Variation in US Outpatient Antibiotic Prescribing Quality Measures According to Health Plan and Geography

Antibiotic prescribing has become viewed as a patient safety and quality-of-care issue. The authors analyzed quality measures related to appropriate antibiotic prescribing and testing.
Published Online: August 17, 2016
Rebecca M. Roberts, MS; Lauri A. Hicks, DO; and Monina Bartoces, PhD

Antibiotic prescribing has become increasingly viewed as an issue related to patient safety and quality of care. The objective of this study was to better understand the differences between health plan reporting and the geographic variation seen in quality measures related to antibiotic use.

Study Design: We focused on 3 measures from the Healthcare Effectiveness Data and Information Set (HEDIS) related to antibiotic prescribing and testing to guide antibiotic prescribing.

Methods: We analyzed data for 3 relevant measures for the years 2008 to 2012, including only commercial health plans. We analyzed the following 3 HEDIS measures: 1) “Appropriate Testing for Children With Pharyngitis,” 2) “Appropriate Treatment for Children With Upper Respiratory Infections,” and 3) “Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis.”

Results: Out of these 3 measures, health plans consistently performed poorly on the adult bronchitis measure. Performance was better on the 2 measures focused on the pediatric population. We also saw geographic variation between measures when looking at Census divisions across all years.

Conclusions: There is wide variation between individual health plan performance on the measures related to antibiotic use. Geographic differences were also observed on these measures, with health plans in the South Central Census division performing worse than other parts of the country. Stakeholders, such as public health, advocacy groups, foundations, and professional societies, interested in improving the quality of care that patients receive related to antibiotic use in the outpatient setting should consider how existing measures and working with health plans could be used to improve prescribing.

Am J Manag Care. 2016;22(8):519-523
Take-Away Points

Antibiotic prescribing has become viewed as a patient safety and quality-of-care issue. With antibiotic-resistant infections on the rise and national support to improve antibiotic use, the time to focus efforts on improving prescribing practices in the outpatient setting is now. 
  • Explore opportunities to expand existing quality measures, or create new measures, that focus on appropriate antibiotic use. 
  • Share lessons learned from high-performing plans with lower-performing plans. 
  • Implement proven interventions to improve antibiotic use, especially with providers who treat adults, as progress has been minimal in decreasing inappropriate antibiotic prescribing in the adult population.
Antibiotic resistance has become one of the most pressing public health issues of our time. In 2013, the CDC published a report that quantified the dangers of antibiotic resistance in the United States. This report revealed a staggering statistic: at least 2 million illnesses and 23,000 deaths can be attributed each year to serious bacterial infections that are resistant to 1 or more antibiotics.1 Further, it is well documented that antibiotic use is a main driver of antibiotic resistance.2-4 Antibiotics are life-saving drugs that are essential for treating bacterial illnesses, but unnecessary use for viral illnesses increases selective pressure that contributes to antibiotic resistance. Although antibiotic prescribing for children has improved since the 1990s, over half of all antibiotic prescriptions in the outpatient setting are still written for mild respiratory infections—many of which are caused by viruses.5,6 Antibiotic overprescribing also contributes to avoidable adverse drug events, such as Clostridium difficile infections.7,8
Antibiotic prescribing has become increasingly viewed as an issue related to patient safety and quality of care. The Healthcare Effectiveness Data and Information Set (HEDIS) contains many healthcare quality measures. According to the National Committee for Quality Assurance (NCQA), HEDIS measures are used by more than 90% of US health plans to measure performance on important dimensions of care and service, and are also used by public health policy makers, the public, and the health plans themselves to identify high-performing plans and to focus improvement efforts.9 HEDIS measures cover a wide variety of healthcare performance issues, such as asthma medication use, breast cancer screening, and childhood and adolescent immunization status. Participating health plans report HEDIS data annually through surveys, medical chart reviews, and insurance claims, and the results are audited by an NCQA-approved auditing firm prior to public reporting.9
We analyzed 2 HEDIS measures related to appropriate antibiotic prescribing (upper respiratory infection in children and acute bronchitis in adults) and a measure related to appropriate testing to guide antibiotic prescribing (pharyngitis testing). The primary objectives of this study were to assess overall health plan performance on the 3 HEDIS measures for 2008 to 2012 and explore potential variation between health plans. Prior studies in the United States have shown geographic variation in antibiotic prescribing10,11; therefore, we also wanted to explore whether health plan performance on these 3 measures varied geographically.

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