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Dvorin EL, Lamb MC, Monlezun DJ, Boese AC, Bazzano LA, Price-Haywood EG. High Frequency of Systemic Corticosteroid Use for Acute Respiratory Tract Illnesses in Ambulatory Settings. JAMA Intern Med. 2018;178(6):852–854. doi:10.1001/jamainternmed.2018.0103
Clinical practice guidelines do not recommend systemic steroids in the treatment of acute respiratory tract infections (ARTIs).1 While some studies have shown earlier symptom resolution with steroids given for pharyngitis,2 clinical trials show no efficacy of systemic steroids for sinusitis3 and bronchitis.4 Adverse events can develop within 30 days of short-term steroid use, which raises concern about the safety of systemic steroids for ARTIs.5 We conducted the present study to examine the frequency of steroid use for ARTIs in Louisiana and nationally and to examine factors associated with this clinical practice.
We conducted a retrospective observational study of adults who had outpatient ambulatory care encounters that included an ARTI diagnosis (otitis, upper respiratory infection, sinusitis, pharyngitis, bronchitis, allergic rhinitis, influenza, and pneumonia) through Ochsner Health System primary care clinics in 2014 (“Health System”) and as reported in the National Ambulatory Medical Care Survey (NAMCS) in 2012 to 2013. Asthma and chronic obstructive pulmonary disease (COPD) encounter diagnoses were not considered inclusion criteria to minimize encounters for patients with exacerbations of these chronic diseases, which may be appropriately treated with steroids. Protocols for the health plan and health system analyses were reviewed by the Ochsner institutional review board and determined to be exempt based on federal regulations for human subjects research. Patient consent was deemed unnecessary for this retrospective observational study of adults.
The main outcome for Health System analysis was steroid injection and for NAMCS analysis was steroid prescription. We chose steroid injection usage because we anecdotally observed that this was common practice in the Southeast United States. The NAMCS database does not query for intramuscular injections used in outpatient encounters; for this reason, we chose systemic oral steroid prescriptions. The covariates of interest included patient-, health care professional–, and encounter-specific factors. We conducted propensity score–adjusted, fixed-effects, and multivariable logistic regression analyses. Statistical significance was set at P < .05. All analyses were conducted using Stata statistical software (version 14.2; StataCorp).
Almost 11% of adult outpatient encounters for ARTI included a steroid prescription. There was a significant regional variation in prescribing steroids for ARTI diagnoses, from a 13.6% prevalence in the South to a 8.3% prevalence in the Midwest (Table 1). In multivariate analysis, there were significantly higher odds for steroid prescriptions among patients’ with a medical history of COPD or asthma (odds ratio [OR], 2.62; 95% CI, 2.24-3.06), visit diagnosis of bronchitis (OR, 1.73; 95% CI, 1.22-2.46), and an encounter with a nurse practitioner (NP) (OR, 1.65; 95% CI, 0.79-3.42) or physician assistant (PA) (OR, 1.74; 95% CI, 0.98-3.06) (Table 1).
Twenty-three percent of adult primary care encounters for ARTI in the Health System included steroid injections (Table 2). In multivariate analysis, odds for steroid injection were significantly higher among patients with a medical history of COPD (OR, 1.47; 95% CI, 1.31-1.64); visit diagnoses of sinusitis or otitis (OR, 2.10; 95% CI, 1.89-2.33), allergic rhinitis (OR, 1.42; 95% CI, 1.30-1.56), upper respiratory infection (OR, 1.17; 95% CI, 1.05-1.30), or bronchitis (OR, 1.82; 95% CI, 1.67-1.99); and encounters with a NP (OR, 1.61; 95% CI, 1.53-1.71). Odds for steroid injection were lower among encounters with patients who were nonwhite (eg, African American [OR, 0.88; 95% CI, 0.83-0.93], or Medicaid or Medicare insured [OR, 0.80; 95% CI, 0.68-0.95 and 0.75; 95% CI, 0.69-0.81, respectively]), had medical history of diabetes (OR, 0.73; 95% CI, 0.67-0.79) and/or osteoporosis (OR, 0.88; 95% CI, 0.79-0.98), had been seen by a PA (OR, 0.78; 95% CI, 0.71-0.86), and with a visit diagnosis of pneumonia (OR, 0.55; 95% CI, 0.46-0.64) (Table 2). We observed substantial clinician variation with 17% never using steroid injections and 13% of clinicians using an injection more than 40% of the time (data not shown).
Adverse effects of systemic steroids, even for short-term use, are well documented. Future research is needed to further explore regional and national trends in use of corticosteroids for patients with ARTIs, as it likely represents high-cost, potentially harmful care. This study revealed high rates of systemic corticosteroid use among patients with ARTIs in Louisiana and nationally. Study limitations include possible inclusion of encounters for exacerbation of chronic respiratory illnesses such as asthma or COPD and discordance in corticosteroid outcomes measured (injection vs oral). This hypothesis-generating study highlights the need to further examine use of systemic corticosteroid for ARTIs and associated safety issues.
Corresponding Author: Evan L. Dvorin, MD, Center for Primary Care and Wellness, Ochsner Health System, 1401 Jefferson Hwy, New Orleans, LA 70121 (firstname.lastname@example.org).
Accepted for Publication: January 8, 2018.
Published Online: February 26, 2018. doi:10.1001/jamainternmed.2018.0103
Author Contributions: Dr Dvorin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Dvorin, Bazzano, Price-Haywood.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: Dvorin, Bazzano, and Price-Haywood.
Statistical analysis: Dvorin, Monlezun, Boese, Bazzano, Price-Haywood.
Administrative, technical, or material support: Dvorin, Price-Haywood.
Study supervision: Dvorin, Bazzano, Price-Haywood.
Conflict of Interest Disclosures: None reported.