Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract Infections in a Commercially Insured Population, United States, 2017.

Background: Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population. Methods: We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis. Results: Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33-1.34). Conclusions: It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing.

Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data - United States, 2019.

Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes.

A Veterans' Healthcare Administration (VHA) antibiotic stewardship intervention to improve outpatient antibiotic use for acute respiratory infections: A cost-effectiveness analysis.

OBJECTIVES: The Core Elements of Outpatient Antibiotic Stewardship provides a framework to improve antibiotic use, but cost-effectiveness data on implementation of outpatient antibiotic stewardship interventions are limited. We evaluated the cost-effectiveness of Core Element implementation in the outpatient setting. METHODS: An economic simulation model from the health-system perspective was developed for patients presenting to outpatient settings with uncomplicated acute respiratory tract infections (ARI). Effectiveness was measured as quality-adjusted life years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug events (ADEs), and healthcare utilization were obtained from the literature. Probabilities for antibiotic treatment and appropriateness, ADEs, hospitalization, and return ARI visits were estimated from 16,712 and 51,275 patient visits in intervention and control sites during the pre- and post-implementation periods, respectively. Data for materials and labor to perform the stewardship activities were used to estimate intervention cost. We performed a one-way and probabilistic sensitivity analysis (PSA) using 1,000,000 second-order Monte Carlo simulations on input parameters. RESULTS: The proportion of ARI patient-visits with antibiotics prescribed in intervention sites was lower (62% vs 74%) and appropriate treatment higher (51% vs 41%) after implementation, compared to control sites. The estimated intervention cost over a 2-year period was $133,604 (2018 US dollars). The intervention had lower mean costs ($528 vs $565) and similar mean QALYs (0.869 vs 0.868) per patient compared to usual care. In the PSA, the intervention was dominant in 63% of iterations. CONCLUSIONS: Implementation of the CDC Core Elements in the outpatient setting was a cost-effective strategy.

A Learning Collaborative to Improve Antibiotic Prescribing in Primary Care Pediatric Practices.

An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM.

Antibiotic and opioid prescribing for dental-related conditions in emergency departments: United States, 2012 through 2014.

BACKGROUND: Patients visiting the emergency department (ED) for nontraumatic dental conditions usually receive nondefinitive health care and are referred to treatment elsewhere. This may lead to potentially avoidable antibiotic and opioid use. METHODS: A retrospective study was conducted in IBM MarketScan Research Databases in Treatment Pathways from 2012 through 2014. This study included patients with commercial insurance or enrolled in Medicaid. Patients receiving a diagnosis of a dental condition in the ED with no secondary diagnosis warranting an antibiotic prescription were included. Patients were stratified on the basis of the primary payer and available demographics, as well as on the basis of repeat visits to the ED. RESULTS: A higher proportion of Medicaid beneficiaries (280,410, 4.9%) had dental-related visits compared with the commercially insured (159,066, 1.3%). The most common diagnoses were similar for both groups and included caries. In both cohorts, the 18- through 34-year age group had the highest rate of dental-related ED visits. Within 7 days of a dental-related ED visit, 54.9% of Medicaid beneficiaries and 55.0% of commercially insured beneficiaries filled a prescription for an antibiotic and 39.6% of Medicaid patients and 42.0% of commercially insured patients filled an opioid prescription. CONCLUSIONS: Antibiotics and opioids are frequently prescribed during ED visits for dental conditions. Access to preventive and acute oral health care for routine dental symptoms, such as caries, may reduce unnecessary prescriptions in both the commercially insured and Medicaid beneficiary populations. PRACTICAL IMPLICATIONS: Treatment of dental conditions in the ED often indicates a lack of access to preventive or acute oral health care. Data-driven solutions, such as guideline implementation, could improve oral health access, reduce medication-related harms, and avert health care expenditures.

Race, otitis media, and antibiotic selection.

BACKGROUND AND OBJECTIVE: Previous research suggests that physicians may be less likely to diagnose otitis media (OM) and to prescribe broad-spectrum antibiotics for black versus nonblack children. Our objective was to determine whether race is associated with differences in OM diagnosis and antibiotic prescribing nationally. METHODS: We examined OM visit rates during 2008 to 2010 for children ≤14 years old using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. We compared OM visits between black and nonblack children, as percentages of all outpatient visits and visit rates per 1000. We compared antibiotic prescribing by race as the percentage of OM visits receiving narrow-spectrum (eg, amoxicillin) versus broader-spectrum antibiotics. We used multivariable logistic regression to examine whether race was independently associated with antibiotic selection for OM. RESULTS: The percentage of all visits resulting in OM diagnosis was 30% lower in black children compared with others (7% vs 10%, P = .004). However, OM visits per 1000 population were not different between black and nonblack children (253 vs 321, P = .12). When diagnosed with OM during visits in which antibiotics were prescribed, black children were less likely to receive broad-spectrum antibiotics than nonblack children (42% vs 52%, P = .01). In multivariable analysis, black race was negatively associated with broad-spectrum antibiotic prescribing (adjusted odds ratio 0.59; 95% confidence interval, 0.40-0.86). CONCLUSIONS: Differences in treatment choice for black children with OM may indicate race-based differences in physician practice patterns and parental preferences for children with OM.

Acute care costs in overweight children: a pediatric urban cohort study.

BACKGROUND: Evidence indicates obese children have increased health care utilization. It is unknown if this is true within the emergency department (ED) setting. Our purpose is to determine if overweight children presenting for emergency care have increased resource utilization over normal weight peers. METHODS: We conducted a retrospective cohort study of children 2 to <18 years old presenting to a pediatric ED in 2007. Overweight was defined as >95th percentile sex-specific weight-for-age, and normal weight was defined as ≤95(th) percentile. We used a subsample validation to compare these study definitions to BMI-based definitions. We compared total billed charges and secondary outcomes of ED length of stay and admission rate using multivariate and logistic regression models. Outcomes were reported for admitted and discharged patients. Four diagnoses were examined for primary and secondary outcomes. RESULTS: Of 32,996 included visits, 6333 (19.2%) were for overweight children. Study definitions correctly classified 98.3% of normal weight children but only 51.3% of overweight children. Overweight children were more likely to be older, black, and publicly insured. Median charges for overweight and normal weight children, whether discharged or admitted, were not different in the adjusted model. Admitted overweight children with asthma and fractures or dislocations had higher median charges than normal weight $4617 (2065-375,669) versus $4177 (1980-37,432, p=0.01) and $9855 (6681-58,546) versus $8137 (1461-52,557, p=0.01), respectively. CONCLUSIONS: Overall acute care costs for overweight children are not different from normal weight children. However, admitted overweight children have disease-specific increased use of resources.