About CERTs
Annual Report Year 4
CERTs Progress
Advancing Knowledge | Informing Providers and Patients | Improving the System | Referenced Projects
Informing Providers and Patients
Understanding the risks and benefits of medical therapies is a critical step to improving the safety and effectiveness of their use. Also critical is ensuring that medical therapies are used appropriately.
To address these situations, we are studying physician prescribing habits. As part of these studies, we aim to uncover any biases in prescribing patterns. We are also studying why some physicians are prescribing certain drugs more frequently than others. The CERTs are committed to informing both health care providers and patients about the results of our research in these important areas.
PREVENTING ANTIBIOTIC RESISTANCE 6,7,8
Throughout our four-year history, the CERTs have been concerned about the problem of antibiotic-resistant bacteria. In the 1940s, antibiotics became available to treat human diseases caused by bacteria. Unfortunately, the more antibiotics are used, the more opportunity bacteria have to become resistant to them. We are attempting to lower inappropriate antibiotic use by learning about the types of situations in which antibiotics are needlessly prescribed.
Antibiotics called fluoroquinolones treat a wide range of bacterial infections that include diarrhea, pneumonia, urinary tract infections, and bone infections. Fluoroquinolones also treat infections caused by the bioterrorism agent anthrax. With the increased use of fluoroquinolones, bacterial resistance to them has also increased. To learn more about whether fluoroquinolones are being used inappropriately, we studied their use in emergency departments at two hospitals. Of 100 patients who received fluoroquinolones, 81 received them outside of established guidelines. Of these 81 cases, 53% should have received a different antibiotic, 33% had no evidence of infection, and 14% were not fully evaluated before receiving treatment. Future studies should test ways to educate health care providers in emergency departments about using fluoroquinolone antibiotics less often.
New antibiotics have been created to fight resistant bacteria, but as use of these newer antibiotics increases, the same problems of resistance will arise. From a societal perspective, it would be best to use the newest antibiotics only when they are truly needed. However, this leaves health care providers with the dilemma of deciding when to prescribe newer antibiotics or when not to prescribe them to preserve their effectiveness. Many doctors believe they must choose between an individual patient's needs and the needs of the population.
We studied whether physicians are willing to use established antibiotics in the face of drug resistance to preserve newer antibiotics for future use. We found that in hypothetical situations, the decision to prescribe newer antibiotics is based on how sick a patient is. The sicker the patient, the more likely it is that a doctor will prescribe a newer antibiotic. This attitude is more prevalent among generalist physicians than infectious disease specialists. As physicians are being asked to follow guidelines that encourage reduced use of newer, broad antibiotics, the conflicts they face need to be considered. Unfortunately, most physician education programs do not address these issues. Because generalists and infectious disease specialists have different attitudes, educational programs should be tailored accordingly.
Our work has most often uncovered areas where antibiotics are prescribed too often. But antibiotic use has recently dropped in one area. Between 1996 and 2000, there was a significant drop in the number of antibiotics prescribed to children aged three months to 17 years. In previous years, from 1977 through the early 1990s, antibiotic use in children had increased. This increase coincided with more children being placed in group child care and more reports of ear infections, which are the most common cause of prescribing antibiotics to children.
In 1998, the Centers for Disease Control and Prevention, working with other national and state organizations, began to actively promote more judicious prescribing for children. Their efforts appear to have paid off. The drop in antibiotic prescriptions for children is encouraging and suggests that it is possible to effectively educate both health care providers and patients about the dangers of overusing antibiotics.
FINDING GAPS IN OSTEOPOROSIS TREATMENT 9,10
Approximately 10 million Americans have osteoporosis, a condition that leads to low bone mass and bone fragility. Bone fragility can cause fractures, disability, pain, deformity, and even death.
Fortunately, there are medicines that lower the risk of having a fracture. Unfortunately, people who need treatment do not always get it.
People with both osteoporosis and a fracture are 20 times more likely to have a future fracture than those who have neither osteoporosis nor a history of fracture. At least 80% to 90% of bone fractures in women past menopause are associated with osteoporosis. For these patients, getting treatment for osteoporosis is especially important. Yet recent studies suggest that physicians are missing opportunities to deliver treatment.
To explore this issue, we used databases from seven health maintenance organizations to examine how often physicians recommended treatment to women 60 years and older to prevent a second fracture. We found that the vast majority of these women did not receive treatment for osteoporosis in the year after they suffered a fracture.
This is not the only gap in osteoporosis care that we found. We surveyed 8,909 black and white women about the care they received for osteoporosis. The women were at least 50 years old and were participants in a health maintenance organization. Compared with white women, black women reported having fewer bone density tests and receiving less osteoporosis therapy. The difference was not fully explained by lifestyle or other health factors. Even black women who had fractures in the past received less care than white women.
Our study suggests that physicians are not taking needed steps to prevent and treat osteoporosis as readily in black women. This may be because black women are less likely than white women to have osteoporosis. But when black women do have fractures, they have more disability, longer hospital stays, and greater risk of death than white women do. Work is needed to find ways of making osteoporosis treatment available to all who need it.