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The American Journal of Managed Care August 2016
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Variation in US Outpatient Antibiotic Prescribing Quality Measures According to Health Plan and Geography
Rebecca M. Roberts, MS; Lauri A. Hicks, DO; and Monina Bartoces, PhD
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Variation in US Outpatient Antibiotic Prescribing Quality Measures According to Health Plan and Geography

Rebecca M. Roberts, MS; Lauri A. Hicks, DO; and Monina Bartoces, PhD
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.
Health plans that performed well on 1 measure often performed well on the other 2 measures. For example, the highest-performing health plan for the adult bronchitis measure (71.7%) was also in the top 5 performing plans for both pharyngitis testing (95.6%) and URIs (98.7%) in 2012.
 
We further examined the available descriptive statistics of the health plans for the 3 HEDIS measures by the product reported (eg, HMO, PPO, POS) to determine if there were any differences in performance (eAppendix, available at www.ajmc.com). For the adult bronchitis measure, in all years, a majority of the plans reported PPO (45%-48%), followed by HMO/POS combined (37%-40%), and HMO (12%-13%). Analyses on differences of mean rates show that in all years, HMO rates were significantly higher than the rate of HMO/POS combined (P <.001). Also, HMO rates were higher than PPO rates in 2010 to 2012 (P <.001), but PPO rates were higher than HMO/POS combined rates in 2008 and 2009 (P <.001).
 
For pharyngitis testing, the distribution of health plans show a similar pattern to that of the adult bronchitis measure. Comparisons of mean rates show no statistically significant differences between HMO, PPO, or HMO/POS combined. A similar distribution was also observed for children diagnosed with URIs. Comparisons of mean rates show HMO rates were higher than PPO rates in all years (P <.01). HMO rates were also higher than HMO/POS combined rates in 2008 (P = .04) and 2009 (P = .03).
 
We also saw geographic variation between measures when looking at US Census divisions across all years (Figure). For pharyngitis testing, the highest-performing division was New England (80.1%) and the lowest-performing division was the Pacific (69.1%), followed by the South Central (71.4%). For children with URIs, the highest-performing division was New England (91.7%) and the worst-performing division was South Central (72.0%). For bronchitis, all divisions performed poorly, ranging from a high of 29.7% in the Pacific division to a low of 21.9% in the New England division.
 
DISCUSSION
Out of the 3 measures of interest, health plans consistently performed poorly on the adult bronchitis measure. In 2012, health plans reported an average antibiotic avoidance of 20.6% for adults with bronchitis, meaning that adults diagnosed with acute bronchitis were prescribed an antibiotic nearly 80% of the time, despite the fact that antibiotics are not indicated for this diagnosis. Other studies using other data sets have shown that approximately 70% of visits for acute bronchitis result in antibiotic prescription.15,16 Health plans performed better on the 2 measures focused on the pediatric population (URI and pharyngitis testing). One reason for this could be because of programs and organizations promoting appropriate antibiotic use in the community, such as the CDC’s “Get Smart: Know When Antibiotics Work” program, and the American Academy of Pediatrics. Both have provided appropriate antibiotic use guidance and education for parents of young children, as well as resources for pediatric healthcare providers. In spite of the seemingly high rates of performance associated with these 2 pediatric measures, there is room for improvement. The common cold (a URI) is always viral in nature, so an antibiotic is never necessary and the goal should be 100% antibiotic avoidance for common cold diagnoses.
 


 
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