Check Engine Light, Red Herring, or MacGuffin? Clinician-Level Correlations of the Antibiotic Utilization for Respiratory Conditions (AXR) Metric With Outpatient Antimicrobial Stewardship Metrics, Diagnostic Practices, and Prescription Characteristics.

Abstract

The Healthcare Effectiveness Data and Information Set's antibiotic utilization for respiratory conditions (AXR) is a new, broad antibiotic prescribing metric. Higher AXR values indicate higher respiratory encounter prescribing rates. Relationships between clinician-level AXR and prescribing/diagnostic practices are unclear. This was a retrospective observational study of respiratory urgent care (UC) encounters across 32 UC centers in our health system, conducted from 1 July 2022 to 30 June 2025. Correlations between clinician-level AXR and prespecified outcomes (tier 3 prescribing, antibiotics for pharyngitis despite negative group A Streptococcus antigen testing, sinusitis/acute otitis media (AOM) treatment/diagnosis rates, narrow-spectrum antibiotic prescriptions excluding encounters with penicillin allergy, and <7-day treatment duration for sinusitis/AOM in patients ≥2 years) were assessed using quartile-based logistic regression and weighted Spearman correlations. Among 528 444 respiratory encounters, 37.1% (195 891) were associated with an antibiotic prescription; 303 clinicians were included. Clinicians in the highest AXR quartile (AXR quartile 4 [Q4]) were more likely to be in Q4 than in quartile 1 for the following: tier 3 prescribing (odds ratio, 15.38 [95% confidence interval, 5.58-42.39]), pharyngitis prescribing despite negative group A Streptococcus testing (11.16 [4.04-30.79]), and the treatment (8.95 [3.23-24.80]) or diagnosis (33.92 [11.14-103.27]) of sinusitis/AOM. AXR-Q4 clinicians were less likely to be in Q4 for narrow-spectrum antibiotic prescriptions excluding encounters with penicillin allergy (odds ratio, 0.36 [95% confidence interval, .17-.77]) and prescriptions of <7 days for sinusitis/AOM for patients ≥2 years old (0.25 [.11-.55]). In our UC network, high clinician-AXR was correlated with antibiotic prescription/diagnostic measures. AXR can serve as an efficient screening metric but should be paired with prescription/diagnosis-specific measures and prescription characteristics to guide outpatient stewardship efforts.