Popular urgent care centers may be the biggest—and most overlooked—culprits in the dangerous overuse of antibiotics in clinics, according to a new analysis in JAMA Internal Medicine.
Further Reading Hospitals failed to rein in antibiotics—prescribing stronger drugs instead Based on insurance claims from patients with employee-sponsored coverage, researchers estimated that about 46 percent of patients who visited urgent care centers in 2014 for conditions that cannot be treated with antibiotics—such as a common cold that’s caused by a virus—left with useless antibiotic prescriptions that target bacterial infections. That rate of inappropriate antibiotic use is almost double the rate the researchers saw in emergency departments (25 percent) and almost triple the rate seen in traditional medical offices (17 percent).
The authors of the analysis—a team of researchers from the Centers for Disease Control and Prevention, the University of Utah, and the Pew Charitable Trusts—concluded that interventions for urgent care centers are “urgently needed.”
The data is concerning, the team notes, because such misuse of antibiotics can fuel the development and spread of drug-resistant bacteria, which can go on to become resistant to multiple types of antibiotic drugs and cause intractable, sometimes deadly, infections.
As antibiotics have become less effective at knocking back infections in recent decades, public health experts worldwide have amped up calls for more judicious use of the critical drugs. In 2016, researchers analyzing data from 2010-2011 estimated that 30 percent of antibiotics prescriptions given in US emergency rooms and traditional medical offices were inappropriate. But that estimate didn’t account for prescriptions doled out at urgent care and retail clinics, which are growing in popularity and now prescribe about 40 percent of all antibiotics used outside of hospitals. In other words, the true rate of antibiotic overuse may be even worse than experts thought.
Moreover, some doctors fear that overuse in urgent care centers will be tricky to fix. In an accompanying commentary, doctors and editorial staff from JAMA Internal Medicine, argue that judicious use of antibiotics doesn’t seem to fit into the business model of urgent care centers. These clinics thrive on providing same-day appointments in convenient locations with low out-of-pocket costs for ailments that might not warrant a trip to the emergency room or standard doctor’s office. This model may select for patients seeking an easy answer—like an antibiotic prescription—for a relatively mild illness that would otherwise resolve on its own, the doctors suggest. And doctors at urgent care centers may not have the necessary relationships with patients to talk them out of wanting an antibiotic. But they do have a financial incentive to keep them happy and returning.
This scenario is particularly concerning given the boom in urgent care centers in recent years. They now make up a $15 billion sector with more than 10,000 high-volume clinics around the country.
JAMA Internal Medicine, 2018. DOI: 10.1001/jamainternmed.2018.1632 (About DOIs).
Ravager135 on July 18th, 2018 at 02:28 UTC »
Urgent care medical director here. I am fortunate in that our CMO has never once pressured me or any of my providers to prescribe anything we didn’t feel was necessary. Every bad review I have ever personally received when I have seen patients myself regard not prescribing antibiotics for viral illnesses. Patients will literally scream and yell at you if you do not give antibiotics if they are convinced they require them.
It does not surprise me in the least that many urgent cares hand them out for any upper respiratory complaint. Urgent cares primarily lose their business over bad Yelp and Google reviews. The bulk of these bad reviews: you guessed it, patients complaining they did not get a Zpak. I have a friend who works at an urgent care in Florida who’s CMO fired an infectious disease doctor working there part time because he didn’t prescribe enough antibiotics. They literally set a policy where any upper respiratory complaint would result in antibiotics and steroids.
I tend to be pretty conservative when it comes to my prescribing habits. I do not know the patient. I do not have follow up with them. If I can justify a reason to prescribe something I will. I will not just hand out an antibiotic to a patient with a normal exam and short duration of symptoms. I am still called every name under the sun by patients. It’s exhausting and it’s why I plan to focus on my private boutique practice moving forward.
EDIT: Make no mistake urgent cares and their providers are complicit in this behavior, but also realize it is reactionary to patient demands. When a patient pays a copay (which is typically a larger amount than they would pay at their primary care office) they view that as paying for a service. The real service they are getting is almost instantaneous access to a board certified physician. What the patient thinks they are paying for is a prescription. Once the patient pays a 50 dollar copay, they don’t want to be told that the only thing that can help them is Tylenol, rest, and fluids. They are frustrated because many patients today have zero tolerance for being ill. It’s why it is not uncommon for a doctor to hear a patient say, “I can’t be sick this weekend” or “I need to feel better by tomorrow.” Patients are unrealistic.
EDIT2: My obligatory first Reddit gold edit! I appreciate it immensely!
Endotracheal on July 18th, 2018 at 02:17 UTC »
When the business-school types started bringing that “the customer is always right” attitude to medicine, and began using patient-satisfaction scores as a basis to grade doctors (and determine reimbursement), it was all just a matter of time. BTW, this same dynamic is part of what drove the opiate epidemic to its current level.
“The customer is always right” philosophy is predicated on the assumption that the customer already knows their diagnosis, or the best way to test for it, and precisely the best way to treat it. This, of course, is not reality. Unfortunately, there is no way to pull that out of a simple statistic, and so the patients’ unmet expectations (no matter how unrealistic or ill-informed) are treated with seemingly complete credulity.
Incentives matter... be they beneficial or perverse incentives. They change behavior. Maybe not overnight, and maybe not with every provider, but eventually that drop of water wears away the stone.
PuggMonster on July 18th, 2018 at 00:56 UTC »
So the article specifically points to patient satisfaction surveys that are promoting antibiotic prescriptions from doctors who want returning patients and/or faster appointments...but it doesn’t explain how urgent care centers are different than other medical businesses that collect surveys.
To my knowledge nearly every place collects patient satisfaction surveys. How exactly do urgent care centers use this info compared to other places? Do negative surveys have greater consequences for urgent care doctors than in hospitals? Shouldn’t they profit from actually testing people for viral infections more so than just skipping that step?