https://orcid.org/0000-0003-2217-184X
Abstract
The proportion of sinusitis visits that meet antibiotic prescribing criteria is unknown. Of 425 randomly selected sinusitis visits, 50% (214) met antibiotic prescribing criteria. There was no significant difference in antibiotic prescribing at visits that did (205/214 [96%]) and did not (193/211 [92%]; P = .07) meet antibiotic prescribing criteria.
Sinusitis is common and accounts for more antibiotic prescribing in the United States than any other single diagnosis, but many antibiotic prescriptions for acute sinusitis are probably inappropriate [1, 2]. Inappropriate antibiotic prescriptions increase costs, exposure to adverse drug reactions, and the prevalence of antibiotic-resistant bacteria.
The Infectious Diseases Society of America (IDSA) defined clinical criteria for the antibiotic treatment of bacterial sinusitis in 2012: patients must have persistent, severe, or worsening symptoms [3]. The IDSA guideline recommends amoxicillin-clavulanate as the first-line antibiotic.
Despite reasonably clear clinical criteria and many studies of rates of ambulatory antibiotic prescribing that have considered acute sinusitis a “potentially antibiotic appropriate” diagnosis [1, 2], the percentage of visits that meet criteria for antibiotic prescribing is unknown. Knowing the rate of sinusitis visits that meet appropriateness criteria could help inform future ambulatory stewardship efforts. To measure the proportion of acute sinusitis visits by adults in primary care that met criteria for antibiotic prescribing, we conducted a chart review study.
METHODS
Setting, Data Source, and Overview
Northwestern Medicine is an integrated health system in the Chicago, Illinois, area that includes 62 urban, suburban, and rural primary care practices. The Northwestern Medicine Enterprise Data Warehouse, a joint initiative of the Northwestern University Feinberg School of Medicine and Northwestern Memorial Health Care, includes data from 6.6 million distinct patients. We randomly selected 500 acute sinusitis visits and then conducted chart review to verify the diagnosis of acute sinusitis, measure the proportion of visits that met antibiotic prescribing criteria, and measure the actual antibiotic prescribing rate.
Data Extraction
We queried the Northwestern Medicine Enterprise Data Warehouse from 1 January 2017 to 31 December 2017 for visits to primary care clinicians by adults aged 18 to 60 years with an International Classification of Diseases, Tenth Revision, code of acute sinusitis (J01 and all subcodes). We excluded visits by patients with an antibiotic prescription in the prior 30 days and patients with a diagnosis code of chronic sinusitis (ICD-10 J32). We excluded patients on immunosuppressive medications using Generic Product Identifier codes 9940000000 (“Immunosuppressive Agents”) and 2100000000 (“Antineoplastic and Adjunctive Therapies”), which includes mTor inhibitors, calcineurin inhibitors, antiproliferative agents, steroids, and antineoplastic therapies. We excluded patients with immunodeficiency, including patients with primary/congenital immunodeficiency (ICD-10 D80, D82, D82) or secondary immunosuppressive diseases including human immunodeficiency virus (ICD-10 B20) and blood cancers (ICD-10 C81, C82, C83, C84, C85, C90, C91, C92, C93, C94, C95).
This search generated 2452 distinct visits. From these visits, we randomly selected 500 for manual chart review. Because we sought to measure the overall antibiotic appropriateness and antibiotic prescribing rates, we did not stratify the random selection by practice or on patient, clinician, or practice factors.
Chart Review
During review, we excluded visits with insufficient documentation (ie, no mention of acute sinusitis or discussion of symptoms in the visit note), an antibiotic prescription in the prior 30 days, a concomitant antibiotic indication (ie, acute otitis media), immunosuppression, or previous diagnosis of chronic sinusitis.
We extracted patient and clinician descriptive information, whether the clinician prescribed an antibiotic, and which antibiotic was prescribed.
To meet criteria for antibiotic prescribing, patients had to have persistent, severe, or worsening symptoms [3], defined as follows: persistent, symptoms consistent with sinusitis for ≥10 days and not improving; severe, fever >102°F and purulent nasal discharge or facial pain lasting 3 to 4+ days at beginning of illness; or worsening (or “double-sickening”), new fever, headache, or increase in nasal discharge following an upper respiratory tract infection that lasted 5 to 6 days and was initially improving.
We extracted whether patients met at least 1 or any combination of criteria for antibiotic prescribing.
Initially, 2 reviewers independently reviewed 50 charts. Concordance rates between the 2 reviewers for the presence of each of the symptom criteria—persistent, severe, or worsening—were 90% (45/50), 90% (45/50), and 86% (43/50), respectively. Following dual review and discussion, to be more forgiving to treating physicians, we changed the review protocol to include temperatures recorded at home as meeting the definition of fever for criterion 2 and included any mention of symptoms worsening after initial improvement or stabilization in meeting criterion 3.
RESULTS
During the study period from January 2017 to December 2017, there were 2452 visits to primary care clinicians by patients aged 18–60 years with acute sinusitis that met our inclusion and exclusion criteria. We randomly selected 500 of these visits.
Of the 500 selected visits, 425 met all inclusion criteria (Figure 1). Patients were an average age of 41 years old; were 71% women, 6% black, and 6% Latino; and 52% had commercial insurance and 39% had Medicaid. Patients had symptoms for a mean of 7 days (range, 1 to 61) prior to presentation. The median number of active medications was 3 (range, 0 to 20). Clinicians were 82% physicians, 16% nurse practitioners or physician assistants, and 3% residents or fellows.
Visit flow and appropriateness of antibiotic prescribing for sinusitis. 1Visits had “insufficient documentation” if there was no mention of acute sinusitis or discussion of symptoms in the visit note. 2The most common concomitant antibiotic indication was acute otitis media (10/15; 67%). 3Only 21 (5%) antibiotic prescriptions had documentation about patient use if they were not improving (ie, delayed antibiotics).
Among the 214 (50%) patients who met criteria for antibiotic prescribing (Figure 1), the most common symptom criteria for antibiotic prescribing were persistent symptoms (165 [77%]), persistent and worsening symptoms (31 [15%]), worsening symptoms (9 [4%]), severe symptoms (7 [3%]), persistent and severe symptoms (1 [<1%]), and severe and worsening symptoms (1 [<1%]). Combined, 92% (197/214) of visits that met antibiotic prescribing criteria included persistent symptoms.
Clinicians prescribed antibiotics at 205 (96%) of the 214 visits that met criteria and in 193 (92%) of the 211 visits that did not meet criteria (P = .07). The most commonly prescribed antibiotics were amoxicillin-clavulanate (46% of antibiotic prescriptions), azithromycin (20%), amoxicillin (12%), and cefdinir (6%). The median duration of antibiotic treatment was 10 days (interquartile range, 6 to 10).
Visits that did and did not meet antibiotic prescribing criteria did not significantly differ in patient age, gender, race, ethnicity, or insurance; antibiotic selection; or duration (data not shown).
DISCUSSION
Half of adult primary care patients who made a visit for acute sinusitis met criteria for antibiotic prescribing. The actual antibiotic prescribing rate was significantly higher. Nationally, the antibiotic prescribing rate for sinusitis is 72% [1].
Our inclusion criteria were very specific, and the assessment of guideline-concordant antibiotic appropriateness was very forgiving. Inclusion of patients with sinus symptoms, but less specific, nonsinusitis diagnosis codes (eg, “acute upper respiratory infection, unspecified”) might appear to “decrease” the proportion of patients who met antibiotic prescribing criteria and the antibiotic prescribing rate. Exclusion of patients with a diagnosis of sinusitis, but no mention of sinus symptoms, increased the apparent appropriateness rate. At the same time, nearly all of the appropriate visits met criteria for persistent symptoms (92%). Patients could have had persistent, mild symptoms (eg, only rhinorrhea), which was still likely to be viral and for which antibiotics might be unlikely to help. We were also extremely forgiving in considering “worsening,” including any mention of worsening, as fulfilling the criteria. Given these assumptions, that half of patients with acute sinusitis met criteria for antibiotic prescribing likely represents an upper bound of appropriateness.
Antibiotic selection was not guideline-concordant. Guidelines recommend amoxicillin-clavulanate or amoxicillin as first-line antibiotics and specifically recommend against use of macrolides and third-generation cephalosporins [3, 4]. Despite this, azithromycin and cefdinir were frequently prescribed.
Many reasons may explain clinicians’ high antibiotic prescribing rate. Patients often expect to be prescribed antibiotics—70% expect antibiotics for acute rhinosinusitis [5]—and physicians respond to perceived patient desire for antibiotics [6]. Indeed, a physician’s perception of a patient’s desire for antibiotics is more strongly associated with an antibiotic prescription than whether or not the patient actually desires an antibiotic [7]. Clinicians prescribe antibiotics in an attempt to provide value to their patients, avoid negative repercussions of not prescribing antibiotics, and fear interactions with an “inconvincible patient” who will not be satisfied without an antibiotic prescription [8]. High antibiotic-prescribing clinicians may frequently use the diagnosis of sinusitis as an implicit justification [9].
Limitations of this study include that it was a retrospective chart review; had stringent inclusion and exclusion criteria for an acute sinusitis visit; was conducted in a single health system; was dependent on specific billing codes and clinical documentation; focused only on antibiotic prescribing, not use; focused on a single US guideline; and did not assess clinical outcomes. A newer guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation is more restrictive about antibiotic prescribing [4].
Several interventions have been shown to decrease inappropriate antibiotic prescribing for acute respiratory infections. These include peer comparison audit and feedback, requiring justifications for antibiotic prescribing, precommitment posters, communication training for clinicians, combined patient–clinician education, and electronic health record clinical decision support [10]. Because clinicians might be responding to perceived patient annoyance at having made a visit for sinusitis, virtual visits have the potential to decrease antibiotic prescribing [11]. Multifaceted interventions directed at all antibiotic prescribing could also decrease inappropriate prescribing for sinusitis [12].
In conclusion, despite the existence of clear clinical criteria for sinusitis and the harms of inappropriate antibiotic prescribing, primary care clinicians did not use guideline-based symptoms to inform antibiotic prescribing and overprescribed antibiotics. Ambulatory stewardship measures have generally addressed only antibiotic inappropriate diagnoses, such as nonspecific upper respiratory tract infections, or the requirement for streptococcal testing with a diagnosis of pharyngitis. To meaningfully reduce inappropriate antibiotic prescribing, future stewardship efforts should address the diagnosis of and appropriateness of antibiotic prescribing for sinusitis.
Notes
Disclaimer. The funding source played no role in the design of the study; the collection, analysis, and interpretation of the data; and the decision to approve publication of the finished manuscript.
Financial support. This work was supported by a grant from the Agency for Healthcare Research and Quality (R01HS024930) and a contract from the Agency for Healthcare Research and Quality (HHSP233201500020I). J. A. L. is also supported by grants from the National Institute on Aging (R21AG057400, R33AG057395, R33AG057383), the National Institute on Drug Abuse (R33AG057395), and the Agency for Healthcare Research and Quality (R01HS026506), the Peterson Center on Healthcare (grant number 19041).
Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.
Presented in part: Northwestern University Feinberg School of Medicine 15th Annual Lewis Landsberg Research Day, Chicago, Illinois, USA, 4 April 2019.
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