Antibiotics are prescribed at more than 100 million adult ambulatory care visits annually, and 41% of these prescriptions are for respiratory conditions. In the United States, at least 2 million antibiotic-resistant illnesses and 23,000 deaths occur each year, at a cost to the U.S. economy of at least $30 billion.1
The most common reason for acute outpatient physician office visits and antibiotic prescriptions in both adults and children is acute respiratory tract infection (acute uncomplicated bronchitis, pharyngitis, rhinosinusitis, and the common cold).2
Most of these conditions are of viral origin. Therefore, using antibiotics is unnecessary and may lead to avoidable drug-related adverse events, contribute to antibiotic resistance, and add to unnecessary medical costs.
The most recent clinical guidelines for the management of acute uncomplicated bronchitis recommended against routine antibiotic treatment in the absence of pneumonia. Antibiotic therapy is recommended only for patients with a positive streptococcal test result.1
To identify the use of antibiotics in patients with acute upper respiratory infections (URI), we conducted an analysis on an administrative claims dataset with over 1.7 million lives (2019) using MedInsight’s Health Waste Calculator application. The Health Waste Calculator measure (Antibiotics for Acute Upper Respiratory and Ear Infections) identifies the use of oral antibiotics for members with acute URI or ear infection (acute sinusitis, viral respiratory illness, or acute otitis externa) as wasteful, except in specific circumstances.
Certain conditions necessitate the prescription of antibiotics for members with upper URI or ear infection and are identified as not wasteful in the measure. These conditions include persistent symptoms of complicated sinusitis within 10 days before the antibiotic prescription, members with acute otitis externa and underlying middle ear disease, or malignant otitis externa before the antibiotic prescription. This measure also excludes certain clinical scenarios where use of antibiotics cannot be confirmed as wasteful. These may include certain co-morbidities like Cancer, HIV or other immunocompromised conditions, as well as other potential clinical indications for other diagnoses or procedures in the recent past.
We analyzed patterns in an antibiotic prescription for URI in terms of appropriateness of services and associated costs of antibiotic prescription. Table 1 highlights the cost and frequency of wasteful services. The key observations were:
- Out of the total 1.7 million members, 17% (281K members) were identified with a diagnosis of acute upper respiratory infections (URI).
- 40% (111K members) of these members were prescribed antibiotics within seven days of the diagnosis.
- 70% (78K members) of these prescriptions were identified to be a wasteful service.
- These wasteful services attributed to 57% ($1 million) of the total antibiotic prescription costs for URI.
Table 1: Cost and utilization of antibiotic prescription
|Members with URI
|Members with URI and Antibiotic Prescription
|Total Antibiotic cost
We further analyzed the frequency of antibiotic prescription for different clinical diagnoses. We compared top URI diagnoses for which antibiotics were prescribed and where it was not prescribed as displayed in Figure 1. We identified that both the categories showed similar diagnosis and the prescription (Ab pres) pattern did not change much with diagnosis.
Figure 1: Common diagnoses associated with members with antibiotic prescription
|Acute upper respiratory infection, unspecified
|Acute sinusitis, unspecified
|Acute bronchitis, unspecified
|Acute maxillary sinusitis, unspecified
|Acute pharyngitis, unspecified
|Acute frontal sinusitis, unspecified
|Acute bronchitis due to other specified organisms
|Acute pansinusitis, unspecified
|Other acute sinusitis
We analyzed different Lines of Business (LOB) and age to compare and identify the members where an antibiotic was prescribed for URI and those where an antibiotic was not prescribed. Age over 65 years and Medicare LOB had a significantly higher rate of antibiotic prescription for the diagnosis of URI. Figure 2 and figure 3 shows the member distribution based on LOB and age. Physician’s choice or patient demand likely are factor for antibiotic prescription for members with URI. Studies also indicate that the primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures.3
Figure 2: Member distribution on the basis of LOB
Figure 3: Member distribution on the basis of age
Another analysis was carried out to identify the major antibiotics contributing to frequency and cost. We found that Azithromycin was the most common and frequently prescribed antibiotic among members with URI and showed maximum utilization (Figure 4).
Figure 4: Antibiotic utilization pattern
Amoxicillin/clavulanic acid, on the other hand was the major contributor to the total cost for members with URI, as shown in figure 5. Drugs like Xifaxan (Rifaximin) ($680), Erythromycin ($430), and Ceftin (Cefuroxime) ($320) had the highest unit cost among all the antibiotics prescribed for URI. However, Xifaxan and Erythromycin had low utilization and did not fall into the major total cost contributors. Amoxicillin/clavulanic acid and Azithromycin contributed to the maximum total cost and utilization count, although they had comparatively lower unit costs at $14 and $8, respectively.
Figure 5: Antibiotic cost distribution
Indiscriminate use of antibiotics can be associated with a risk of adverse reactions. These adverse reactions may have a cascading harmful effect with the increased cost burden of care. The Health Waste Calculator allows detailed analytics to identify such cascading effects after a wasteful antibiotic prescription. The application identified 4% of members who developed adverse reactions after the wasteful antibiotic prescription showing a significant increase in the overall allowed dollars spent (Table 2).
Table 2: Cascade reaction summary
|Members with antibiotic prescription
|Members with wasteful antibiotic prescription
|Members who developed cascade reaction
Various studies summarized the multiple adverse reactions of antibiotics which include allergic reactions, gastrointestinal disturbance, some of these may lead to inpatient admission or emergency department visit.4 Our analysis identified only abdominal pain (65%) and other GI disturbances (35%) related diagnoses reported as the main adverse reaction within five days after the wasteful prescription. None of them warranted an inpatient or emergency admission.
It is important to note that claims data alone allows only an approximate identification of wasteful antibiotic prescription for acute upper respiratory infections. The Health Waste Calculator identifies wasteful services, which can help identify opportunities to address avoidable costs and achieve appropriate clinical care. This analysis confirmed the high prevalence of wasteful antibiotic prescription for viral respiratory illnesses, which aligns with various publications.
- Aaron M. Harris, Lauri A. Hicks, Amir Qaseem Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care from the American College of Physicians and the Centers for Disease Control and Prevention. American College of Physicians. March 15, 2016; Vol. 164 No. 6.
- Hersh AL, Jackson MA and Hicks LA. Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics. Pediatrics. December 2013; Volume 132, Number 6.
- O’Connor R, O’Doherty J, O’Regan A et al. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Irish journal of medical science. 2018, Vol. 187,4: 969-986.
- Nadine Shehab, PharmD, MPH1; Maribeth C. Lovegrove, MPH1; Andrew I. Geller, MD1; et al. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016; 316(20):2115-2125.