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An IDWeek 2013 poster presentation quantified clinician fatigue with the finding that Boston-area primary care physicians were more likely to prescribe antibiotics for ARIs at the end of the day than when they were fresh on the job in the morning.
The drive to reduce inappropriate prescribing of antibiotics in primary care practice may need to incorporate creative new tactics: clinic siestas come to mind after learning the results of a recent study presented at IDWeek 2013.
“Antibiotic Prescribing for Acute Respiratory Infections Increases as the Clinic Session Wears On” began with the premise that fatigue and stress may compromise a clinician’s “capacity to resist prescribing antibiotics for acute respiratory infections (ARIs)” and the hypothesis that primary care physicians would be less likely to prescribe antibiotics at the beginning and more likely to prescribe them at the end of clinic sessions.
The authors compared the antibiotic prescribing rates for all ARI diagnoses-both antibiotic-appropriate (eg, sinusitis, pneumonia) and non–antibiotic-appropriate (eg, acute bronchitis)-for the first visit of a half-day clinic session and the last hour of a half-day clinic session (so, the the 11 AM and 4 PM hours) to the remaining visits.
There were 678,982 total visits and 31,838 ARI visits scheduled from 8 AM to 5 PM, Monday to Friday, by patients aged 18 to 64 years without chronic lung disease to 561 clinicians in 23 Boston-area primary care practices, between May 2011 and September 2012. The antibiotic prescribing rate for the first visit of the session was significantly lower than for later visits for all ARIs (55.2% vs 58.7%; p < .001), antibiotic-appropriate diagnoses (74.2% vs 77.4%; p =.008), and non–antibiotic-appropriate diagnoses (45.1% vs 48.8%; p <.001). The antibiotic prescribing rate was significantly higher during the last hour of each session compared with the remainder of the session for all ARIs (60.3% vs 57.6%; p <.001), antibiotic-appropriate diagnoses (78.8% vs 76.4%; p = .01), and non–antibiotic-appropriate diagnoses (50.6% vs 47.6%; P < .001). In multivariable modeling, clinicians were less likely to prescribe antibiotics at the first visit of the session (odds ratio [OR] = 0.88; 95% confidence interval [CI], 0.81 to 0.96) and more likely to prescribe antibiotics in the last hour of a clinic session (OR = 1.12; 95% CI, 1.04 to 1.19).
The authors conclude that these Boston-area primary care physicians are slightly, but significantly less likely, to prescribe antibiotics at the beginning of a clinic session and more likely to prescribe antibiotics at the end of a clinic session. Siesta anyone?
Linder J, Doctor J, Friedberg M, et al. Antibiotic prescribing for acute respiratory infections increases as the clinic session wears on. Abstract presented at: IDWeek 2013; October 3, 2013; San Francisco. Abstract 1022. View on IDWeek 2013 Web site.