Antibiotic resistance is one of the most pressing public health challenges of our time. The overuse and misuse of antibiotics have led to the emergence of resistant bacteria, making infections harder to treat and increasing morbidity and mortality worldwide. In the United States, older adults are particularly vulnerable to the consequences of antibiotic resistance, as they are more likely to receive antibiotics than younger individuals. Understanding the factors that influence antibiotic prescribing patterns among healthcare providers is crucial for developing effective stewardship interventions.
A recent study published in JAC-Antimicrobial Resistance (https://academic.oup.com/jacamr/article/6/6/dlae191/7907358) sought to explore whether there is a relationship between the ranking of a provider’s medical school and their antibiotic prescribing rates among Medicare Part D beneficiaries. The study analyzed data from over 197,000 providers across the United States to determine if graduating from a higher-ranked medical school was associated with lower antibiotic prescription rates. The findings of this study provide valuable insights into the factors that influence antibiotic prescribing and highlight areas where stewardship efforts can be improved.
Background: The Problem of Antibiotic Overprescription
Antibiotic resistance is a growing global threat. The Centers for Disease Control and Prevention (CDC) estimates that over 2.8 million people in the U.S. develop antibiotic-resistant infections each year, resulting in more than 35,000 deaths. Additionally, Clostridioides difficile infections, which are often linked to antibiotic use, cause nearly 223,000 cases and 12,800 deaths annually. If current trends continue, it is projected that by 2050, antibiotic resistance could lead to 10 million deaths worldwide each year.
Older adults are particularly at risk. Patients aged 65 and older are 50% more likely to receive antibiotics than younger individuals, and they are also more susceptible to the adverse effects of antibiotic use, including C. difficile infections and drug interactions. Outpatient antibiotic overprescription is a significant contributor to antibiotic resistance, and studies have shown that prescribing patterns vary widely by region and provider specialty. For example, a CDC study found that while only 36% of all prescribers are located in the U.S. South, this region accounted for 48% of the highest-volume prescribers. Similarly, Family Medicine (FM) and Internal Medicine (IM) providers, who represent only 25% of all prescribers, made up 52% of the highest-volume prescribers.
The Role of Medical School Education in Antibiotic Stewardship
Given the variability in antibiotic prescribing patterns, researchers have sought to understand the behavioral and educational factors that influence provider decisions. Previous studies have shown that provider characteristics such as age, gender, years of experience, and specialty can impact antibiotic use. However, the role of medical school education, particularly the ranking of the medical school, has not been thoroughly explored.
Medical schools in the U.S. vary widely in their approach to antimicrobial stewardship (AS) training. Some schools have adopted comprehensive, evidence-based curricula, while others offer limited instruction. This variability in training could lead to differences in prescribing behaviors among graduates. For example, a study by Schnell et al. found that graduates of higher-ranked medical schools had lower opioid prescription rates compared to those from lower-ranked schools. However, no prior study had examined whether a similar relationship exists for antibiotic prescriptions.
The study hypothesized that providers who graduated from higher-ranked medical schools would have lower antibiotic prescription rates due to potentially stronger training in AS, using data from five repositories: (1) Medicare Part D Prescribers by provider data (2013–2021), (2) Medicare Part D Prescribers by provider and drug data (2013–2021), (3) the Doctor and Clinicians National dataset (2017–2023), (4) the 2023 teaching hospital repository, and (5) the 2023–2024 U.S. News Best Medical School for Research rankings. The researchers included providers in specialties such as Family Medicine, Internal Medicine, Emergency Medicine, Hospitalists, Nurse Practitioners (NPs), Physician Assistants (PAs), and students. Providers from U.S. territories or overseas were excluded due to smaller populations.
The primary outcome of the study was the rate of antibiotic days supplied per 100 beneficiaries at the provider level. Secondary outcomes included antibiotic claims per 100 beneficiaries, days per claim, and antibiotic cost per 100 beneficiaries. The study controlled for various covariates, including provider gender, specialty, years of experience, teaching location, metropolitan area, and patient characteristics such as age, race, and health risk score.
Key Findings
The study analyzed data from 197,540 providers and found no significant association between medical school ranking and the rate of antibiotic days supplied per 100 beneficiaries. This suggests that graduating from a higher-ranked medical school does not necessarily lead to lower antibiotic prescription rates. Instead, the study found that other factors, such as provider type, experience, and location, were more strongly associated with prescribing patterns.
- Provider Type: Hospitalists and Emergency Medicine providers had fewer days supplied per 100 beneficiaries compared to Family Medicine providers. In contrast, students, more experienced providers (those with over 20 years of experience), and female providers had higher rates of antibiotic days supplied.
- Geographic Variation: The study found regional differences in antibiotic prescribing, with the South and Midwest having higher rates of antibiotic days supplied compared to the Northeast and West. Nebraska had the highest rate of antibiotic days supplied (449.0 days per 100 beneficiaries), while Maine had the lowest (264.3 days per 100 beneficiaries), see Figure 1.
- Trends Over Time: There was a general downtrend in antibiotic days supplied per 100 beneficiaries between 2013 and 2021, driven mainly by a decrease in the claims rate per 100 beneficiaries. However, the number of days per claim increased during this period, suggesting that while providers were prescribing antibiotics less frequently, they were prescribing longer courses when they did.
Figure 2 illustrates the trends in antibiotic days supplied per 100 beneficiaries by provider type. Hospitalists and Emergency Medicine providers consistently had lower rates compared to Family Medicine providers.
- Costs: The cost of antibiotics per 100 beneficiaries increased after 2018, likely due to the introduction of new brand-name antibiotics and rising prices of generics.
The findings of this study have important implications for antibiotic stewardship efforts. While the study did not find a significant relationship between medical school ranking and antibiotic prescribing rates, it highlighted other factors that influence prescribing patterns. For example, the higher prescription rates among students and more experienced providers suggest that targeted stewardship interventions could be beneficial for these groups.
While many hospitals have implemented AS programs, outpatient settings have received less attention. The CDC’s Core Elements of Outpatient Antibiotic Stewardship, published in 2016, and the Joint Commission’s requirements for AS in ambulatory healthcare, effective in 2020, are steps in the right direction. However, more needs to be done to ensure that these programs are effectively reducing inappropriate antibiotic use.
Conclusion
This study provides valuable insights into the factors that influence antibiotic prescribing patterns among Medicare Part D providers. While medical school ranking was not found to be a significant factor, the study highlighted the importance of provider type, experience, and geographic location in shaping prescribing behaviors. These findings underscore the need for targeted stewardship interventions, particularly in outpatient settings, and the importance of incorporating outcome-based approaches into medical school curricula.
As antibiotic resistance continues to pose a significant threat to public health, it is crucial that healthcare providers, policymakers, and educators work together to promote the responsible use of antibiotics. By addressing the factors that contribute to overprescription, we can help ensure that antibiotics remain effective for future generations. However, the fight against antibiotic resistance is not just the responsibility of healthcare professionals; it is a collective effort that requires the involvement of patients, communities, and policymakers. One of the key takeaways from this study is the importance of education and training in shaping prescribing behaviors. While the ranking of a medical school did not significantly impact antibiotic prescription rates, the study suggests that there is still room for improvement in how medical schools teach antimicrobial stewardship (AS). Medical education should not only focus on the science of antibiotics but also on the practical aspects of when and how to prescribe them responsibly. This includes understanding the risks of overprescription, the importance of adhering to guidelines, and the long-term consequences of antibiotic resistance. By integrating these principles into medical school curricula, we can better prepare future healthcare providers to make informed decisions about antibiotic use.
Another important finding is the variation in prescribing patterns based on provider type and experience. For example, the study found that hospitalists and emergency medicine providers prescribed fewer antibiotics compared to family medicine providers. This could be due to differences in patient populations, clinical settings, or the nature of the conditions being treated. On the other hand, students and more experienced providers had higher prescription rates, suggesting that there may be gaps in training or awareness among these groups. Targeted interventions, such as continuing education programs or mentorship opportunities, could help address these disparities and promote more responsible prescribing practices. Geographic location also played a significant role in antibiotic prescribing, with higher rates observed in the South and Midwest compared to the Northeast and West. This regional variation could be influenced by factors such as local healthcare practices, patient expectations, or even cultural attitudes toward antibiotics. Public health campaigns that raise awareness about the dangers of antibiotic resistance and the importance of appropriate antibiotic use could help bridge these regional gaps. Additionally, policymakers could consider implementing region-specific guidelines