Urgent care centers lead the way in unneeded antibiotic prescribing

The Pediatric Insider

© 2018 Roy Benaroch, MD

Urgent care centers are way ahead in prescribing unnecessary, potentially harmful antibiotics that are doing no one any good – at least no patients any good. The owners of the urgent care centers are the ones who are benefitting. And you and your family are being bilked, misled, and harmed.

A July, 2018 study published in JAMA Internal Medicine looked at the proportion of antibiotic prescriptions that were made for viral respiratory infections – things like the common cold and bronchitis. These are viral infections, caused by viruses (sorry if I’m hammering that too much – but obviously it bears repeating.) The researchers looked at over 150 million visits to emergency departments, urgent care centers, retail pharmacy clinics, and medical office visits to compare the rates of inappropriate prescribing between these settings.

Why is this important? Because antibiotics will not help anyone who has a viral infection. But they can lead to allergic reactions and serious complications like C. difficile colitis. They also contribute to antibiotic resistance, or the emergence of so-called “superbugs” that we can’t kill with any antibiotics. This is not just a theoretical problem – it’s a huge a growing nightmare occurring in hospitals all over the world. Some bacteria have figured out how to evade all of our antibiotics, and it’s entirely our fault.

Big differences were found in the rates of inappropriate antibiotic prescriptions. In ordinary medical offices, 17% of respiratory viral infections were treated with antibiotics. That’s way too high, and we need to work on that. But even worse: emergency departments prescribed antibiotics for about 25% of these viral infections. And topping the list was urgent care centers, where 46% of viral respiratory infections were treated with antibiotics. That’s about three times as bad as regular office visits.

The best prescribing habits – and they deserve credit for this – was found at the retail pharmacy clinics, at about 14%. They often use protocol-driven clinical pathways which leave little “wiggle room” for the nurse practitioners that usually are on staff. I’ve been critical of these quick-minute-clinics before, and I still don’t think they’re a good place for children to be seen, but give them credit for not throwing around antibiotics.

But those urgent care centers – why are they so quick to write for an unneeded and potentially harmful antibiotic? Though this study didn’t look at potential reasons, one potential driver may be profit. Urgent cares may be especially quick to write antibiotics because they make more money that way.

Some urgent care centers sell the antibiotics (and other medicines) that are prescribed, so there’s a direct profit there. But more commonly, antibiotics are prescribed because it’s a quick way to give patient what they want, to get them out the door so the next patient can be seen. It takes much more time to explain why an antibiotic isn’t needed than it takes to write the prescription. And writing that prescription seems to feed a cycle of dependence – now, the patient thinks every cough needs an antibiotic. Repeat business!

It’s not just antibiotics that fly off the shelves at urgent care centers. They make money from lab tests and x-rays, too. I spoke with one urgent care center physician who had this to say:

Our pay was a small base compensation and all the rest was a percentage of our billing. The more patients you saw, and the more lab, x-ray and meds you ordered, the more you got paid. Plain and simple. So not only was prescribing an antibiotic lucrative, not wasting time explaining why was also lucrative.

Now, many urgent care physicians are good doctors who genuinely want to help people. And it’s convenient to have them nearby for quick visits. But their employees may be under financial pressure to over-prescribe and over-test – and that can affect the care that you get.

How can you protect yourself?

  • Tell the physician, plainly, that you don’t want an antibiotic if it’s not needed. The doctor may be assuming incorrectly that everyone wants a prescription. Tell her that’s not the case.
  • Have reasonable expectations about ordinary illnesses. Coughs and cold symptoms rarely need antibiotics, even when they make you feel miserable. Most sore throats are caused by viral infections. We know you want to return to work and feel better, but an antibiotic isn’t going to help.
  • Use your primary care physician’s office as your main site of care. Get to know your doctors, and let them get to know you as someone who isn’t there just to get a prescription. If your own doctor is one of those that’s quick to prescribe, think about why that might be the case, and think about getting a new doctor.
  • Prevention is key! Wash your hands, stay away from sick people, get a good night’s sleep, and get all recommended vaccines. Remember, immunizations are the real immune boosters.

Earlier:

Keeping the world safe from antibiotics

Fighting back the superbugs

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6 Comments on “Urgent care centers lead the way in unneeded antibiotic prescribing”

  1. wzrd1 Says:

    The last time I was looking for a new doctor (it was right after we relocated halfway across the country), I perused several physician rating websites looking specifically for those who complained that doctor didn’t prescribe antibiotics for a head cold.
    I narrowed my search down from there.

    We’ve since relocated again, back to our home state, albeit near the middle of the state. Looking for the same signs doesn’t seem to be working.
    Oh well, I guess we’ll have to try a few on for size and see who fits.
    Offering an antibiotic for a viral infection is the fastest way to lose this patient! The second fastest, not listening or ignoring, the third, overprescribing.

    Like

  2. Mama J Says:

    Excellent insight, thank you. We just got back from a vacation to DC. My 9 year old developed a pretty significant sore throat in the middle of our visit. He is prone to strep. I took him to a nearby CVS Minute Clinic and was seen promptly by a NP. I was so pleasantly surprised by her thorough history taking and clinical exam and her kind compassionate demeanor with my son. The rapid test came back negative. Because we were out of town and were going to be driving back within a couple of days, I asked if she could call in an RX for abx that I could have on hand in case the culture came back positive in a couple days. She said she could not do that as clinical findings do not support abx at this time, that his sore throat was likely viral or irritation from post nasal drip from his allergies and she gave me pointers/natural/OTC remedies on treating his sore throat. She said if the culture were positive, they would call me and find the nearest CVS where I was driving and I could pick it up there.

    I was very impressed that this wasn’t an abx factory and that she took so much time to examine and discuss my child’s treatment and why needless abx we’re harmful. I knew about that already from my travels though healthcare as a Mom and patient, but she didn’t know what I knew, and I was quite impressed by her patience and willingness to explain.

    In contrast, I went to an UC the day before we left for vacation because I felt my own bronchitis coming on, and after also a very thorough exam, the doc went ahead and Rx abx for me by request as I explained that I didn’t want to have to go somewhere random if it got way way worse. She also gave me steroids and an inhaler which I really wound up needing but I never took the abx because it never got that bad….. But she had no problem prescribing it for me.

    So I just lived an example of what you wrote above!

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  3. Missy Says:

    Hi
    I completely agree reference the overprescribing of antibiotics however I have been a nurse in Urgent Care for 13 years and I think the reason for is much more complicated than profit. Many patients receive antibiotics because of comorbidities or to cover atypical with respiratory infections. With throat infections some providers prescribe antibiotics even if strep is negative because of exam or potential of infection by other bacteria other than strep. I feel the thought of missing a bacterial infection is more unsettling tomthe providers. All the providers I work with are hard workers and attentive to giving great care. Closely looking at patterns for each provider and reviewing them may be helpful. Many of the patients we see do not have a PCP and it takes months to get one in this area so close follow up for some of the more fragile or compromised patients can be difficult.
    Just some other thoughts on the why aspect??
    I

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  4. wzrd1 Says:

    Missy, there are significant differences between Urgent Care centers and “family doctor” offices.
    Not the least of which is physician familiarity with the patient, as heaven knows who is on staff at appointment time and many Urgent Care centers discourage single physician to patient matching.
    The side effect is, a physician won’t have a memory of the patient and reminder of their condition(s) and minimal (read, nearly no) time to review the history.
    That frequently results in a lowest common denominator situation and the easiest path out, resulting in inflammation being viewed as a bacterial infection sign (not necessarily) and the anticipated RX for an antibiotic.
    I’ll add, based upon a small number of experiences in such centers, I was left with a desire to remain away from them. “The road to hell is paved with good intentions”, where absent knowledgeable skill, isn’t a very smoothly paved road. One Urgent Care Center had a physician who was billed as a “pediatrician”, but never heard of pediaprofen, which had been available for half a decade. Casual conversation to probe current (read within a decade) medical knowledge came up equally lacking. How he managed to retain his medical license when he obviously lacked CE units is beyond me! Indeed, frightened me!!
    To the point where, having seen doctors selling vaccination exceptions online, questioning self-policing of the medical licensee ranks.

    Full disclosure, I am not a physician. I’m now a retired Special Forces medic. I was fully qualified to commit certain major surgical acts (I say commit for a reason, in a clinic or hospital, it’d be perform, where a sterile field is entirely absent, you’re committing surgery and hoping antibiotics prevent infection that is more dire than the initial disease or injury) and other advanced medical tasks that are never assigned to non-professional staff in the civilian world. I carried and utilized drugs that would give most medical professionals a panic attack. I’ve likely digitally intubated casualties in the field due to equipment damage or malfunction at least 50 times, several hundred times with an operational laryngoscope. Brachial artery anastomosis? Did it, evacuation impossible for at least 16 hours. Amazed when the vascular surgeon pronounced it good. I actually reviewed the surgical notes, thinking he was trying to make me feel good!
    Called in for and received an epidemiological team to assist in a simultaneous epidemic of measles and polio. I still have nightmares from those villages, but the epidemiologists did wonders and managed to plot a way to get in front of the damnable scourges.
    So, suffice it to say, my medical knowledge is quite good. I’m also infamous for in depth pharmaceutical effects and modes of action discussions with pharmacologists.
    And pharmacists always loved my prescriptions. Using the generic name, precise dosage, zero errors.
    But then, in the latter instance, doctor would’ve hit me over the head with my 50 pound medical bag if I did make an error. 😉

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  5. lynnawiensmd Says:

    Nice post and I agree with your comments. Unfortunately, many patients come in to the office requesting antibiotics and in fact, I’ve had patients request an antibiotic by name. Sigh!

    Like

  6. wzrd1 Says:

    I’ve been known to suggest a family of antibiotic, such as a macrolide or a cephalosporin and listen to what doctor thinks would be better, pending any culture results.
    But, the need for one is somewhat rare, such as a dental infection, pending a dental visit.

    Like


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