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Letters

information will be important to allow patients to better an- 30% of antibiotic prescriptions in ambulatory care settings in
ticipate and plan their medical spending and to achieve a broad the United States from 2010 to 2011 were unnecessary. Inap-
impact on health care spending. propriate antibiotic prescribing also includes choosing an un-
necessarily broad spectrum antibiotic instead of an equally or
Anna D. Sinaiko, PhD, MPP more effective narrower spectrum alternative. Otitis media
Karen E. Joynt, MD, MPH (OM), sinusitis, and pharyngitis collectively account for nearly
Meredith B. Rosenthal, PhD one-third of all antibiotics prescribed in outpatient settings,2
Author Affiliations: Department of Health Policy and Management, Harvard T. and professional guidelines recommend narrow spectrum
H. Chan School of Public Health, Boston, Massachusetts (Sinaiko, Joynt, agents as first-line therapy for these conditions.2 Alterna-
Rosenthal); Cardiovascular Division, Brigham and Womens Hospital, Boston, tives to first-line therapy are indicated in selected circum-
Massachusetts (Joynt).
stances, including for patients with penicillin allergy or re-
Corresponding Author: Anna D. Sinaiko, PhD, MPP, Department of Health
Policy and Management, Harvard T. H. Chan School of Public Health, 677
cent treatment failure. Our objective was to measure the
Huntington Ave, Room 409, Boston, MA 02115 (asinaiko@hsph.harvard.edu). frequency with which first-line agents are prescribed for OM,
Published Online: October 24, 2016. doi:10.1001/jamainternmed.2016.6622 sinusitis, and pharyngitis.
Author Contributions: Dr Sinaiko 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 Methods | We identified antibiotic prescribing visits during
analysis. 2010 to 2011 for OM (only patients 19 years old), sinusitis,
Study concept and design: Sinaiko, Rosenthal.
Acquisition, analysis, or interpretation of data: Sinaiko, Joynt.
and pharyngitis using the National Ambulatory Medical
Drafting of the manuscript: Sinaiko. Care Survey (NAMCS), which samples office-based physi-
Critical revision of the manuscript for important intellectual content: Joynt, cians and the National Hospital Ambulatory Medical Care
Rosenthal.
Survey (NHAMCS), which samples hospital outpatient and
Statistical analysis: Sinaiko, Rosenthal.
Obtained funding: Sinaiko. emergency departments. The International Classification of
Conflict of Interest Disclosures: None reported. Diseases, Ninth Revision, Clinical Modification, codes were
Funding/Support: This work was supported by the Robert Wood Johnson
used to identify visits and assign diagnoses as described
Foundation (grant 71412). previously.2
Role of the Funder/Sponsor: The Robert Wood Johnson Foundation had no National guidelines recommend first-line antibiotic therapy
role in the design and conduct of the study; collection, management, analysis, for each condition: amoxicillin or amoxicillin with clavulanate
and interpretation of the data; preparation, review, or approval of the (alternative) for OM, amoxicillin or amoxicillin with clavula-
manuscript; and decision to submit the manuscript for publication.
nate for sinusitis, and penicillin or amoxicillin for pharyngitis.2
Previous Presentations: Some of the findings reported here were presented at
First-line therapy represents the initial recommended antibi-
the American Society of Health Economists Biannual meeting; June 14, 2016;
Philadelphia, Pennsylvania; and at the AcademyHealth Annual Research otics for treatment of patients without drug allergies, includ-
Meeting; June 27, 2016; Boston, Massachusetts. ing alternative therapy indicated for specific situations (eg,
Additional Contributions: We thank Chris Riedl, BS; Jessica Harris, MBA, MPP; amoxicillin-clavulanate for OM with concurrent conjunctivi-
Charity Boutte, MA; and others at Aetna for help accessing study data, and tis). First-line therapy would not apply to treated patients re-
Chapin White, PhD, for helpful comments on an earlier draft. They received no
compensation for such contributions. Harlan Pittell, BA, provided excellent turning for unplanned follow-up care with worsening symp-
research assistance; a portion of his salary was supported by the grant from the toms suggesting treatment failure.
Robert Wood Johnson Foundation that funded this work. For each condition, the primary outcome was the percent-
1. Government Accountability Office. Heath Care Transparency: Actions age of visits that received first-line antibiotics (stratified by age:
Needed to Improve Cost and Quality Information for Consumers. October 2014.
pediatric, 19 years, adult >19 years). All analyses were per-
http://www.gao.gov/assets/670/666572.pdf. Accessed February 15, 2015.
formed using Stata statistical software (version 12; Stata Corp).
2. Sinaiko AD, Rosenthal MB. Increased price transparency in health
carechallenges and potential effects. N Engl J Med. 2011;364(10):891-894.
Results | During 2010 to 2011, among visits where antibiotics
3. Robinson JC, Whaley C, Brown TT. Association of reference pricing for
diagnostic laboratory testing with changes in patient choices, prices, and total were prescribed, physician prescribing of first-line antibiot-
spending for diagnostic tests. JAMA Intern Med. 2016;176(9):1353-1359. ics ranged from a low of 37% (95% CI, 32%-43%) for adult
4. Whaley C, Schneider Chafen J, Pinkard S, et al. Association between patients with sinusitis and pharyngitis to a high of 67%
availability of health service prices and payments for these services. JAMA. (95% CI, 63%-71%) for pediatric patients with OM (Figure).
2014;312(16):1670-1676.
For all 3 conditions overall, use of first-line agents was 52%
5. Sinaiko AD, Rosenthal MB, Examining A. Healthcare price transparency tool:
(95% CI, 49%-55%). Physicians prescribed first-line thera-
who uses it and how they shop for care. Health Aff. 2016;35(4):662-670.
pies more commonly to pediatric patients than to adults
6. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use
with administrative data. Med Care. 1998;36(1):8-27. (P < .001 for sinusitis and pharyngitis). The most common
nonfirst-line antibiotic class prescribed was macrolides
(Figure).
Frequency of First-line Antibiotic Selection
Among US Ambulatory Care Visits for Otitis Media, Discussion | Collectively, physicians prescribed first-line rec-
Sinusitis, and Pharyngitis ommended antibiotics approximately half of the time dur-
The National Action Plan for Combating Antibiotic-Resistant ing visits for OM, sinusitis, and pharyngitis. Overuse of non
Bacteria set a goal of reducing inappropriate outpatient anti- first-line agents, especially macrolides, was higher for
biotic use by 50% by 2020.1 A recent study2 estimated at least adults than children. Available evidence suggests that 10%

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Letters

Figure. Percentage of Visits in Which Antibiotics Were Prescribed That Are First-line and NonFirst-line for Otitis Media, 2010-2011

Amoxicillin-penicillin
Amoxicillin-clavulanate
Macrolide
A Otitis media B Sinusitis C Pharyngitis
Broad cephalosporin
100 100 100
Fluoroquinolone
Others

75 75 75
Percentage

Percentage

Percentage
50 50 50

25 25 25

0 0 0
First-line NonFirst- First-line NonFirst- First-line NonFirst- First-line NonFirst- First-line NonFirst-
line line line line line
Pediatric Pediatric Adult Pediatric Adult

A, Otitis media. First-line: amoxicillin or amoxicillin-clavulanate. B, Sinusitis. First-line: amoxicillin or amoxicillin-clavulanate. C, Pharyngitis. Amoxicillin or penicillin.
Estimates were based on 1705 sampled visits for otitis media, 463 for pediatric sinusitis, 1223 for adult sinusitis, 1006 for pediatric pharyngitis and 830 for adult
pharyngitis. Broad cephalosporin includes second- and third-generation agents. Pediatric patients were defined as those 19 years or younger.

of the population report penicillin allergy3 and 10% of visits (Fleming-Dutra, Hicks); School of Medicine, University of California,
for sinusitis4 and OM result from failed first-line therapy,5 San Francisco, San Francisco (Shapiro); The Pew Charitable Trusts, Washington,
DC (Hyun).
suggesting that approximately 80% of visits for these diag-
Corresponding Author: Adam L. Hersh, MD, PhD, 295 Chipeta Way, Salt Lake
noses should be treated with first-line therapy.
City, UT 84108 (adam.hersh@hsc.utah.edu).
This study has limitations. It was not possible to con-
Published Online: October 24, 2016. doi:10.1001/jamainternmed.2016.6625
firm the presence of allergy or previous treatment history,
Author Contributions: Drs Hersh and Shapiro had full access to all the data in
factors that influence appropriate antibiotic selection.
the study and take responsibility for the integrity of the data and the accuracy
These data are from 2010 to 2011 but are the most recent of the data analysis.
complete data available from NAMCS/NHAMCS, and we do Concept and design: Hersh, Fleming-Dutra, Hyun, Hicks.
not have reason to believe practice patterns have substan- Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Hersh, Hicks.
tially changed.
Critical revision of the manuscript for important intellectual content: All authors.
This study provides evidence of substantial overuse of Statistical analysis: Hersh, Shapiro.
nonfirst-line antibiotics for 3 of the most common condi- Obtained funding: Hicks.
tions in ambulatory care that collectively account for more Administrative, technical, or material support: Fleming-Dutra, Hyun, Hicks.
Study supervision: Hersh, Hicks.
than 40 million antibiotic prescriptions annually.2 These
findings indicate that the problem of inappropriate antibi- Group Information: The Outpatient Antibiotic Use Target-Setting Workgroup
Collaborators were Monina Bartoces, PhD, Centers for Disease Control and
otic prescribing includes not only prescriptions that are Prevention (CDC), Atlanta, Georgia; Eva A. Enns, PhD, Division of Health Policy
unnecessary altogether, but also selection of inappropriate & Management, University of Minnesota, Minneapolis; Thomas M. File Jr, MD,
agents. 2 As a result, stewardship interventions should Summa Health System and Northeast Ohio Medical University, Akron; Jonathan
A. Finkelstein, MD, MPH, Boston Childrens Hospital and Harvard Medical
address both antibiotic overuse and inappropriate antibiotic
School, Boston, Massachusetts; Jeffrey S. Gerber, MD, PhD, Childrens Hospital
selection to improve patient safety and health care quality. of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia;
Implementation of stewardship strategies is a key compo- David Y. Hyun, MD, The Pew Charitable Trusts, Washington, DC; Jeffrey A.
nent to meeting the National Action Plan goal of reducing Linder, MD, MPH, Brigham and Womens Hospital and Harvard Medical School,
Boston, Massachusetts; Ruth Lynfield, MD, Minnesota Department of Health, St
inappropriate antibiotic use by 50% in outpatient settings.1 Paul; David J. Margolis, MD, PhD, University of Pennsylvania Perelman School of
Medicine, Philadelphia; Larissa S. May, MD, MSPH, Department of Emergency
Adam L. Hersh, MD, PhD Medicine, University of CaliforniaDavis, Sacramento; Daniel Merenstein, MD,
Katherine E. Fleming-Dutra, MD Department of Family Medicine, Georgetown University Medical Center,
Washington, DC; Joshua P. Metlay, MD, PhD, Division of General Internal
Daniel J. Shapiro, MD Medicine, Massachusetts General Hospital, Boston; Jason G. Newland, MD,
David Y. Hyun, MD MEd, Division of Pediatric Infectious Diseases, Washington University School of
Lauri A. Hicks, DO; Medicine, St Louis, Missouri; Jay F. Piccirillo, MD, Department of
OtolaryngologyHead and Neck Surgery, Washington University School of
for the Outpatient Antibiotic Use Target-Setting Workgroup
Medicine, St Louis, Missouri; Rebecca M. Roberts, MS, Centers for Disease
Control and Prevention, Atlanta, Georgia; Guillermo Sanchez, MPH, PA-C,
Author Affiliations: Pediatric Infectious Diseases, University of Utah, Salt Lake Centers for Disease Control and Prevention, Atlanta, Georgia; Katie J. Suda,
City (Hersh); Centers for Disease Control and Prevention, Atlanta, Georgia PharmD MS, Department of Veterans Affairs, University of Illinois at Chicago,

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Letters

Chicago; Ann Thomas, MD, MPH, Oregon Public Health Division, Portland; Teri
Moser Woo, PhD, Pacific Lutheran University, Tacoma, Washington; Rachel M.
Table 1. Characteristics of Participants
Zetts, The Pew Charitable Trusts, Washington, DC. Participants,
Conflict of Interest Disclosures: Dr Hersh has received funding from the CDC, Variable No. (%)a
the Agency for Healthcare Research and Quality, Pfizer/Joint Commission, and Sociodemographic characteristics
Merck. No other conflicts are reported. Age, y
Funding/Support: This project was made possible through a partnership with
65-74 719 (48.7)
the CDC Foundation. Support for this project was provided by Pew Charitable
Trusts. 75-84 831 (36.6)
Role of the Funder/Sponsor: The CDC participated in the design and conduct 85 465 (14.6)
of the study; collection, management, analysis, and interpretation of the data; Sex
preparation, review, or approval of the manuscript; and decision to submit the
manuscript for publication. The Pew Charitable Trusts participated in the Female 1154 (55.7)
interpretation of the data; preparation, review, or approval of the manuscript; Male 861 (44.3)
and decision to submit the manuscript for publication. The Pew Charitable
Race/ethnicity
Trusts sponsored in-person and telephone author meetings and supported
some author travel to in-person meetings. White 1380 (80.7)
Disclaimer: The findings and conclusions in this report are those of the authors Black/African American 451 (8.5)
and do not necessarily represent the official position of the CDC.
Hispanic/Latino 118 (6.8)
Additional Contributions: Tia Carter, MS, Allan Coukell, BSc Pharm, and
English-speaking 59 (50.9)
Elizabeth Jungman, JD, MPH, of The Pew Charitable Trusts assisted in
convening author meetings. They did not receive any compensation for their Spanish-speaking 59 (49.1)
role in the study.
Other 66 (3.9)
1. The White House. National action plan for combating antibiotic resistant
Education
bacteria. https://www.whitehouse.gov/sites/default/files/docs/national_action
_plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed August 3, 2015. High school diploma or less 1119 (51.4)
2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate Greater than high school 896 (48.6)
antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. Annual income,b $
2016;315(17):1864-1873.
<25 000 963 (41.2)
3. Joint Task Force on Practice Parameters; American Academy of Allergy,
Asthma and Immunology; American College of Allergy, Asthma and 25 000 1052 (58.8)
Immunology; Joint Council of Allergy, Asthma and Immunology. Drug allergy: an Health-related characteristics
updated practice parameter. Ann Allergy Asthma Immunol. 2010;105(4):259-273.
Self-rated health
4. Piccirillo JF, Mager DE, Frisse ME, Brophy RH, Goggin A. Impact of first-line
vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA. Excellent or very good 805 (45.4)
2001;286(15):1849-1856. Good 664 (31.3)
5. Capra AM, Lieu TA, Black SB, Shinefield HR, Martin KE, Klein JO. Costs of Fair or poor 546 (23.3)
otitis media in a managed care population. Pediatr Infect Dis J. 2000;19(4):
354-355. Dementiac
None 1502 (80.0)
Possible or probable dementia 513 (20.0)
Low Completion and Disparities in Advance Care Number of chronic medical conditions d

Planning Activities Among Older None 1032 (53.4)


Medicare Beneficiaries
1-2 723 (35.1)
Advance care planning (ACP) is an iterative process that in-
>2 260 (11.4)
cludes discussions about preferences for end-of-life (EOL) care,
completion of advance directives (AD), and designation of a Number of ADLs requiring helpe

surrogate decision maker in a durable power of attorney for 0 1559 (82.0)


health care (DPOA).1,2 Engagement in ACP has increased over 1 or 2 251 (10.5)
time.3 However, the rising tide of ACP may not have lifted all 3 205 (7.5)
boats equally. Minorities, those with lower levels of educa-
(continued)
tional attainment, and the poor may not have benefited from
rising rates of ACP to the same extent that white, highly edu-
cated, affluent individuals have. Rates of ACP by older Lati-
nos in particular are unknown. Further, we do not know if ACP
uptake is greater among those in worse health and with poorer participants who responded to a supplemental module on
prognoses. ACP fielded in 2012. This study was considered exempt by the
institutional review board of the University of California,
Methods | We used data from the National Health and Aging San Francisco.
Trends Study (NHATS), a longitudinal cohort study using a Outcome variables included 3 self-reported elements of
nationally representative sample of community-dwelling Medi- ACP: (1) discussing with any individual the medical treat-
care beneficiaries ages 65 years and older (2011 round 1 re- ment desired if seriously ill in the future (EOL discussion), (2)
sponse rate, 71%; 2012 round 2 response rate, 86%).4 This cross- having legal arrangements for a proxy to make decisions about
sectional analysis used a random one-third sample of 2015 medical care (DPOA), or (3) having written instructions about

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