You probably know by now that many, many antibiotics are prescribed inappropriately — when they couldn’t possibly be of help — like for viral infections since the medications only treat bacterial infections. In fact, research finds tens of millions of unnecessary antibiotic prescriptions are written each year in the outpatient setting, like doctors’ offices, alone.
While certainly there are some clinical judgment calls, factors associated with this glut of overprescribing often have little or nothing to do with what’s in the patient’s best interest. Even the time of day a patient sees a doctor (later in the day) has been linked to a greater likelihood that person will be prescribed an antibiotic. What’s more, research finds factors from the doctor’s age (older doctors tend to prescribe more antibiotics than younger ones) to patient demographics — including race and age — are linked to variations in inappropriate antibiotic prescribing rates.
While the reasons for these associations still aren’t fully understood, experts say investigating the various factors that may be linked to inappropriate prescribing could help in curbing the problem. That’s important because, clinicians and public health officials point out, unnecessary antibiotics contribute to resistance to the drugs — creating so-called superbugs that are much harder to treat — and patients are exposed to medication side effects with no upside or benefit.
[See: 8 Questions to Ask Your Pharmacist.]
“We were really interested in trying to understand how you even go about creating a system in a large integrated health care network to teach clinicians and patients how to appropriately use antibiotics,” says Dr. Lisa Davidson, medical director of the Antimicrobial Support Network at Atrium Health, and an attending physician in the division of infectious diseases at Carolinas Medical Center in Charlotte, North Carolina. That led Davidson and fellow researchers to review nearly 448,990 outpatient visits for common upper respiratory conditions that don’t require antibiotics within what was formerly Carolinas HealthCare System — now Atrium Health.
The results of that research, published in Infection Control & Hospital Epidemiology in March, suggest factors ranging from patient demographics and insurance status to health provider characteristics are associated with differences in inappropriate antibiotic prescribing, including a patient’s race. “When compared to Caucasian patients, African-American patients were less likely to get an antibiotic,” notes Davidson, who was the study’s senior author. In fact, researchers note, patients of all other races, including African-American and Asian patients, were less likely to receive an antibiotic than white patients.
Similarly, research on pediatric patients in the emergency room found white children were more likely to be prescribed antibiotics inappropriately than black or Hispanic children, according to a study published in September last year in the journal Pediatrics.
This follows other research that has found white kids and adults are often overtreated — or receive care that’s not recommended — more frequently than minority patients. “It kind of turns racial disparities a little bit on its head — in the sense that we’re not discriminating against blacks and Hispanics in our medical care. What we are doing is overprescribing medications, CAT scans and admissions to the hospital to white people,” says Dr. James Chamberlain, a co-author of the Pediatrics study and director of analytics and informatics in the division of emergency medicine at Children’s National Health System in Washington. That doesn’t lessen the fact, however, that racial bias is still a pervasive problem in medicine, experts say, just as it is in society as a whole. “It’s still a bias,” Chamberlain says.
While in the case of inappropriate antibiotic prescribing, fewer — or actually no drugs — are better, past research has found discriminatory practices in medicine and racial disparities in treatment often lead to lower quality care for African-American patients and other minorities.
In both the Pediatrics and the Infection Control & Hospital Epidemiology studies, it’s not clear why a patient’s race (as well as other factors studied in the Infection Control & Hospital Epidemiology research) correlates with significantly different rates of unnecessary antibiotic prescribing. “Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias,” the researchers write in the Pediatrics study.
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It’s clear from previous research though that racial disparities exist in care; and, as a result, the latest findings aren’t surprising, says Dr. Colleen Nash, an assistant professor of pediatric infectious diseases at Rush University Medical Center in Chicago. “What’s happening in these minority populations by not receiving antimicrobials is actually appropriate care, and more evidence-based,” she says. “But the way in which they’re getting there is flawed.”
Chamberlain says though there’s no evidence for what caused the disparities in inappropriate antibiotic prescribing among pediatric ER patients, he and his fellow researchers hypothesize that what’s called referral bias may play a role. Where blacks and Hispanics are likely to walk into the ER without a doctor referral, it could affect the care they receive. “Whites tend to be referred in by their pediatricians with specific expectations already set,” Chamberlain says. “It’s not unusual for us to have a white family referred in, already having talked to their pediatrician” about specific care that doctor thinks may be needed — whether it’s a CT scan or medication. “Sometimes we have to fight against preconceived expectations of parents.”
It’s theorized from previous research that in pediatric patients, parental expectations may play a role in who gets antibiotics unnecessarily and who doesn’t. “There is a perception that white parents tend to be more pushy when demanding things like antibiotics for their child’s cold,” Chamberlain says. But, as the researchers note, while physician perceptions of parents’ expectations seem to affect prescribing — those perceptions, too, may be off — and colored by a patient’s race. “Physicians’ perceptions were not associated with actual parental expectations for antibiotics,” the researchers wrote. “Implicit bias of clinicians may also affect quality of delivered care.”
Experts say more study is needed to determine the reasons factors like race may affect antibiotic prescribing and to develop solutions that better fit individual circumstances. While certainly overt racism isn’t a thing of the past, either — inside or outside the health care arena — researchers say typically it’s not explicit, but implicit, bias that affects care, and it’s more extensive. That makes it all the more important for health providers to be introspective about possible biases, and proactive about delivering more equitable treatment.
“If ever a patient feels that they may be experiencing bias in their care, they should speak up,” Chamberlain suggests. “You should do it in a nice way, of course, and be diplomatic,” he says; but though it may be a difficult conversation to broach, he and other clinicians say it’s reasonable to raise such concerns and to expect a health provider to be responsive to them. Just naming it and questioning it would prompt most physicians to step back, and assess the issue; and “I would say if your doctor is not willing to engage in that conversation, then you should probably get another doctor,” Chamberlain says. “In the setting of the emergency department, there’s always a supervisor that you can talk to, or a patient ombudsman who can help you.”
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
Generally speaking, experts say, patient and provider should always discuss specifics regarding the need for antibiotics — or why they aren’t helpful or appropriate in a given circumstance. “I think far too few questions are asked about what antibiotics are for and what they’re treating,” Nash says.
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Is Race a Factor in Whether You — or Your Child — Get Antibiotics? originally appeared on usnews.com
