Prescribing systemic steroids for acute respiratory tract infections in United States outpatient settings: A nationwide population-based cohort study

English version

Autoři: Kueiyu Joshua Lin ^aff001; Evan Dvorin ^aff003; Aaron S. Kesselheim ^aff001
Působiště autorů: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America ^aff001; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America ^aff002; Ochsner Health System, Jefferson Parish, Louisiana, United States of America ^aff003
Vyšlo v časopise: Prescribing systemic steroids for acute respiratory tract infections in United States outpatient settings: A nationwide population-based cohort study. PLoS Med 17(3): e32767. doi:10.1371/journal.pmed.1003058
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1003058

Souhrn

Background

Evidence and guidelines do not support use of systemic steroids for acute respiratory tract infections (ARTIs), but such practice appears common. We aim to quantify such use and determine its predictors.

Methods and findings

We conducted a cohort study based on a large United States national commercial claims database, the IBM MarketScan, to identify patients aged 18–64 years with an ARTI diagnosis (acute bronchitis, sinusitis, pharyngitis, otitis media, allergic rhinitis, influenza, pneumonia, and unspecified upper respiratory infections) recorded in ambulatory visits from 2007 to 2016. We excluded those with systemic steroid use in the prior year and an extensive list of steroid-indicated conditions, including asthma, chronic obstructive pulmonary disease, and various autoimmune diseases. We calculated the proportion receiving systemic steroids within 7 days of the ARTI diagnosis and determined its significant predictors. We identified 9,763,710 patients with an eligible ARTI encounter (mean age 39.6, female 56.0%) and found 11.8% were prescribed systemic steroids (46.1% parenteral, 47.3% oral, 6.6% both). All ARTI diagnoses but influenza predicted receiving systemic steroids. There was high geographical variability: the adjusted odds ratio (aOR) of receiving parenteral steroids was 14.48 (95% confidence interval [CI] 14.23–14.72, p < 0.001) comparing southern versus northeastern US. The corresponding aOR was 1.68 (95% CI 1.66–1.69, p < 0.001) for oral steroids. Other positive predictors for prescribing included emergency department (ED) or urgent care settings (versus regular office), otolaryngologist/ED doctors (versus primary care), fewer comorbidities, and older patient age. There was an increasing trend from 2007 to 2016 (aOR 1.93 [95% CI 1.91–1.95] comparing 2016 to 2007, p < 0.001). Our findings are based on patients between 18 and 64 years old with commercial medical insurance and may not be generalizable to older or uninsured populations.

Conclusions

In this study, we found that systemic steroid use in ARTI is common with a great geographical variability. These findings call for an effective education program about this practice, which does not have a clear clinical net benefit.

Klíčová slova:

Critical care and emergency medicine – Outpatients – Physicians – Pneumonia – Respiratory infections – Steroid therapy – Steroids – Pharyngitis

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