they would support stewardship in response to their state or local health department publishing a report on antibiotic resistance patterns in their area, and 70% said they would respond to a letter from their state health department notifying them that they are a high prescriber compared with other practices in the region. Eighty percent said they would support stewardship implementation if they received additional reimbursement from a public or private insurer.
"It's really going to take action from a wide range of stakeholders in the outpatient space to insure national uptake of outpatient stewardship," Zetts said.
For his part, Linder said he'd like to see more "professional righteousness" and a little bit of paternalism among his fellow primary care physicians when it comes to antibiotic prescribing, even if it rubs people the wrong way.
"We all have to take collective responsibility here, or this tragedy of the commons is just going to keep going on and we're going to run out of effective antibiotics," he said. "If you, in your heart of hearts, think that there's more chance that an antibiotic is going to hurt your patient than help them…you are professionally obligated to not prescribe that antibiotic, regardless of what the patient wants."
Survey highlights stewardship barriers in primary care
Filed Under:
Antimicrobial Stewardship
Chris Dall | News Reporter | CIDRAP News
| Aug 13, 2020
A new survey of US primary care physicians shows that a vast majority recognize that antibiotic resistance and inappropriate prescribing of antibiotics are problems in the nation's outpatient settings.
The issue is that far fewer see it as their problem.
In the survey of 1,500 primary care physicians, conducted by the Pew Charitable Trusts and the American Medical Association (AMA) from August 2018 through October 2018, 93% agreed that antibiotic resistance is a problem in the United States, and 91% agreed that inappropriate antibiotic prescribing is a problem in outpatient healthcare.
But only 55% of respondents agreed antibiotic resistance is a problem in their practice, and only 37% said overprescribing is a problem in their practice. Sixty percent said they believed their prescribing habits are better than those of their peers.
In addition, only 26% of internal medicine and family medicine physicians ranked antibiotic resistance as a top three public health issue, compared to 73% of pediatricians. Obesity and being overweight were the issues of highest concern.
The authors of the survey say the results show the potential barriers to implementing stewardship strategies in doctors' offices, urgent care clinics, and other outpatient settings.
"It really underscores the need for any strategies to improve antibiotic use in the outpatient setting to bridge that perception gap," said David Hyun, MD, of Pew's antibiotic resistance project.
Patient pressure cited as a problem
The goal of the survey, said Pew's Rachel Zetts, MPH, was to get a better view of how primary care physicians in the United States view antibiotic resistance and inappropriate antibiotic prescribing, as well as the need for antibiotic stewardship interventions within their practices. Although outpatient settings account for the vast majority of antibiotics used in healthcare, and nearly one in three antibiotic prescriptions issued in primary care settings are considered unnecessary, much of the stewardship focus to date has been in-hospital antibiotic use.
"While we've seen a real expansion of stewardship in hospitals, we haven't necessarily seen a national uptake of stewardship within outpatient practices, despite the fact that we know that inappropriate prescribing is occurring in outpatient practices in the US," said Zetts, who helped develop the survey with Hyun and researchers from the AMA, the University of Southern California, Children's Hospital of Philadelphia, and Northwestern University's Feinberg School of Medicine.
Ultimately, the hope is that the answers could provide a roadmap for how to design stewardship interventions that could help reduce inappropriate antibiotic prescribing in outpatient settings. But the responses to the survey questions indicate primary care physicians might not always be open to these efforts.
In the survey, 91% of the respondents—who included family and internal medicine physicians and pediatricians—said they believed that antibiotic stewardship programs are appropriate for office-based practices, and 78% said they believed that educating patients about antibiotic resistance and antibiotic use are essential to the success of any stewardship program.
But fewer primary care physicians were in favor of efforts to track and report antibiotic use. Half said they felt that tracking appropriate antibiotic use would be hard to do in a fair and accurate manner, and 52% said requiring practices to report their antibiotic use would be too onerous.
That skepticism toward efforts to track antibiotic prescribing, Zetts said, along with the belief that patient demand is a major driver of inappropriate prescribing, were some of the themes that emerged from a series of primary care physician focus groups that Pew and the AMA conducted in 2017, prior to the survey.
"It will not work unless you educate the population," a pediatrician in Birmingham, Alabama, said in one of the focus groups. "You cannot attack the doctors and curtail what they are doing until you educate patients that your doctor is doing the right thing."
Some participants in the focus groups expressed concern that not giving in to a patient's request for an antibiotic could lead to complaints or poor patient satisfaction scores, while others blamed other providers.
"A lot of us don't like to prescribe antibiotics, but they go to urgent cares and they go to…1 min clinics and they get prescribed antibiotics," a family and internal medicine physician in Los Angeles said.
Jeffery Linder, MD, MPH, a primary care physician at Northwestern's Feinberg School of Medicine who studies inappropriate antibiotic prescribing and helped design the survey, said he wasn't surprised by the focus on patient pressure. But he thinks that blaming patients is misguided, because research indicates that in a lot of cases, patients don't really want an antibiotic—physicians just think they do.
"Doctors are terrible at knowing which patients actually want antibiotics," Linder said. "Even operating from the assumption that the patients want antibiotics as a default, I actually don't think is correct. The vast majority just want to understand what's going on, get reassurance, and understand the course of the illness."
Linder said that the low percentage of respondents who see overprescribing as a problem in their practice is related, in part, to a well-known psychological phenomenon—the inclination for people to think they are better than average. But he also thinks that it's hard for primary care physicians, even if they think that unnecessary antibiotic use is a national problem, to recognize it in their own practice and individual patients, who may have specific issues that factor into the decision to prescribe an antibiotic.
"All of the mental defense mechanisms that allow you to prescribe antibiotics for an individual patient, you see that and you don't see the volume of antibiotics that you prescribe as a problem," he said.
Outside stakeholders could encourage stewardship
Nearly half of the survey participants (47%) also indicated that if they are going to implement stewardship strategies in their practices, they're going to need to help. But Hyun and Zetts said they were encouraged by responses to questions about what type of efforts by external organizations would spur primary care providers to implement stewardship interventions. The answers suggest state and local health departments and insurers could play a significant role.
More than 80% said they would support stewardship in response to their state or local health department publishing a report on antibiotic resistance patterns in their area, and 70% said they would respond to a letter from their state health department notifying them that they are a high prescriber compared with other practices in the region. Eighty percent said they would support stewardship implementation if they received additional reimbursement from a public or private insurer.
"It's really going to take action from a wide range of stakeholders in the outpatient space to insure national uptake of outpatient stewardship," Zetts said.
For his part, Linder said he'd like to see more "professional righteousness" and a little bit of paternalism among his fellow primary care physicians when it comes to antibiotic prescribing, even if it rubs people the wrong way.
"We all have to take collective responsibility here, or this tragedy of the commons is just going to keep going on and we're going to run out of effective antibiotics," he said. "If you, in your heart of hearts, think that there's more chance that an antibiotic is going to hurt your patient than help them…you are professionally obligated to not prescribe that antibiotic, regardless of what the patient wants."