Abstract
Objective:
To identify whether differences in antibiotic prescribing practices by prescriber type and specialization in nursing home (NH) care exist for urinary tract infection (UTI) and pneumonia.
Design:
Retrospective cohort.
Setting and Participants:
This national study included antibiotic dispensings to Traditional Medicare beneficiaries aged ≥65 years with UTI or pneumonia infections residing long-term (≥100 days) in United States NHs between 2016 and 2018.
Methods:
Minimum Data Set assessment data were linked to Medicare data (Part D prescription drug, inpatient hospital [MedPAR], prescriber characteristics, and enrollment). We compared antibiotic prescribing patterns by prescriber type (physician versus advanced practice practitioner [AP]) and NH specialization (≥ 90% versus <90% of all associated medication dispensings to NH residents). Antibiotic dispensing measures included the total number of dispensings and duration of therapy (median number of days supplied) by antibiotic class.
Results:
There were 264,735 antibiotic dispensings prescribed by 32,437 prescribers for 140,360 residents in 14,035 NHs. NH specialists were less likely to prescribe fluoroquinolones for UTI (22.9% NH specialist physician, 23.9% non-NH specialist physician, 21.3% NH specialist AP, 24.2% non-NH specialist AP), but more likely to prescribe fluoroquinolones for pneumonia (38.9%, 37.8%, 38.8%, 37.3%, respectively). Over time, NH specialists reduced fluoroquinolone prescribing for pneumonia to a greater extent than non-NH specialists. The duration of therapy was similar across prescriber groups for UTI, but longer among non-NH specialist APs for several antibiotic classes for pneumonia, including tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole.
Conclusions and Implications:
There were differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Understanding how antibiotic prescribing differs based on prescriber characteristics is essential to inform antibiotic stewardship efforts. Tailoring antibiotic stewardship efforts to prescribers by NH specialization is rational given differences in antibiotic prescribing patterns based on NH specialization.
Keywords: Antimicrobial Stewardship, Practice Patterns, Physicians’, Anti-Bacterial Agents, Nursing Homes, Long-Term Care, Urinary Tract Infections
Brief Summary:
Differences in antibiotic prescribing were found by prescribers’ type and nursing home (NH) specialization between 2016 and 2018 for US NH residents with urinary tract infections or pneumonia.
INTRODUCTION
Potentially inappropriate prescribing of antibiotics continues to be a concern in the United States (US) and globally.1 Overuse and misuse of antibiotics are of particular concern for older adults residing in nursing homes (NHs), who are especially susceptible to antibiotic-related adverse events.2 While there has been substantial regulatory attention to antibiotic stewardship programs in the US,3 up to 75% of antibiotics prescribed in NHs may be inappropriate or unnecessary and nearly 10% of residents receive antibiotic therapy on any given day.4, 5 Fluoroquinolone use remains particularly widespread despite the potential for antimicrobial resistance and association with significant adverse events.7, 8
One potentially effective, yet underexplored, approach to improve antibiotic stewardship programs in NHs is to tailor programs based on the characteristics of prescribers, including the type of prescriber (i.e., physicians and advance practice practitioners [APs]) and specialization in NH care. The prevalence of prescribers who practice predominantly in NHs appears to be increasing,9 and APs continue to supplement the NH physician workforce,10 yet the antibiotic prescribing practices for physicians versus APs and NH specialists versus non-specialists remains understudied. A necessary first step to inform future research, policy, and clinical practice changes that are tailored to prescribers based on certain characteristics is to understand how prescriber groups prescribe antibiotics and respond to ongoing antibiotic stewardship efforts.
Our objective was to identify whether differences in antibiotic prescribing practices between prescriber groups exist for the two most common infections in NHs: UTI and pneumonia.11, 12 We hypothesized that NH specialists would be less likely than non-NH specialists to 1) prescribe antibiotics with a higher potential for antimicrobial resistance and adverse events, and 2) prescribe antibiotics for longer durations.
METHODS
Study Design and Data Sources
We conducted a national retrospective cohort study using Medicare claims data (a 20% random sample of Part D prescription drug claims [including all claims to NH residents]) linked to Minimum Data Set (MDS) assessments. The MDS includes comprehensive clinical assessments of NH residents, including active diagnoses of infections, clinical conditions, and functional status. Our study was conducted at the “person-dispensing” level, whereby residents could receive multiple antibiotic dispensings per infection and could be represented multiple times if diagnosed with UTI or pneumonia in multiple years. The Brown University Institutional Review Board approved the study. A graphical depiction of the study design is provided in Supplementary Figure 1, and additional information regarding the study design, data sources, and methodology can be found in the Brown University Digital Repository.13
Study Population
Our study population included long-stay (≥100 days in any US NH) residents aged ≥65 years and enrolled in Traditional Medicare between January 1, 2016 and December 31, 2018.14 We identified oral and injectable antibiotic dispensings from Medicare Part D prescription drug claims. Infection diagnoses were ascertained from MDS assessments, which capture active UTI in the past 30 days and pneumonia in the past 7 days. Because Part D prescription drug claims do not include dispensing indications, we associated antibiotic dispensings with an infection if any day of antibiotic therapy overlapped with the MDS assessment period (Supplementary Figure 2). We excluded antibiotic dispensings for residents enrolled in Medicare Advantage (for whom claims data are managed separately by private insurers) during the month of dispensing or two months prior. We also excluded antibiotic dispensings for residents diagnosed with UTI and pneumonia on the same MDS assessment, missing covariate information, hospitalized in the three days before the antibiotic dispensing (emphasizing infections diagnosed and treated within the NH), and dispensings not prescribed by physicians or APs or where the National Provider Identifier (NPI) did not link to Medicare prescriber characteristics files. Finally, we restricted antibiotic dispensings to one randomly sampled infection (UTI or pneumonia) per resident per year.
Prescriber Type and Specialization in NH Care
We compared antibiotic prescribing patterns across four prescriber groups: NH specialist physicians, non-NH specialist physicians, NH specialist APs, and non-NH specialist APs. Prescriber type (physician or AP) was determined using prescriber primary taxonomy codes obtained from the Medicare prescriber characteristics files. NH specialists were defined as prescribers for whom ≥90% of all medication dispensings attributed to their NPI were for nursing home residents. NH specialization was reassessed yearly.
Antibiotic Class and Duration of Therapy
We examined antibiotic prescribing patterns and duration of therapy by medication class. Antibiotic classes were separated into 15 categories (Supplementary Table 1). Antibiotics with low prescribing prevalence were aggregated into an “other antibiotics” category, which differed between UTI and pneumonia.
Baseline Characteristics
We obtained demographics (age, sex, and race/ethnicity) from the Medicare Beneficiary Summary File. Clinical characteristics were obtained from the MDS assessment most proximal up to 185 days prior to the assessment which documented UTI or pneumonia. Characteristics related to devices and special treatments were only measured based on the assessment which documented UTI or pneumonia. Information on prior hospitalizations was obtained from Medicare Provider Analysis and Review files.
Statistical Analysis
We calculated the total number of dispensings and the proportion of total dispensings by antibiotic class across prescriber groups, overall and by year. For the duration of therapy, we calculated the median (first quartile [Q1], third quartile [Q3]) number of days supplied by antibiotic class across prescriber groups.
Stability Analyses
We examined antibiotic prescribing patterns, stratified by year, to explore how prescribing decisions may have changed over time. To examine whether antibiotic prescribing patterns differed by prescriber group between initial and subsequent prescribing events for a given infection, we assessed the distribution of antibiotic dispensings by medication class across prescriber groups, stratified by initial versus subsequent prescribing events. Dispensings on the first date of a UTI or pneumonia episode were defined as initial prescribing events.
RESULTS
Study Cohort
The study included 264,735 antibiotic dispensings for 140,360 residents in 14,035 NHs (Supplementary Figure 3). Of the 32,437 unique prescribers in the analysis, 23,350 (69.0%) were non-NH specialist physicians, 3,965 (11.7%) were NH specialist physicians, 4,900 (14.5%) were non-NH specialist APs, and 1,642 (4.9%) were NH specialist APs. Non-NH specialist physicians prescribed antibiotics most frequently (66.3% of all dispensings), whereas NH specialist APs prescribed antibiotics least frequently (3.1% of all dispensings). NH specialists prescribed a greater proportion of antibiotics to non-White residents, residents with greater health instability, and residents with increased cognitive impairment (Table 1).
Table 1.
Demographic and Clinical Characteristics of Long-Stay Nursing Home Residents with UTI or Pneumonia, by Prescriber Group, 2016–2018. (N= 264,735 residents)
| Resident Characteristic* | NH specialist physician n=66,880 | Non-NH specialist physician n=175,548 | NH specialist advanced practitioner n=8,258 | Non-NH specialist advanced practitioner n=14,049 |
|---|---|---|---|---|
| Age, years, mean (SD) | 82.9 (8.6) | 84.0 (8.4) | 83.6 (8.7) | 84.3 (8.5) |
| Female sex | 49,938 (74. 7%) | 135,043 (76.9%) | 6,073 (73.5%) | 10,865 (77.3%) |
| Race/ethnicity | ||||
| White, non-Hispanic | 54,809 (82.0%) | 151,904 (86.5%) | 7,299 (88.4%) | 12,663 (90.1%) |
| Black, non-Hispanic | 7,825 (11.7%) | 12,567 (7.2%) | 602 (7.3%) | 826 (5.9%) |
| Hispanic | 2,956 (4.4%) | 7,366 (4.2%) | 241 (2.9%) | 315 (2.2%) |
| Other | 1,290 (1.9%) | 3,711 (2.1%) | 116 (1.4%) | 245 (1.7%) |
| ADL dependence† | ||||
| Independent to limited assistance required | 1,932 (2.9%) | 6,151 (3.5%) | 225 (2.7%) | 683 (4.9%) |
| Extensive assistance required | 56,095 (83.9%) | 148,727 (84.7%) | 7,119 (86.2%) | 12,168 (86.6%) |
| Extensive dependency | 8,853 (13.2%) | 20,670 (11. 8%) | 914 (11. 1%) | 1,198 (8.5%) |
| Health instability‡ | ||||
| None | 29,360 (43.9%) | 79,310 (45.2%) | 3,634 (44.0%) | 6,528 (46.5%) |
| Minimal | 22,181 (33.2%) | 58,266 (33.2%) | 2,742 (33.2%) | 4,645 (33.1%) |
| Low | 11,479 (17.2%) | 29,573 (16.9%) | 1,424 (17.2%) | 2,352 (16.7%) |
| Moderate to very high | 3,860 (5. 8%) | 8,399 (4. 8%) | 458 (5. 6%) | 524 (3.7%) |
| Cognitive impairment§ | ||||
| Cognitively intact | 20,037 (30.0%) | 53,320 (30.4%) | 2,588 (31.3%) | 4,485 (31.9%) |
| Mildly impaired | 15,559 (23.3%) | 41,969 (23.9%) | 1,911 (23.1%) | 3,361 (23.9%) |
| Moderately impaired | 23,794 (35.6%) | 62,593 (35.7%) | 2,839 (34.4%) | 4,897 (34.9%) |
| Severely impaired | 7,490 (11.2%) | 17,666 (10. 1%) | 920 (11.1%) | 1,306 (9.3%) |
| MDS comorbidities | ||||
| Diabetes | 25,755 (38.5%) | 66,255 (37.7%) | 3,032 (36.7%) | 5,073 (36.1%) |
| Anemia | 24,549 (36.7%) | 62,119 (35.4%) | 2,887 (35.0%) | 4,631 (33.0%) |
| Alzheimer’s disease or related dementia | 40,841 (61.1%) | 103,753 (59.1%) | 4,936 (59.8%) | 8,176 (58.2%) |
| Asthma/COPD | 18,699 (28.0%) | 48,747 (27.8%) | 2,341 (28.4%) | 3,954 (28.1%) |
| Atrial fibrillation | 8,262 (12.4%) | 22,491 (12.8%) | 1,198 (14.5%) | 1,921 (13.7%) |
| Coronary artery disease | 8,276 (12.4%) | 22,458 (12.8%) | 1,103 (13.4%) | 1,717 (12.2%) |
| Heart failure | 18,237 (27.3%) | 48,157 (27.4%) | 2,313 (28.0%) | 3,991 (28.4%) |
| Hypertension | 54,595 (81.6%) | 143,979 (82.0%) | 6,596 (79.9%) | 11,194 (79.7%) |
| Neurogenic bladder | 4,623 (6.9%) | 12,104 (6.9%) | 698 (8.5%) | 1,029 (7.3%) |
| Renal insufficiency/ESRD | 5,518 (8.3%) | 14,526 (8.3%) | 757 (9.2%) | 1,268 (9.0%) |
| Devices and special treatments|| | ||||
| Indwelling catheter | 9,222 (13.8%) | 22,589 (12.9%) | 1,235 (15.0%) | 1,864 (13.3%) |
| Oxygen therapy | 14,555 (21.8%) | 36,309 (20.69%) | 1,908 (23.1%) | 3,006 (21.4%) |
| Intravenous medications | 8,111 (12.1%) | 18,315 (10.4%) | 825 (10.0%) | 991 (7.1%) |
| Hospital use in past 90 days | 8,286 (12.4%) | 21,404 (12.2%) | 915 (11.1%) | 1,579 (11.2%) |
Abbreviations: UTI; Urinary Tract Infection; NH, Nursing Home; SD, standard deviation; ADL, Activities of Daily Living; ESRD, End-Stage Renal Disease; COPD, Chronic Obstructive Pulmonary Disease/Chronic Lung Disease; BiPAP/CPAP, Bilevel Positive Airway Pressure/Continuous Positive Airway Pressure; ICU, Intensive Care Unit; MDS, Minimum Data Set.
Note: Nursing home specialists were defined as prescribers for whom ≥ 90% of all dispensings (not only antibiotics) attributed to their National Provider Identifier were for nursing home residents. Nursing home specialization was reassessed yearly. Our analyses were conducted at the person-dispensing level to understand unique prescribing decisions by prescriber group. Nursing home residents could be represented multiple times if they received multiple dispensings during the study period or had infections in multiple years.
Characteristics are reported as number (%) unless otherwise noted.
Dependence in ADLs was measured using the MDS Morris 28-point ADL scale, categorized as 0 to 14 (independent to limited assistance required), 15 to 19 (extensive assistance required), and 20 or higher (extensive dependency). Dependence in ADLs is a measure of physical function.
Health instability was measured using the MDS 6-point Changes in Health, End-stage disease and Symptoms and Signs score, categorized as 0 (no instability), 1 (minimal health instability), 2 (low health instability), and 3 or higher (moderate to very high health instability).
Cognitive impairment was measured using the MDS 4-point Cognitive Function Scale, which ranged from 1 (intact) to 4 (severe impairment).
Devices and special treatments were only measured on the MDS assessment that included a diagnosis of UTI or pneumonia.
Antibiotic Classes Prescribed for UTI and Pneumonia
Fluoroquinolones were the most prevalent antibiotic class prescribed for UTI across prescriber groups, followed by nitrofurantoin and sulfonamides and related agents (Figure 1). NH specialists prescribed a smaller proportion of fluoroquinolones than non-NH specialists and a greater proportion of third generation cephalosporins +/− β lactamase inhibitors.
Figure 1. Antibiotic Classes Prescribed to Long-Stay Nursing Home Residents with UTI, by Prescriber Group, 2016–2018. (N=214,759 dispensings).
Abbreviations: NH, Nursing Home.
Note: Nursing home specialists were defined as prescribers for whom ≥ 90% of all dispensings (not only antibiotics) attributed to their National Provider Identifier were for nursing home residents. Nursing home specialization was reassessed yearly. Antibiotics with low frequencies were categorized as “other antibiotics.” Individual antibiotics included in each class are listed in Supplementary Table 1.
The most prevalent antibiotic classes prescribed for pneumonia across prescriber groups were fluoroquinolones, penicillins +/− β lactamase inhibitors, and third generation cephalosporins +/− β lactamase inhibitors (Figure 2). NH specialists prescribed a greater proportion of fluoroquinolones, but non-NH specialists prescribed a greater proportion of macrolides.
Figure 2. Antibiotic Classes Prescribed to Long-Stay Nursing Home Residents with Pneumonia, by Prescriber Group, 2016–2018. (N=49,976 dispensings).
Abbreviations: NH, Nursing Home.
Note: Nursing home specialists were defined as prescribers for whom ≥ 90% of all dispensings (not only antibiotics) attributed to their National Provider Identifier were for nursing home residents. Nursing home specialization was reassessed yearly. Antibiotics with low frequencies were categorized as “other antibiotics.” Individual antibiotics included in each class are listed in Supplementary Table 1.
Duration of Therapy
The median duration of antibiotic therapy for UTI was largely consistent across prescriber groups (Supplementary Table 2). However, the Q1 for physicians was lower for penicillins +/− β lactamase inhibitors, first generation cephalosporins, and second generation cephalosporins compared to APs.
We observed greater variation in the median duration of therapy for pneumonia, where non-NH specialist APs had the longest median duration of therapy for tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole (Supplementary Table 3).
Stability Analyses
Stratified by year, the prevalence of fluoroquinolones prescribed for UTI and pneumonia decreased across all prescriber groups from 2016 to 2018, with the largest decrease observed among physician prescribing for pneumonia (Supplementary Tables 4–5). Changes between initial and subsequent dispensings were largely consistent across prescribers (Supplementary Figures 6–7).
DISCUSSION
In this national study, antibiotic prescribing patterns for UTI and pneumonia between 2016 and 2018 differed by prescriber type and specialization in NH care. Compared to non-NH specialists, NH specialists prescribed fluoroquinolones less frequently for UTI but more frequently for pneumonia. Over time, NH specialists reduced prescribing of fluoroquinolones for pneumonia to a greater extent than non-NH specialists. NH specialist physicians prescribed several antibiotic classes for shorter durations for UTI, and non-NH specialist APs prescribed several antibiotic classes for longer durations for pneumonia. These results highlight NH specialization as a potential focus for future antibiotic stewardship programs.
The prevalence of prescribers who practice predominantly in NHs appears to have increased over time.9 Similarly, we found that the proportion of total antibiotics prescribed by NH specialists increased from 26.9% in 2016 to 31.1% in 2018. A prior study reported that NH specialists were associated with a lower risk of hospitalization but greater risk of mortality for NH residents with pneumonia.15 Others have reported associations between NH specialists and lower risk of hospitalization,16 shorter duration of psychoactive medication use, and reduced indwelling catheter use.17 To our knowledge, this study is the first to examine antibiotic prescribing patterns by NH specialization and prescriber type. Our findings of the most prevalent antibiotic classes align with prior studies and clinical practice guidelines.18, 19 However, we found that NH specialists prescribed fluoroquinolones less frequently for UTI than non-NH specialists and further reduced prescribing of fluoroquinolones over time for pneumonia. These findings suggest that NH specialists are less likely to prescribe antibiotics with a higher potential for antimicrobial resistance and adverse events and are more likely to respond to antibiotic stewardship initiatives. Limited research exists on how prescriber characteristics affect the duration of antibiotic therapy.20 Our results reveal that physicians, and to a lesser extent, NH specialists, were more likely to prescribe antibiotics for shorter durations for several antibiotic classes. This result suggests that physicians may be more likely to prescribe short-course antibiotics or be more aware of opportunities to post-prescriptively modify antibiotic prescriptions.21
National attention in the US was brought to antibiotic stewardship in NHs during our study period,22 and evidence suggests that NHs have made progress in implementing antibiotic stewardship programs.23 In our study, we found the total number of antibiotics prescribed decreased by 71.9% for UTI, which may correspond to improved UTI diagnostic criteria and reductions in unnecessary prescribing.24 We also found that the proportion of fluoroquinolones dispensed each year decreased, which may reflect modification of prescribing patterns in response to antibiotic stewardship programs.
Our results suggest there may be a role for tailoring antibiotic stewardship interventions, such as prescriber education or audit and feedback,24, 25 to specific prescriber groups based on their unique prescribing patterns. To inform such interventions, future research on the drivers of differences in antibiotic prescribing patterns (e.g., antimicrobial stewardship policies across NHs) is first needed. Given the limited prevalence of antibiotics prescribed by APs (APs accounted for less than 10% of antibiotic prescriptions), it may be most efficient for future efforts to focus on NH specialization, regardless of prescriber type.
Limitations
Because Part D prescription drug claims do not include indications for dispensings and MDS infection diagnoses do not include diagnosis dates, we were unable to directly identify medication indications (e.g., whether antibiotics were prescribed prophylactically or for treatment). We were also unable to assess the clinical appropriateness of antibiotic therapy because laboratory/imaging results and other necessary clinical information were unavailable.26 However, the distribution of antibiotic classes we observed for UTI and pneumonia concords with prior antibiotic prescribing literature.8 Further, urinary and respiratory tract infections account for the large majority of NH bacterial infections.12, 27 Any potential misattributions of antibiotics are unlikely to substantially alter our inferences.
UTI and pneumonia were only ascertained from quarterly MDS assessments, therefore we did not identify infections that occurred between assessments.28 It is possible that antibiotic prescribing patterns for undocumented infections differed from those we observed.
Finally, there remains no single definition of specialization in NH care, and our approach may not capture all factors that may be used to define NH specialization.29 Claims-based measures of NH specialization have been correlated with NH administrator perceptions of physician practice,30 providing evidence that these methods may be valid approaches to identify NH specialists.
CONCLUSIONS AND IMPLICATIONS
There were substantial differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Given these observed differences, tailoring antibiotic stewardship efforts to prescribers by NH specialization would be rational.
Supplementary Material
Funding Sources:
This work was supported by the National Institute on Aging at the National Institutes of Health [R01AG077620 to A.R.Z]. A.R.Z. was also supported by additional National Institute on Aging grants [R01AG065722, R01AG077620].
Footnotes
CONFLICTS OF INTEREST
A.R.Z. reports grants from Sanofi for collaborative research on the epidemiology of infections and vaccinations in older nursing home residents and infants. No other authors report conflicts of interest relevant to the subject matter of the manuscript. Some authors are VA employees [A.R.Z.]. The content and views expressed in this article are those of the authors and do not necessarily reflect the position or official policies of the United States Government or the US Department of Veterans Affairs.
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