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Report: Competition Among Physicians and Retail Clinics Drives Up Antibiotic Prescribing Rate

Findings underscore fact that health care is a business, authors say

Competition among doctors’ offices, urgent care centers, and retail medical clinics in wealthy areas of the U.S. often leads to an increase in the number of antibiotic prescriptions written per person, according to new research led by a team at Johns Hopkins.

“We found that both the number of physicians per capita and the number of clinics are significant drivers of antibiotic prescription rate,” the authors say in a report published online in the Journal of Antimicrobial Chemotherapy.

“The increase in the number of antibiotic prescriptions written in wealthy areas appears to be driven primarily by increased competition among doctors’ offices, retail medical clinics, and other health care providers as they seek to keep patients satisfied with medical care and customer service,” said lead author Eili Klein, PhD.

On a regional basis, the highest per capita rates of antibiotic prescriptions were found in the southeastern U.S. and along the west and east coasts.

At a more metropolitan scale, notably high rates of antibiotic prescribing were found in Manhattan, southern Miami, and Encino, California, among other areas. Overall, the researchers' analysis revealed highly variable prescription rates across the U.S.

The team’s comparative analysis of data for the years 2000 and 2010 were collected from the U.S. Census Bureau and the IMS Health Xponent database, which tracks prescriptions dispensed at the ZIP code level.

The data showed that the presence of retail medical clinics, such as those found in chain drug and “super” stores, and of urgent care centers increases the prescribing rate, but the effect was different in wealthy versus poor areas. In wealthy areas, the presence of clinics correlated with an increase in physicians’ prescribing rates.

However, while the presence of retail or urgent care clinics in poorer areas increased access to health care, it did not generate competition among providers that resulted in higher prescribing behavior by physicians’ offices.

The findings, according to the research team, add to the growing body of evidence indicating that social and economic factors are contributing to the overuse of antibiotics in the U.S. The Centers for Disease Control and Prevention reports that such overuse is a major factor in the spread of antibiotic resistance and is a worldwide health threat, resulting in 23,000 deaths each year in the U.S.

The findings also suggest that residents in wealthy areas may be more able and more likely to shop for a health care provider willing to write a prescription than are residents in poorer areas.

“We were surprised to find in this study that there is a really strong suggestion in the data that physicians are competing with other physicians, and they are doing that through the mechanism of prescribing antibiotics,” Klein said.

“It speaks to the fact that health care is a business,” he added. “But it also underscores that there is a lot of pressure on doctors to prescribe antibiotics –– even when they aren’t 100 percent certain they are necessary.”

One of those pressures, Klein said, is the time available to spend with each patient. There are reliable estimates, he noted, that it takes a doctor 5 minutes to see a patient who isn’t feeling well and write a prescription for an antibiotic, but it takes 15 minutes to explain to the patient why they don’t need one.

Klein says physicians’ offices also face pressure from patients shopping around for care or from retail medical clinics that may offer a prescription if a physician’s office doesn’t.

“These are all real pressures contributing to a public health crisis driven by the overuse of antibiotics,” said Klein, who has published other studies looking at how social and economic interactions and trends are contributing to antibiotic resistance.

The authors hope that the study contributes to a greater understanding of the many factors that contribute to antibiotic overuse, and that others will use the study findings to develop solutions to help curb inappropriate antibiotic prescribing behavior.

For example, Klein said, the findings could be used to help guide the development of a program to educate physicians by showing how their antibiotic-prescribing behavior compares with others on a local, regional, or national level.

Source: Johns Hopkins Medicine; February 25, 2015.

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