Right Care at the Right Time in the Right Way – The Case of Antibiotics

One of the most difficult problems to address in the U.S. health care system is treatment recommendations that are out-of-date, inaccurate, or based on an incorrect diagnosis. We write about this topic frequently () and Dr. Atul Gawande (who was recently named as the CEO of the new company being formed by Amazon.com Inc., Berkshire Hathaway Inc. and JPMorgan Chase & Co.) highlighted it most recently in a conversation with reporter Judy Woodruff at the Aspen Ideas Festival. Gawande argued there are three sources of waste that require different work but the biggest bucket is misutilization, “meaning the wrong care, at the wrong time, in the wrong way.”

A perfect example is antibiotic use. According to the Centers for Disease Control and Prevention (CDC) about 30% of antibiotics prescribed in physician’s offices and other outpatient settings are unnecessary. Further, says the CDC, “even when antibiotics are needed, prescribers often favor drugs that may be less effective and carry more risk over more targeted first-line drugs recommended by national guidelines.” In other words, clinical recommendations are often out-of-date or simply not following guidelines.

In urgent care centers, an increasingly popular site of care, the problem is even worse. According to a brief published this month by The Pew Charitable Trusts, “46% of all urgent care visits for non-antibiotic recommended diagnoses resulted in an antibiotic prescription,” compared to 14% of the time in retail clinics, 25% of the time in emergency departments, and 17% in office-based clinics. Acute respiratory conditions, for example, asthma and allergy, bronchitis, flu, and pneumonia are common reasons for a visit to a physician’s office or clinic, but in urgent care centers, it is fairly likely an antibiotic will be prescribed for these conditions, when they shouldn’t be, as shown in the table from Pew below.

Considering urgent care usage has skyrocketed in recent years, increasing by 1,675% (that is not a typo!) in rural areas and 2,308% in urban areas between 2007 and 2016, the higher rate of inappropriate antibiotic use is an even bigger problem than just comparing prescribing rates across site of care might indicate.

Inappropriate antibiotic prescription use plus skyrocketing urgent care visits equals a perfect case of “wrong care, at the wrong time, in the wrong way.”