Clinicians' Reasons for Non-Visit-Based, No-Infectious-Diagnosis-Documented Antibiotic Prescribing: A Sequential Mixed-Methods Study.

Among all ambulatory antibiotic prescriptions, about 20% are non-visit-based (ordered outside of an in-person clinical encounter), and about 30% are not associated with an infection-related diagnosis code. To identify the rationale for ambulatory antibiotic prescribing, we queried the electronic health record (EHR) of a single, large health system in the Midwest United States to identify all oral antibiotics prescribed from November 2018 to February 2019 and examined visit, procedure, lab, department, and diagnosis codes. For the remaining antibiotic prescriptions-mostly non-visit-based, no-infectious-diagnosis-documented-we randomly selected and manually reviewed the EHR to identify a prescribing rationale and, if none was present, surveyed prescribers for their rationale. During the study period, there were 47,619 antibiotic prescriptions from 1177 clinicians to 41,935 patients, of which 2608 (6%) were eligible non-visit-based, no-infectious-diagnosis-documented. We randomly selected 2298. There was a documented rationale for 2116 (92%) prescriptions. The most common documented reasons-not mutually exclusive-were patient-reported symptoms (71%), persistence of symptoms after initial management (18%), travel (17%), and responding to lab or imaging results (11%). We contacted 160 clinicians who did not document any prescribing rationale in the EHR and received responses from 62 (39%). Clinicians' stated reasons included upcoming or current patient travel (19%), the antibiotic was for the prescriber's own family member (19%), or the clinician made a diagnosis but did not document it in the EHR (18%). Non-visit-based, no-infectious-diagnosis-documented antibiotic prescriptions were most often in response to patient-reported symptoms, though they also occur for a variety of other reasons, some problematic, like in the absence of documentation or for a family member.