Racial Differences in Antibiotic Prescribing by Primary Care Pediatricians

Discussion

Our data from a large, diverse group of pediatric primary care practices demonstrates that, for individual clinicians, rates of both antibiotic prescribing and ARTI diagnoses varied by patient race. Compared with nonblack children, clinicians were 25% less likely to prescribe an antibiotic to a black child at an acute visit, which equated to 36% fewer antibiotic prescriptions per child per year. Further, clinicians were significantly less likely to diagnose common ARTIs in black children. When black children were prescribed antibiotics, they were less likely to receive a broad-spectrum agent than nonblack children with the same diagnosis seen by the same provider. Exploration of the causes of these differences is critical to ensure the judicious use of antibiotics for ARTIs, which account for the vast majority of antibiotic use in ambulatory pediatrics.⁷

Previous studies have identified differences in health care delivery by patient race in a variety of populations and settings,^1,2 including adult oncologic surgery,¹⁸ cardiac care,³ HIV treatment,¹⁹ and emergency department prescribing,²⁰ as well as pediatric leukemia,⁴ appendicitis,²¹ asthma care,²² and child abuse assessment.^23,24 Little is known, however, about disparities in diagnosis and treatment of simple and common pediatric conditions. Additionally, previous analyses were unable to isolate the impact of patient race on management decisions for illnesses of comparable severity within individual providers. Studies using national sampling data have reported lower rates of broad-spectrum antibiotic prescribing to black adults⁸ and a similar (but not significant) trend in children⁷ diagnosed with ARTIs in ambulatory settings, but these analysis were unable to compare prescribing by race within clinicians and had relatively limited clinical data available. Our study, however, isolates individual clinician decision-making, by comparing antibiotic prescribing and ARTI diagnosis rates between black and nonblack patients seen by the same clinician at the same practice in the same year, adjusted for patient-level factors that could be associated with the need for antibiotic use.

The difference in diagnosis rates of ARTIs and the associated need for antibiotics cannot be explained biologically. For example, although racial differences in the incidence of otitis media have been reported,^25,26 these findings were not based on within-clinician analyses. Similarly, the definitive, prospective study of otitis media revealed that, when objectively followed over time, black children developed otitis media at the same rate, if not more often, than white children.²⁷ In contrast, black children in our study were 21% less likely to receive a diagnosis of acute otitis media. Even more surprising, black children were 40% less likely to receive a diagnosis of streptococcal pharyngitis, a condition for which the case definition included laboratory testing. To our knowledge, there is neither a biological rationale nor epidemiologic evidence consistent with a lower incidence of streptococcal pharyngitis in black children.

We could not evaluate the drivers or effects of these differences. Although nonblack children attended more acute visits per year, we measured prescriptions and diagnoses per acute visit, which should adjust for this discrepancy. Also, black children did not have an increased rate of emergency department encounters. Finally, our population-based analysis revealed an even more profound difference in antibiotic prescribing, 36% fewer prescriptions per child per year, consistent with our findings that black children both attended fewer acute visits and, when presenting, received fewer antibiotics than nonblack children. Given the tight link between diagnosis and antibiotic prescribing, it is unclear from these data whether the diagnosis always drove antibiotic prescribing or, alternatively, whether the diagnosis of an ARTI was sometimes driven by the desire (and justification) for an antibiotic prescription.

The complex nature of the doctor-patient relationship might partially explain these observations. Differences in stated parental expectations (“My child needs antibiotics”), physician perception of parental expectations (“This parent is going to demand antibiotics”), or the use of shared decision-making (“Here are the options. Let’s decide together how to proceed.”²⁸) that correlate with patient race could account for some or most of the differential prescribing rates apparent in these analyses, consistent with previous reports.^9,29 Practitioner bias affecting medical decision-making by patient race and socioeconomic status has been described,^1,30 but its relevance to the diagnosis and treatment of ARTIs is unclear. Because overprescribing of antibiotics to children with ARTIs is common,^5–7 we hypothesize that this discrepancy reflects overprescribing, both for all antibiotics and for the relative proportion of broad-spectrum antibiotics, to nonblack patients, rather than underprescribing to black patients. Whether this represents a true health care disparity, however, remains uncertain, and future evaluation should include clinical outcomes, including treatment failure and adverse drug effects. The relatively subjective diagnosis (and subsequent treatment) and limited severity of illness of the ARTIs studied might facilitate such variable prescribing. Our study revealed no racial differences in diagnosis rates of urinary tract infection, a condition with more objective diagnostic criteria, or pneumonia, one with potentially more severe sequelae if left untreated.

This study had limitations. First, these results might not be generalizable. This network, however, included 222 clinicians serving 208 015 patients across urban, rural, and suburban settings in both academic and community practice environments, and results were consistent across these locations. Second, although data were extracted from an EHR by using ICD-codes to identify ARTIs, we used multifactorial case definitions (eg, streptococcal pharyngitis required an acute pharyngitis code, antibiotic receipt, and a positive laboratory test) to reduce misclassification, and case definitions were consistent across race categories. Third, we could not adjust for patient socioeconomic status, which is correlated with race; however, adjustment for insurance type did not affect the results. Fourth, although comparisons across individual practice groups revealed a consistent association between patient race and prescribing/diagnosis, we could not estimate variability in prescribing between individual practitioners because of a limitation in statistical power at this level of data. Last, unobserved factors might have influenced the relationship between patient race and antibiotic prescribing or diagnosis; however, selection differences were minimized by the within-clinician analyses, which controls for both physician characteristics and the racial composition of his or her practice, coupled with the broad scope of adjustments and exclusions.

In conclusion, compared with nonblack children managed by the same primary care pediatrician, black children received fewer overall antibiotic prescriptions, a lower rate of ARTI diagnoses, and, when receiving an antibiotic for an ARTI, a lower proportion of broad-spectrum antibiotic prescriptions. More research is needed to elucidate the factors that account for these differences, including parental preferences, provider perceptions of parental preferences, and implicit and unconscious biases of providers. A better understanding of these factors could inform interventions to help improve antibiotic use for all children.