Prevalence of Inappropriate Antibiotic Prescribing by Antibiotic Among Privately and Publicly Insured Non-Elderly US Pat
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J Gen Intern Med DOI: 10.1007/s11606-020-06189-z © Society of General Internal Medicine 2020
INTRODUCTION
Outpatient antibiotic prescribing is a major driver of antimicrobial resistance, which causes 35,000 US deaths per year.1 Stewardship initiatives are typically broad-based, but antibiotic-specific initiatives may be warranted if particular antibiotics disproportionately account for inappropriate prescribing. Previously, we developed a scheme classifying whether each ICD-10-CM diagnosis code “always,” “sometimes,” or “never” justifies antibiotics.2 Using this scheme, we estimated that 23% of antibiotic prescriptions among privately insured Americans in 2016 were for antibiotic-inappropriate conditions.2 However, we did not assess inappropriate prescribing by antibiotic or include the publicly insured. We address these gaps using 2018 commercial and Medicaid claims.
We identified pharmacy claims for 39 oral antibiotics included in a national quality measure.4 Following our prior study, we compiled diagnosis codes on medical claims occurring during a look-back period that began three days prior to the antibiotic claim date and ended on this date.2 We assigned claims to one of four categories: (1) “Appropriate” if associated with ≥ 1 “always” diagnosis code during the look-back period; (2) “Potentially appropriate” if associated with ≥ 1 “sometimes” code but no “always” codes; (3) “Inappropriate” if associated only with “never” codes; and (4) “Not associated with a recent diagnosis code” if there were no codes during the look-back period (e.g., non-visit-based prescribing2,5). For example, if the look-back period contained codes for pneumonia (an “always” code) and sinusitis (a “sometimes” code), the claim was classified as appropriate. If only sinusitis was coded, the claim was classified as potentially appropriate. We calculated the proportion of claims in each category overall, by age (adults aged ≥ 18 years versus children), by age and payer type (public versus private), and by an antibiotic. For adults and children, we calculated the proportion of antibiotic claims and inappropriate claims accounted for by each antibiotic.
METHODS
RESULTS
We analyzed the 2018 IBM MarketScan Commercial and Multi-State Medicaid Databases. The former includes 27 million enrollees with employer-sponsored insurance; the latter includes 12 million publicly insured enrollees from several states.3 We included non-dual eligible enrollees aged 0–64 years continuously enrolled throughout 2018. The University of Michigan Institutional Review Board exempted this study from review.
The 24,850,477 enrollees included had mean (SD) age of 31 (19) years; were 33% children, 52% female, and 26% publicly insured; and had 18,711,397 antibiotic claims (753 per 1000). Of all enrollees, 9,258,637 (37%) had ≥ 1 antibiotic claim. Of all claims, 14% were appropriate, 38% were potentially appropriate, 22% were inappropriate, and 26% were not associated with a recent diagnosis code (Table 1). Among adults, 24% of claims were inappropriate (26% vs 24
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