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Regional Variation Points Out Value of Antibiotic Stewardship

A new study in outpatient antibiotic prescribing quality measures shows regional variation in antibiotic prescribing habits, suggesting a need for antibiotic stewardship programs.

- Health plans are not exhibiting uniformly high rates of performance on clinical quality measures related to antibiotic use, according to a new study from the American Journal of Managed Care, indicating an increased need for standardized antibiotic stewardship programs.

Antibiotic stewardship

The study, conducted by researchers from the Centers for Disease Control and Prevention (CDC), found geographical variations in how health plans reported performance on certain Healthcare Effectiveness Data and Information Set (HEDIS) quality benchmarks, and also uncovered significant opportunities for improvement in the realm of antibiotic stewardship.

The study analyzed three relevant HEDIS related to antibiotic prescribing and testing to guide antibiotic use:

  • appropriate testing for children with pharyngitis
  • appropriate treatment for children with upper respiratory infections (URIs)
  • avoidance of antibiotic treatment in adults with acute bronchitis

Out of these three measures, health plans consistently performed poorly on the adult bronchitis measure. However, performance improved on the two other measures that focused on the pediatric population.

The overall mean of children tested for group A Streptococcus (pharyngitis) and prescribed an antibiotic was 77 percent. The mean percent of children treated appropriately for URIs was approximately 84 percent. And the avoidance of antibiotic treatment for adults with bronchitis was a mere 24 percent.

Over time, testing for pharyngitis improved, with the lowest average of 74.6 percent in 2008 and the highest in 79.9 percent in 2012.

The proportion of children not prescribed antibiotics for URIs did not change significantly over the course of the study. The highest average was 85 percent in 2011 and the lowest was 83.4 percent in 2012.

There was a decreasing trend in antibiotic avoidance for bronchitis, with the best average of 26.6 percent occurring in 2008 and a worst of 22.1 percent occurring in 2011. There was no improvement in 2012, with an average of 22.7 percent.

Geographic variation between measures was also apparent when looking at Census divisions across all years.  Health plans in the South Central Census division performed worse than other parts of the country.

New England (80.1%) was the highest performing division for pharyngitis testing. The lowest performing divisions were the Pacific (69.1%) and South Central (71.4) percent. New England (91.7%) was also the highest performing division for children with URIs, while South Central (72%) performed the worst. All divisions performed poorly on bronchitis testing, with a range of 29.7 percent in the Pacific to 21.9 percent in New England.

The study concluded that stakeholders, such as public health, advocacy groups, foundations and professional societies interested in improving antibiotic stewardship in the outpatient setting should consider working with health to improve prescribing habits.

Previous reports, the AJMC study states, showed that antibiotic prescribing rates in the South are higher than rates in other parts of the country. These reports, however, do not contain diagnosis or visit-based data, making it difficult to assess whether providers in the South were more likely to prescribe inappropriately. Because the HEDIS quality measures are direct indicators of appropriate treatment and prescribing, the AJMC study confirms that inappropriate prescribing is higher in the South.

According to a 2014 Centers for Disease Control (CDC) study, a majority of hospitals may be putting patient safety at risk by overusing antibiotics.

“Overuse and inappropriate use of antimicrobials is a major public health issue and contributes to patient harm, antimicrobial resistance, and unnecessary healthcare costs,” the study says. “It has been recognized for several decades that of patients receiving antimicrobial therapy, up to half receive unnecessary or inappropriate therapy, including redundant therapy. Focusing on redundant or duplicate antimicrobial therapy is one recommended strategy to reduce overutilization and its attendant effects on patient safety and hospital costs.”

The AJMC study follows a proposed CMS rule to require antibiotic stewardship programs and improved safety techniques in hospitals, which has already received widespread industry support.

“Antibiotic overuse is a major public health threat because it contributes to antibiotic resistance. Up to 50 percent of all antibiotics prescribed in the United States are estimated to be inappropriate by indication, agent, or duration of therapy,” explained the Pew Charitable Trusts in a letter addressed to CMS officials.

“We support proposed changes to the Centers for Medicare & Medicaid Services (CMS) conditions of participation that would require hospitals, including critical access hospitals (CAH), to develop and maintain an antibiotic stewardship program (ASP) in order to participate in Medicare and Medicaid reimbursement programs."

Among the updates and changes to Medicare and Medicaid participation requirements included in the proposed CMS rule would be the implementation of antibiotic stewardship programs that address the rampant overuse of antibiotics by clinicians in the inpatient setting at hospitals and critical access hospitals.

A recent CDC study found that about one in every three of the 154 million antibiotic prescriptions written each year is considered unnecessary. This jeopardizes patient safety and the hospital quality by over-prescribing antibiotics.

CDC researchers discovered that antibiotic prescriptions used to treat respiratory infections were the most avoidable. While conditions such as the common cold, viral sore throats, bronchitis and ear infections are unresponsive to antibiotics, 44 percent of outpatient antibiotic prescriptions were intended to treat such conditions.

“Antibiotics are lifesaving drugs, and if we continue down the road of inappropriate use we’ll lose the most powerful tool we have to fight life-threatening infections,” said Tom Frieden, MD, MPH, CDC Director. “Losing these antibiotics would undermine our ability to treat patients with deadly infections, cancer, provide organ transplants, and save victims of burns and trauma.”

The overuse or unnecessary prescribing of antibiotics is a threat to quality hospital care because antibiotics can suppress good bacteria in a patient's body, increasingly the likelihood that they could acquire and illness – like Clostridium difficile (C. difficile) – during their stay at a hospital.

However, a CDC study indicated that by reducing the amount of antibiotic prescriptions by 30 percent, the rate of hospital acquired infection for C. difficile could drop by over 25 percent.

“The discovery of antibiotics in the early 20th century fundamentally transformed human and veterinary medicine,” says the proposal. “Antibiotics now save millions of lives each year in the United States and around the world. The rise of antibiotic-resistant bacterial strains, however, represents a serious threat to public health and the economy. The CDC estimates that annually at least two million illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria in the United States alone."

The knowledge of where inappropriate prescribing is most prevalent, along with support from industry stakeholders invested in antibiotic stewardship, can focus on intervention where improvements are needed the most. Furthermore, as inappropriate prescribing habits are identified, the likelihood of bacteria developing a resistance to current antibiotics will decrease, offering better quality of care.

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