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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.
We also observed differences in rates by line of business for both the adult bronchitis measure and the URI measure. For both measures, plans reporting HMO lines of business were reporting significantly higher rates than those by PPO or HMO/POS combined in most instances. It is unclear why we see these differences, as antibiotic prescriptions are written by individual providers who may see many patients with varied insurance types and other payment methods over the course of a year. We believe it would be unlikely for a provider to prescribe differently based on the specific type of health insurance product (HMO, PPO, or some variation), although at least 1 study has found that among older adults, antibiotic prescribing increased when insurance coverage improved.17 As the data for this analysis was commercial only and did not include Medicare or Medicaid patients, it is unclear if differences in insurance coverage are impacting HEDIS rates, and this may be one area where further study is warranted.
We also observed wide geographic variation in health plan performance for the 3 measures. Previous studies have shown that antibiotic prescribing rates are higher in the South than in other parts of the country. Specifically, prescribing rates in some states in the South, and through the Appalachian region of the country, were more than double the state prescribing rates in the Pacific Northwest.10,11 However, because these reports do not contain diagnosis or visit-based data, it is 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, our study confirms that inappropriate prescribing is higher in the South. This is important to both the understanding of this complex issue, and to the planning of future antibiotic stewardship activities in the South. Improving antibiotic use is a national priority,18 and this information is useful for identifying where antibiotic stewardship programs are needed most.10,11
In general, the highest-performing plans tended to do well across all 3 measures and were consistent over time, leading us to conclude that there may be lessons learned that could be shared with the plans that are not performing as well. There may then be opportunities to expand existing measures (eg, measuring URI prescribing for all ages, not only the pediatric population) or creating new measures focused on appropriate antibiotic use (eg, appropriate prescribing for sinusitis). Public health, advocacy groups, foundations, professional societies, and others interested in improving antibiotic use in the outpatient setting should consider how existing quality measures and multi-stakeholder collaborations could be used to impact prescribing. One example of a multi-stakeholder collaboration is California AWARE, a joint effort between the California Medical Association Foundation, the California Department of Health Services, health plans in the state, and others. The California AWARE program has focused on improving antibiotic prescribing rates in the state for many years using a number of different strategies, including educational tools and resources targeting providers, as well as the general public, and also by working closely with health plans to identify high-prescribing providers to target for interventions.

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