Sinusitis Diagnoses Drive Racial Gap in Antibiotic Prescriptions, Study Finds

A sweeping analysis of more than 100,000 urgent care visits at Cleveland Clinic has revealed a striking pattern in how respiratory tract infections are diagnosed and treated across racial groups. Non-White patients were significantly less likely than White patients to receive an antibiotic prescription, and significantly less likely to be diagnosed with sinusitis, the one common respiratory diagnosis most often used to justify antibiotic treatment. The study, published in the Journal of General Internal Medicine by researchers at Cleveland Clinic’s Center for Value-Based Care Research, suggests that racial differences in diagnosis coding partially explain the prescribing gap, but not entirely, pointing to deeper questions about how clinician decisions and patient expectations shape antibiotic use.

The research team, led by Kathryn A. Martinez and Michael B. Rothberg, examined electronic health record data from adults treated at Northeast Ohio urgent care sites of the Cleveland Clinic Health System between 2016 and 2022. They identified visits coded with diagnoses of unspecified respiratory tract infection, sinusitis, pharyngitis, bronchitis, tonsillitis, laryngitis, or influenza, excluding patients concurrently diagnosed with a urinary tract infection, for whom antibiotics would have been appropriate, and excluding all visits in 2020 to avoid the distortions of the early COVID-19 pandemic. The final cohort comprised 100,052 visits by 62,972 unique patients, 84 percent of whom were White and 16 percent non-White, the latter group including Black, Asian, multiracial, and other patients.

The headline numbers were unambiguous. Forty-eight percent of White patients left urgent care with an antibiotic prescription, compared with 40 percent of non-White patients. Meanwhile, 22 percent of White patients received a sinusitis diagnosis, against just 15 percent of non-White patients. In a mixed effects logistic regression that did not account for diagnosis type, non-White patients had 21 percent lower odds of receiving an antibiotic than White patients, with an adjusted odds ratio of 0.79. When the researchers added diagnosis type to the model, the association weakened but persisted, with an adjusted odds ratio of 0.91, indicating that diagnosis differences explain only part of the prescribing disparity.

The technical heart of the study lies in its modeling strategy. The researchers used mixed effects logistic regression with random effects for both clinician and patient, accounting for the clustering of visits within individual doctors and repeat visits by the same patients. They adjusted for age, sex, insurance type, visit year, and calendar month to capture the seasonality of respiratory infections. A sinusitis diagnosis proved overwhelmingly predictive of antibiotic receipt, carrying an adjusted odds ratio of 76.7 compared with unspecified respiratory tract infection. This makes sense clinically: while most respiratory tract infections are viral and resolve without antibiotics, sinusitis is the diagnosis most often treated with antimicrobials, even though only around 10 percent of sinusitis cases are genuinely bacterial.

When the researchers directly compared the odds of being diagnosed with sinusitis rather than unspecified respiratory tract infection, non-White patients had 39 percent lower odds than White patients, an adjusted odds ratio of 0.61. Male patients and those with non-commercial insurance were also less likely to receive the sinusitis label. Stratifying antibiotic prescribing by diagnosis revealed that the racial gap persisted within diagnostic categories: non-White patients were less likely to receive antibiotics both when diagnosed with unspecified respiratory tract infection and when diagnosed with sinusitis. Notably, for diagnoses where antibiotics are clearly indicated, such as pharyngitis and tonsillitis, no racial differences emerged.

Why would sinusitis diagnoses differ by race? The authors consider several explanations, and none can be definitively confirmed from administrative data. Differences in care seeking are one possibility, though the researchers consider it unlikely that patients can reliably distinguish between types of respiratory infection and tailor their clinic visits accordingly. Even physicians struggle with this distinction; one study cited in the paper found that fewer than 1 percent of sinusitis cases diagnosed by primary care physicians met established clinical criteria, and clinician judgment about bacterial versus viral illness is notoriously inconsistent.

A more provocative explanation is coding bias. The authors theorize that when a physician plans to prescribe an antibiotic, they may choose to code the visit as sinusitis rather than as unspecified respiratory tract infection, for which antibiotics are not indicated. In other words, the diagnosis follows the prescribing decision rather than driving it. If White patients are more likely to arrive at urgent care actively seeking antibiotics, physicians facing time pressure and no prior relationship with the patient may find it easier to prescribe for those who ask than to explain why a prescription is unnecessary. Prior work by the same team found that prescribing antibiotics saves physicians time, and a study of recorded primary care visits documented how patients exert subtle pressure, nudging doctors toward bacterial framings and resisting non-antibiotic suggestions.

This interpretation reframes what might otherwise look like a paradox. Racial disparities in health care typically describe non-White patients receiving inferior treatment, yet here the group receiving more antibiotics, a group that is White, is arguably receiving more inappropriate care, since most respiratory infections do not warrant antimicrobials. The lower prescribing rate among non-White patients may actually be closer to guideline-concordant practice. But the disparity remains troubling, because it implies that prescribing decisions may be influenced by patient race, whether through differential expectations, physician bias, or the accumulated effect of unequal experience navigating the health care system. Evidence suggests White patients hold stronger preferences for medications generally, and studies have found White patients more likely to receive inappropriate antibiotic prescriptions.

The study also documented temporal trends that reinforce the coding-bias hypothesis. Between 2016 and 2022, the share of visits coded as unspecified respiratory tract infection rose steadily, from 26 to 33 percent among White patients and from 28 to 34 percent among non-White patients, while sinusitis diagnoses fell and then partially rebounded. Antibiotic prescribing traced the same arc, dropping from 56 percent of White patient visits in 2016 to 41 percent in 2021 before rising to 46 percent in 2022, with a parallel trajectory for non-White patients. Because the true clinical incidence of sinusitis would not be expected to follow such a trend before the pandemic, the authors attribute these shifts to coding practices, concluding that antibiotic prescribing for respiratory infections is largely driven by the overall proportion of sinusitis diagnoses in a health system.

That conclusion carries a practical warning for antibiotic stewardship programs. Many stewardship frameworks classify sinusitis as potentially appropriate for antibiotics and therefore exclude it from scrutiny, focusing instead on diagnoses where antibiotics are clearly contraindicated. The Cleveland Clinic findings suggest this approach misses the single largest driver of inappropriate prescribing. The authors argue that stewardship efforts should target sinusitis directly, monitoring not only prescribing rates among patients already labeled with sinusitis but also the overall proportion of respiratory visits being coded as sinusitis in the first place. The study has limitations, including the inability to measure patient-reported symptoms, physical exam findings, or antibiotic preferences, reliance on unvalidated ICD-10 codes, and a single health system in one region, which may limit generalizability. Still, the message is clear: both diagnostic and prescribing processes contribute to racial differences in antibiotic treatment, and interventions must address clinician decision-making at the moment a diagnosis label is chosen, not merely at the moment a prescription is written.

Subject of Research: Racial differences in respiratory tract infection diagnosis and antibiotic prescribing in urgent care

Article Title: Racial Differences in Respiratory Tract Infection Diagnosis and Antibiotic Prescriptions

Article References: Racial Differences in Respiratory Tract Infection Diagnosis and Antibiotic Prescriptions. (n.d.). https://doi.org/10.1007/s11606-026-10930-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10930-5

Keywords: antibiotics, respiratory tract infections, sinusitis, racial disparities, urgent care, antibiotic stewardship, diagnostic coding, coding bias, prescribing patterns, health equity, Journal of General Internal Medicine, Cleveland Clinic