Prevalence and appropriateness of in-person versus not-in-person ambulatory antibiotic prescribing in an integrated academic health system: A cohort study

Objectives Ambulatory antibiotic stewardship generally aims to address the appropriateness of antibiotics prescribed at in-person visits. The prevalence and appropriateness of antibiotics prescribed outside of in-person visits is poorly studied. Design and setting Retrospective cohort study of all ambulatory antibiotic prescribing in an integrated health delivery system in the United States. Participants Antibiotic prescribers and patients receiving oral antibiotic prescriptions between January 2016 and December 2019. Main outcome measures Proportion of antibiotics prescribed with in-person visits or not-in-person encounters (e.g., telephone, refills). Proportion of prescriptions in in 5 mutually exclusive appropriateness groups: 1) chronic antibiotic use; 2) antibiotic-appropriate; 3) potentially antibiotic-appropriate; 4) non-antibiotic-appropriate; and 5) not associated with a diagnosis. Results Over the 4-year study period, there were 714,057 antibiotic prescriptions ordered for 348,739 unique patients by 2,391 clinicians in 467 clinics. Patients had a mean age of 41 years old, were 61% female, and 78% White. Clinicians were 58% women; 78% physicians; and were 42% primary care, 39% medical specialists, and 12% surgical specialists. Overall, 81% of antibiotics were prescribed with in-person visits and 19% without in-person visits. The most common not-in-person encounter types were telephone (10%), orders only (5%), and refill encounters (3%). Of all antibiotic prescriptions, 16% were for chronic use, 15% were antibiotic-appropriate, 39% were potentially antibiotic-appropriate, 22% were non-antibiotic-appropriate, and 8% were not associated with a diagnosis. Antibiotics prescribed in not-in-person encounters were more likely to be chronic (20% versus 15%); less likely to be associated with appropriate or potentially appropriate diagnoses (30% versus 59%) or non-antibiotic-appropriate diagnoses (8% versus 25%); and more likely to be associated with no diagnosis (42% versus <1%). Conclusions Ambulatory stewardship interventions that focus only on in-person visits may miss a large proportion of antibiotic prescribing, inappropriate prescribing, and antibiotics prescribed in the absence of any diagnosis.