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Invited Commentary
September 2018

Overprescription in Urgent Care Clinics—The Fast and the Spurious

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Editorial Fellow, JAMA Internal Medicine
  • 3Editor, JAMA Internal Medicine
  • 4New York City Health and Hospitals, New York, New York
  • 5Deputy Editor, JAMA Internal Medicine
JAMA Intern Med. 2018;178(9):1269-1270. doi:10.1001/jamainternmed.2018.1628

Despite clear guidelines and extensive educational campaigns aimed at reducing overprescribing of antibiotics,1 the problem remains. At least 30% of antibiotic prescriptions dispensed in the outpatient setting—80 million prescriptions per year in the United States—are given without an appropriate indication.2-4 Viral upper respiratory tract infections represent a frequent diagnosis for this low-value care.

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    4 Comments for this article
    I Agree
    Ernest M Kraus, BS RPH | Pharmacy

    Over many years I have seen many antibiotic prescriptions for viral infections where the patient is not a compromised host or elderly. It is a problem across all doctors' age groups. How does this change? Too many multiple antibiotic resistant bacteria. The medical community needs education.

    Telemedicine and antibiotics
    James Garrett, MD | Private Practice
    In my private practice and in staffing urgent care in our clinic, I have had multiple patients come in because they are not improving. They tell me they are on antibiotics for Strep or bronchitis given by a telemedicine doctor that their insurance company refers them to. The telemedicine doctor dose no testing for Strep -- tells patient their history sounds like Strep so prescribes an antibiotic. The same insurance company will tell me, in private practice, that prescribing antibiotics for bronchitis is not indicated unless the patient has a secondary disease which would be an indication for such a prescription. But the insurer allows its contracted telemedicine doctor to prescribe antibiotics for bronchitis. One mother brought her child in for possible Strep. He tested positive so was started on antibiotics. She then informed me that he has had Strep six times in the past six months so asked if he needed his tonsils removed. She also informed me on questioning that four of these Strep diagnoses were by telemedicine doctors who did no testing or a physical exam.

    Maybe studies on unwarranted antibiotic prescriptions from telemedicine physicians would be another area of research.

    Retail Clinics are Antibiotic Stewards: Reflecting on the study be Palms et al, and the commentary by Incze et al
    MarcDavid Munk, MD, MPH, MHCM, FACEP | Chief Medical Officer, CVS MinuteClinic
    It is disappointing that the authors of the commentary on the Research Letter from Palms et al failed to acknowledge the limitations of the original retrospective claims analysis and, in fact, represented the data to suggest that retail clinics perform poorly compared to other sites of care when it comes to antibiotic stewardship. Worse, the authors accuse retail and urgent care clinics of having financial motivations that undergird their antibiotic prescribing practices.

    In their study, Palms et.al. clearly distinguished retail and urgent care clinics, and stated that: “among visits for antibiotic-inappropriate respiratory diagnoses, antibiotic prescribing was
    highest in urgent care centers (45.7%; n = 201 682), followed by EDs (24.6%; n = 63 189), medical offices (17.0%; n = 1 563 573), and retail clinics (14.4%; n = 1444)”

    How to explain, then, this sentence In the commentary: “In this issue of JAMA Internal Medicine, Palms et al uncover an underrecognized source of inappropriate antibiotic prescribing—urgent care and retail clinics?”

    What does seem to have been uncovered is the following:

    1) Retail clinics consistently treat conditions where antibiotics are “always” appropriate with greater fidelity than other sites of care. Retail clinics treated 86.5% of patients with UTI, and 91.3% of patients with pneumonia, significantly more than elsewhere.

    2) Pharyngitis was treated with antibiotics in roughly the same proportion as primary care and emergency departments. Since, at least at  MinuteClinic retail clinics, we always test with point of care labs before initiating treatment, it’s likely that variation reflects a higher incidence of streptococcus pharyngitis.

    3) Retail clinics treated patients with otitis media with antibiotics more frequently than patients seen in medical offices (85.5% for retail clinics versus 79.5% for medical offices). We have no idea of the age of patients, and whether a “wait and see” approach was safe. It’s likely that a more episodic population of patients are riskier candidates for a delayed antibiotic strategy.

    4) Retail clinics treated 10.5% of patients with URI with antibiotics. Similarly 31.1% of patients with bronchitis received antibiotics; both percentages were lower than all other sites of care.

    When a widely diverse population of US ambulatory care providers are bucketed into four groups by location of service, variations in antibiotic prescribing can be due to bias and confounders independent of the site of service. One of these is the resources available to the prescribing clinician, which may explain why larger retail clinics may fare well in this analysis.

    One example is MinuteClinic, which is the largest provider of convenience care clinics in the United States. We have an extensive clinical support team that oversees, among other efforts, our antibiotic stewardship program. Other features of MinuteClinic are care guidelines, education, and ongoing monitoring, 

    It’s certainly premature to attribute financial incentives as the cause of prescribing variation. The study by Palms et al was in no way designed to answer this question.

    The subject of variability in antibiotic prescribing will require further, more nuanced and granular investigation before anyone can call out entire sectors of the ambulatory environment as an expensive burden to the healthcare system.
    CONFLICT OF INTEREST: Chief Medical Officer of CVS MinuteClinic, a retail clinic provider
    Agree that Retail Clinics Mischaracterized in Op Ed
    BRUCE QUINN, MD PhD | Physician Federal Policy Expert
    I agree with the remark of another commenter that retail clinics were mischaracterized in the commentary. Urgent care clinics had the highest (apparently) inappropriate prescribing, and retail clinics (e.g. CVS) among the lowest. Therefore, a summary statement that "urgent care and retail clinics" were found to be most worrisome, is incorrect relative to the data.