"Nurse practitioners, physician assistants more frequently prescribe antibiotics"

[RURALMED]

http://www.healio.com/infectious-disease/practice-management/news/in-the-journals/%7B8bc10435-55bd-48d9-9764-07bb31383263%7D/nurse-practitioners-physician-assistants-more-frequently-prescribe-antibiotics

[sk732]

Hmmm...they didn't note if the scripts were in fact justifiable and if the variation in the number of visits resulting in said scripts were due to the fact they were seeing more people with these problems than the MD's.  Oddly enough, there are a bunch of papers out there saying that PA's and NP's are a bit more strict with their ABx scripts than MD's - maybe it's some whiny pushback.

 

SK

[True Anomaly]

Well, I sure as hell don't

[Reality Check 2]

My patients and even my doc say I am stingy with abx.

 

8 hrs of sniffles does not a sinus infx make......

[True Anomaly]

My patients and even my doc say I am stingy with abx.

 

8 hrs of sniffles does not a sinus infx make......

 

I've said it before on this forum, but what amazes me is when I see patients with isolated URI sx's who've seen a PA/NP or a doc and only are taking an antibiotic- and nothing else.  No cough suppressant, no decongestant, no mucolytic, no histamine blocker.  I send URI pt's home with a bevy of meds targeting whatever sx's they're having- and it's almost never including an antibiotic.  I truly don't understand how hard it is to write rx's for symptom control- especially when these meds have no abuse potential (I'm not writing for "sizzurp" and pseudo)

[HJK]

Whan then do you guy write for an abx? 7 day of symptoms? 2 weeks of symptoms? I am probably in between depending on comorbidities. Some patients just won't go without. Spending more time convincing then assessing.

[GetMeOuttaThisMess]

I use the sinusitis/bronchitis guidelines per the respective specialties. Check rhinosinusitis and bronchitis at Medscape for articles. That said, all my folks get a Rx for one sent to pharmacy so as to save them a PCP f/u co-pay since we're a "one and done clinic". I have taken these guidelines and compressed them to just a couple of sentences, in "English", and tell them not to fill Rx yet or at all unless they later meet criteria. We've found only 60% ever fill them. Same thing for STs. Hold off for a week to let resolve unless I tell them otherwise. I don't waste RSTs since not reliable and doesn't check for F. nec. which no one knows about in the non-med community. BTW, no culture capability in my setting.

[taotaox1]

When it comes to unless the patient meeting guidelines for ARBS you are do the patient and the community (and the next provider down the line who has to deal with the entitlement) a serious dis-service by writing abx, even in a "fill this later" fashion.   Even with high suspicion investigated by X-ray... only 1 in 15 get better any faster with antibiotics and 1 in 8 have an abx "harm".    Specific situations are one thing, (eg traveling in a few days, no way to for pt to follow up with anyone, history of abrs, comorbidites, etc) but it is usually pure laziness (dealing with patient tantrums), greed (good for the clinic to have return visits), or a misdirected sense of sympathy (Think they are actually helping) that drives this. There is a reason these medications are RX and to be honest we have been awful stewards of them.

 

Before you consider just giving out antibiotics to make a patient happy. Please consider the following:

 

https://www.cdc.gov/drugresistance/   - 23,000 DIE every year in the United States due to abx resistant bacteria

http://www.bmj.com/content/337/bmj.a1324 -  142 000 visits a year to hospital emergency departments in the United States due to antibiotic reactions.  

 

 

Atrovent Nasal, neti pot, cough suppressants, etc are your friends.  

[True Anomaly]

Whan then do you guy write for an abx? 7 day of symptoms? 2 weeks of symptoms? I am probably in between depending on comorbidities. Some patients just won't go without. Spending more time convincing then assessing.

 

I give at least a week of sx's, and it must include actual sinus tenderness.

 

And a patient insists they won't go without when I think it's unnecessary?  They can go find someone else to take care of them

[Reality Check 2]

The WHO says REAL sinus infx is 14 days, unilateral usually, fever, pain, purulence. My pts freak when I tell them this.

 

"I am NOT waiting that long." Arms across chest, tantrum starting.

 

Well - sudafed, nasal irrigation, mucinex, blow your damn nose, quit smoking, prop your head up, steam, coping...

 

I live with some form of nasal congestion 24/7 for the majority of my life due to allergies. I still manage to function highly and am just as responsible as the next guy for doing the above self management.

 

Patients need to be held accountable for their behaviors - or lack of - and we need to cave less on the rx's

[GetMeOuttaThisMess]

Don't forget "physics/geometry" instructions. Elevate head to put snot on pharynx for GI tract and to not impact respiratory tract. I've yet to see snot grow legs and jump up into airway nocturnally with HOB elevated. Save the best for last. Tell them to wave at their pantry honey bear container and squirt a mouthful h.s. to "tarp" over the pharynx to protect from acidic drainage tissue inflammation. Ever wonder why they awaken with ST/increased cough that improves throughout the day? Acidity of drainage. Look for the midline retro-uvula paint stripe and you've got your dx.. Don't like honey or allergic to bees? Squirt syrup instead. Both thick and sticky. Works great.

[sk732]

I'm a long time sinus sufferer - I'm a firm disbeliever in systemic decongestants simply because they thicken the snot and it doesn't move.  Sinus infections are drainage issues - encourage drainage and they go away for the most part.  The Neil Med rinse (and others) was greatest thing I've ever used frankly...even though it feels like I did a high level water entry without covering my nose.

 

I have little sticky notes with my name/credentials that I use as OTC scripts in the ER.  I used to have the huge CDC "You Have Been Diagnosed With A Viral Infection" checklist/Rx sheets when I was in family med for these situations.  If someone got their back up, I'd first tell them politely that they would not be getting an ABx Rx and if they said they weren't leaving without one, I'd politely tell they would be leaving, without their antibiotic script, whether in or out of handcuffs - option was their's, but they weren't getting any from me that visit. 

 

I was known as the "Antibiotic Nazi" - "No Drugs for you...Get out of my office!!"...well not that bad, but pretty close.

 

SK

[newton9686]

Antibiotic resistance is like global warming. There's not much we can do to make a dent in it. People want their z pacs and they are going to stomp their feet until they get em. Thank goddess some of our old drugs like doxicyclin is regaining sensitivity. I would say if primary care providers weren't charging 300 dollars for a visit, maybe their words would mean more.

[GetMeOuttaThisMess]

I always circle the sentence that <10% are bacterial to drive home the point. My statement also lists the four components that increase the likelihood of bacterial rhinosinusitis. There is a disagreement in the ENT community that while lessening sx.'s, antihistamines may prolong illness duration. Pick your poison, longer duration with lesser sx. or worse sx. for shorter duration.

[Reality Check 2]

Antibiotic resistance is like global warming. There's not much we can do to make a dent in it. People want their z pacs and they are going to stomp their feet until they get em. Thank goddess some of our old drugs like doxicyclin is regaining sensitivity. I would say if primary care providers weren't charging 300 dollars for a visit, maybe their words would mean more.

 

FP doesn't charge $300 per visit. A 99213 MIGHT get $47-67 depending on insurance and copay and coinsurance.

 

Building confidence with your patient in what you say and how you back it up with data is more important.

 

Not sure where you get your info but wildly incorrect

[rev ronin]

FP doesn't charge $300 per visit. A 99213 MIGHT get $47-67 depending on insurance and copay and coinsurance.

 

Building confidence with your patient in what you say and how you back it up with data is more important.

 

Not sure where you get your info but wildly incorrect

If they're getting azithromycin, that's "prescription drug management", therefore moderate risk, therefore 99214. 

 

And sure, while $47-67 is a reasonable range for what might actually be collected, billed for a 99214 is going to be closer to $150-200: Not $300 (at least, not without some labs), but significantly higher than what you cited. This is not just important for the uninsured, but also for the high deductible plan folks, who seem to be more and more common under Obamacare.

[Reality Check 2]

I just take great offense to anyone, much less another PA, criticizing FP - the least reimbursed and much under appreciated "specialty" since we kind of have to know something about everything and see cradle to grave and manage a lot of IM.

 

The overwhelming majority of my patients are not cash pay and at least 35% are some sort of state insurance. The state insured pay nothing - we take what the state gives us. Much the same with many Medicare plans.

 

Considering the neurosurgeon who saw a family member with a brain tumor publishes his rates at $2500 per hour...... I will stick with FP and do some good for my patients.

 

I am not in medicine for the money - and, if I was, I sure wouldn't have picked FP for the past umpteen years.

[Poetsiren]

Well - sudafed, nasal irrigation, mucinex, blow your damn nose, quit smoking, prop your head up, steam, coping...

 

THIS! LOL! Like a broken record in my head with patients!!

 

My sister-in-law refuses to believe that her 6yr old daughter has such bad allergies/drainage that she is vomiting from the excess of mucus. Automatically says "she's sick!" and sets her on the couch with a blanket and Netflix. She's also part of the whole hippy movement of vegan naturopathic blah blah blah..... despite this fact we get along surprisingly well and have a truly wonderful sisterly relationship! (She got her CNA license before she had kids. She also doesn't restrict the rest of her family to the whole vegan diet, which I think is nice. Still, I had to have the discussion with her that giving colloidal silver to her daughter as an "antibiotic" en lieu of going to the doctor's office is NOT a good idea.....)

 

We really are great friends, except, of course, when it comes to my profession......... :/

 

She keeps windows open, burns candles (STOP IT! STOP IT!!) - I'm a person with asthma and MANY allergies, and one time I had such a bad allergic reaction at her house I broke out in hives from being near a candle... not fun! 

 

But one time I was visiting and she says her daughter is sick and vomiting - the kid knows how to play it up for extra mommy-ing attention because mom has a 1 yr old also! - and I examine her and it's friggin allergies. No fever, She has postnasal drip irritation, bluish nasal mucosa with clear drainage, etc. I say give her some claritin otc and I gave her some zofran...... she acts ever so thankful. Next day I get a phone call from my brother-in-law who tells me that she took her to the ER...... what did they do?...... gave her claritin and zofran.......... smh. ( I learned later that she never gave any claritin OR zofran to her daughter, but took her to the ER because of excessive vomiting AT NIGHT and she figured she needed an antibiotic......) But don't mind me over here..... ya know?!

[rev ronin]

I am not in medicine for the money - and, if I was, I sure wouldn't have picked FP for the past umpteen years.

None of us are.  I could go be a HIPAA infosec consultant and make 3x what I'm making now.

 

But that doesn't mean the patients necessarily understand how billing, insurance, and reimbursement works.  I spend a good bit of time explaining the business of medicine to patients, too, which is sad because I'd rather spend my time explaining the MEDICINE of medicine to them instead.

[newton9686]

Reality Check, I promise you my wife was responsible for a $300+ bill with a high deductible insurance plan for a complaint of epigastric pain by her PCP.  He billed her as a new patient, but only did a focused examination. I know not primary care is not the most lucrative field in medicine, however there are quite a few that make 6 figure doing only the minimum for their patients. You do not come off as one of those Reality, but I know they exist in primary care as they do everywhere else in medicine. 

[Reality Check 2]

Reality Check, I promise you my wife was responsible for a $300+ bill with a high deductible insurance plan for a complaint of epigastric pain by her PCP.  He billed her as a new patient, but only did a focused examination. I know not primary care is not the most lucrative field in medicine, however there are quite a few that make 6 figure doing only the minimum for their patients. You do not come off as one of those Reality, but I know they exist in primary care as they do everywhere else in medicine. 

 

 

Just don't lump us all together. Generalizing isn't good for anything.

 

If a person comes to our office then they felt the need to be seen. If seen, they will be charged according to billing guidelines.

 

I cannot be responsible for someone's insurance, deductible, copay or coinsurance.

 

Paying a copay and being seen does not under any circumstances "buy" one an Rx or the prescription of their choice. If the patient does not receive an Rx then it was not clinically indicated but they still received some form of advice or treatment options - OTC, watchful mgmt - something. 

 

Unlike Rev, I know very little about billing and kind of like it that way. I just take care of people. I bill according to the algorithms set forth by the insurance monsters that show how many problems I addressed and what history I took and what I did to take care of the problem(s).  I look at reconciliations and I manage my own family's insurance and billing. Can't say I agree with everything I see but I stay clinical.

 

Insurance or lack thereof does not change the clinical treatment plan - such as calf pain and swelling needs a STAT US to r/o DVT. 

 

Corporate medicine encourages gouging and double billing - Preventative AND E&M at the same stupid visit. I refuse to participate in that.

 

An office visit JUST for URI sx gets a 99213 from me, not a 99214.

 

So, please don't generalize. Sorry your wife got a bad bill and you have a high deductible. See the multiple other threads I have written on about how US Medicine will remain completely messed up as long as commercial insurance exists FOR profit AND their CEOs make 6-7 figures AND 6-7 figure bonuses - all at the expense of the insured that they pride themselves on denying services to.

 

I am one of the lonely few who would actually like to see a single payer system in the US ----- the hate daggers will start flying.

[mmiller3]

None of us are.  I could go be a HIPAA infosec consultant and make 3x what I'm making now.

 

 

 

Where? I can't find anything like that. Sounds like a great part-time deal...

[GetMeOuttaThisMess]

Just don't lump us all together. Generalizing isn't good for anything.

 

If a person comes to our office then they felt the need to be seen. If seen, they will be charged according to billing guidelines.

 

I cannot be responsible for someone's insurance, deductible, copay or coinsurance.

 

Paying a copay and being seen does not under any circumstances "buy" one an Rx or the prescription of their choice. If the patient does not receive an Rx then it was not clinically indicated but they still received some form of advice or treatment options - OTC, watchful mgmt - something.

 

Unlike Rev, I know very little about billing and kind of like it that way. I just take care of people. I bill according to the algorithms set forth by the insurance monsters that show how many problems I addressed and what history I took and what I did to take care of the problem(s). I look at reconciliations and I manage my own family's insurance and billing. Can't say I agree with everything I see but I stay clinical.

 

Insurance or lack thereof does not change the clinical treatment plan - such as calf pain and swelling needs a STAT US to r/o DVT.

 

Corporate medicine encourages gouging and double billing - Preventative AND E&M at the same stupid visit. I refuse to participate in that.

 

An office visit JUST for URI sx gets a 99213 from me, not a 99214.

 

So, please don't generalize. Sorry your wife got a bad bill and you have a high deductible. See the multiple other threads I have written on about how US Medicine will remain completely messed up as long as commercial insurance exists FOR profit AND their CEOs make 6-7 figures AND 6-7 figure bonuses - all at the expense of the insured that they pride themselves on denying services to.

 

I am one of the lonely few who would actually like to see a single payer system in the US ----- the hate daggers will start flying.

You forgot my other favorite, "I'm not responsible for the cost(s) of your prescriptions." I use generics and if that $20 prescription is too much then use OTC and wait it out like you could've most likely done from the get go. On the flip side if it's a generic cough I try to reassure them that it's ok to get looked at to exclude something "more serious", ex.-pneumonia so they don't feel ridiculous for coming in. We're not that busy so it's ok in my setting.

[rev ronin]

Where? I can't find anything like that. Sounds like a great part-time deal...

It wouldn't be a part time deal, and they're not looking for providers, they're looking for infosec-qualified people with 10+ years experience, which also happens to be me.  It would be pretty much just me, working for a major firm or as a solo consultant, living out of my suitcase and hotel rooms 50+% of the time.

[mmiller3]

It wouldn't be a part time deal, and they're not looking for providers, they're looking for infosec-qualified people with 10+ years experience, which also happens to be me.  It would be pretty much just me, working for a major firm or as a solo consultant, living out of my suitcase and hotel rooms 50+% of the time.

Well, that doesn't sound quite as appealing lol.