Improving Antibiotic Use Through Collaboration Among Clinicians, Researchers, and Medicaid By Bethany Wattles, PharmD, MHA and Michael Smith, MD, MSCE Introduction den can be even more significant for smaller, private practices which lack the clinical and Improving antibiotic use is a key strategy for KEY MESSAGES: managing the growing public health threat of administrative support for implementing and tracking quality improvement efforts. Previous • Improving antibiotic use in the antimicrobial resistance. According to the Cen- studies suggest that inappropriate prescribing outpatient setting is key to reducing ters for Disease Control and Prevention (CDC), is highest in certain geographic areas8 and the development of antibiotic there are at least 2.8 million cases of resistant practice settings,9 highlighting the importance resistance infections, resulting in 35,900 deaths annually.1 of widespread implementation of stewardship Approximately 80-90% of all antibiotic use • Medicaid claims data are useful for efforts across the outpatient care continuum. occurs in the outpatient setting where at least measuring antibiotic prescribing 30% of prescriptions are considered unneces- Health insurers are uniquely positioned to • Statewide collaboration ensures sary.2,3 In 2016, the CDC published The Core contribute to outpatient antibiotic stewardship inclusion of vulnerable geographic Elements of Outpatient Antibiotic Steward- efforts through utilization of valuable health areas and practice settings ship, providing a framework for establishing claims data, provider outreach, and incen- Antibiotic Stewardship Programs (ASP) in all tives.10 This issue brief describes key strategies • Partnering with Medicaid can promote outpatient settings.4 The Core Elements of out- discussions for meaningful policy that could be employed by collaborations patient stewardship include: (1) Commitment; among academic clinicians, researchers, Man- changes (2) Action for policy and practice; (3) Tracking aged Care Organizations (MCOs) and Medic- and reporting; and (4) Education and exper- aid departments, that could lead to statewide tise. By implementing the four core elements, reductions in inappropriate antibiotic use. outpatient practices will be working towards the ultimate goal of antibiotic stewardship -- to Measuring Antibiotic Use maximize the benefit of antibiotic treatment Measuring antibiotic use is a critical compo- while minimizing harm to individuals and nent of antibiotic stewardship and is included communities. Despite these recommendations, in various ASP recommendations.4, 11, 12, In there remains a lack of widespread implemen- the outpatient setting, tracking and reporting tation of ASP practices in the outpatient setting. antibiotic use is one of the Core Elements4 Key barriers to appropriate outpatient pre- provided by the CDC and a required Element scribing and subsequent stewardship efforts of Performance for Joint Commission Ambu- include patient demand, time constraints, di- latory Care Center accreditation.12 agnostic uncertainty and externalized respon- Annually, the CDC describes national and sibility.5 While some efforts have been made to state-specific antibiotic prescribing data using implement antibiotic prescribing interventions prescriptions from community pharmacies in large healthcare systems,6,7 these efforts are from all payers (IQVIA Xponent database).13 difficult to establish and maintain. This bur- In 2018, this data source included nearly 250 Improving Antibiotic Use Through Collaboration Among Clinicians, Researchers, and Medicaid Figure 1: Antibiotic prescriptions per 1,000 persons by state (sextiles) for all ages- United States, 2018, estimates created using revised methodology accounting for reversed and voided prescriptions across weeks13 million antibiotic prescriptions, also measured as 763 prescrip- The comprehensive nature of Medicaid claims data and ability to tions per 1000 persons.13 Volume of antibiotic prescribing by state assess appropriateness of antibiotic prescribing, makes it an ideal provides a useful baseline in identifying areas of higher prescrib- source for measuring antibiotic use. Further, due to the frequency ing (Figure 1). For instance, the Southern region of the US has of antibiotic prescribing in the outpatient setting, antibiotic ex- consistently higher rates of antibiotic prescribing.13 penditures are a large portion of Medicaid spending and reducing unnecessary prescriptions has the potential to result in significant To understand more about antibiotic overuse and areas for im- cost-savings.21,22 For example, analyses of Kentucky Medicaid provement, it is also important to consider the appropriateness claims data suggest that certain geographic regions, especially of antibiotic prescribing. Historically, appropriateness has been rural areas, are more likely to have higher rates of antibiotic pre- described using the National Ambulatory Medical Care Survey scribing.19 Previous studies have also shown that some outpatient (NAMCS), a nationally representative survey of office-based phy- practice settings, such as urgent care centers, emergency depart- sicians.3,14 This data source is useful for national representation, ments, and telehealth visits, have higher rates of inappropriate but has limitations including time lags and exclusion of important prescribing.20,21 These findings suggest the importance of wide- outpatient settings (retail clinics and virtual visits).3,14 Pharmacy spread outpatient stewardship policy and practice interventions, and medical claims data are another useful data source to evaluate in order to capture some of the most at-risk populations and the appropriateness of antibiotic prescribing.15 Recent publications practice settings. have provided robust classification systems to identify whether prescriptions are appropriate based on associated International Classification of Diseases (ICD) codes.16,17,18 2 Improving Antibiotic Use Through Collaboration Among Clinicians, Researchers, and Medicaid Educational Materials and Resources Education to both patients and healthcare providers is another key strategy to reduce inappropriate antibiotic use. For providers, the CDC has an interactive, online Antibiotic Stewardship Training series with over 10 hours of free continuing education.23 Providers and health educators can also make an impact by sharing antibiotic awareness messages to the public. The CDC's campaign, Be Antibiotics Aware, has a variety of online and printable materials available for free download for use in outpatient offices, hospitals, long-term care, and public education settings.24 In addition to national resources, many states have individual antibiotic awareness campaigns. The Kentucky Antibiotic Awareness campaign is supported by a State University Partnership contract between Kentucky Medicaid and the University of Louisville.25 For a list of state and local stewardship efforts, visit: CDC State Antibiotic Stewardship Implementation Resources.26 CDC Antibiotic Stewardship Resources Kentucky Antibiotic Awareness Resources • Provider training series • Outpatient ASP Implementation Workbook • Patient handouts • Commitment Posters • Posters • Kids Activity Book • Graphics • Quarterly Newsletters • US Antibiotic Awareness Week • Facebook and Twitter accounts (@KYAbxAwareness) • Sick Child Handout Collaboration and Policy Implications feedback to implement provider feedback reports on antibiotic use. Reports will include individual-level prescribing data and In addition to collaboration among clinicians and Medicaid de- peer-comparison. MCOs can utilize existing Healthcare Effec- partments, it is important to consider how public health officials, tiveness Data and Information Set (HEDIS) measures28 related professional societies, and community stakeholders can assist in to antibiotic use and/or broader antibiotic prescribing metrics to dissemination of outpatient stewardship efforts. If clinicians limit encourage providers to improve their practice. Such data could be their stewardship initiatives to local activities within a health care further leveraged to influence provider reimbursement through system, high priority areas such as rural, private practices could new or existing value-based payment programs. Policy changes be overlooked. Stewardship leaders are encouraged to reach out that would require MCOs to report meaningful antibiotic use data to local, state, and national stakeholders to identify opportunity and/or associated incentives would ensure widespread provider for collaboration. Whether the result is alignment of active project dissemination while taking the responsibility off individual orga- work or dissemination to a wider audience, engaging key players nizations and practices. will assist in establishing widespread uptake of antibiotic steward- ship efforts. Future Directions In order to implement widespread improvement in outpatient According to recent publications, several states are already antibiotic use, policy changes are needed. In hospitals, antimi- utilizing statewide data to report antibiotic use and prescribing crobial stewardship is now a mandatory requirement for Joint trends: Kentucky19,22, Tennessee29,30, South Carolina31, Ohio15, Commission accreditation and Centers for Medicare & Medicaid and Utah.32 It is worth noting that many states with the highest Services (CMS) reimbursement.27 In outpatient settings, the only antibiotic prescribing rates, also have higher rates of Medicaid existing requirement is for Joint Commission Ambulatory Care beneficiaries.33 We believe that a multi-state collaboration to Center accreditation.12 By including Medicaid departments and evaluate antibiotic prescribing and interventions could accelerate managed care organizations in antibiotic stewardship efforts, our knowledge and understanding of how to expand outpatient these established relationships can provide meaningful policy stewardship efforts. For anyone interested in sharing experiences recommendations, leading to widespread implementation of an- of antibiotic stewardship using Medicaid claims data, please email tibiotic prescribing initiatives. For example, clinician researchers KYAntibx@louisville.edu. in Kentucky are working with Medicaid to implement provider 3 Improving Antibiotic Use Through Collaboration Among Clinicians, Researchers, and Medicaid References 17.Fischer MA, Mahesri M, Lii J, Linder JA. Non-infection-related and non-visit- based antibiotic prescribing is common among Medicaid patients. Health Aff. 1. CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: 2020 Feb;39(2):280-288. U.S. Department of Health and Human Services, CDC; 2019. 18.Stenehjem E, Wallin A, Fleming-Dutra KE, Buckel WR, Stanfield V, Brunisholz 2. Duffy E, Ritchie S, Metcalfe S, Van Bakel B, Thomas MG. Antibacterials dis- KD, Sorensen J, Samore MH, Srivastava R, Hicks L, Hersh AL. Antibiotic pre- pensed in the community comprise 85%‐95% of total human antibacterial con- scribing variability in a large urgent care network: A new target for outpatient sumption. Journal of clinical pharmacy and therapeutics. 2018 Feb;43(1):59- stewardship. Clin Infect Dis. 2020 Apr 10;70(8):1781-1787. 64. 19.Wattles B, Vidwan N, Feygin Y, Jawad K, Creel L, Smith M (in press). 3. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, J Rural Health. Finkelstein JA, Gerber JS, Hyun DY, Linder JA, Lynfield R. Prevalence of inap- propriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. 20.Ray KN, Zhuo S, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Anti- JAMA. 2016 May 3;315(17):1864-73. biotic prescribing during pediatric direct-to-consumer telemedicine visits. Pediatrics. 2019 May;143(5):e20182491. 4. Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR- 21.Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Matusiak LM, Schumock GT. 6):1–12. Antibiotic expenditures by medication class, and healthcare setting in the United States, 2010-2015. Clin Infect Dis. 2018 Jan 6;66(2):185-190. 5. Zetts R, Stoesz A, Smith B, Hyun D. Outpatient antibiotic use and the need for increased antibiotic stewardship. Pediatrics. 2018 Jun;141(6):e20174124. 22.Wattles B, Vidwan N, Ghosal S, Feygin Y, Creel L, Myers J, Woods C, Smith M. Cefdinir use in the Kentucky Medicaid Population: A priority for outpatient 6. Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LM, Wasser- antimicrobial stewardship. J Pediatric Infect Dis Soc. 2019 Dec 11;piz084. man RC, Keren R, Zaoutis TE. Effect of an outpatient antimicrobial steward- ship intervention on broad-spectrum antibiotic prescribing by primary care 23.CDC Train. CDC's Antibiotic Stewardship Training Series. Accessed from pediatricians: a randomized trial. JAMA. 2013 Jun 12;309(22):2345-52. https://www.train.org/cdctrain/training_plan/3697 7. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight 24.CDC. Antibiotic Prescribing and Use in Doctor's Offices: Materials and Refer- TK, Hay JW, Doctor JN. Effect of behavioral interventions on inappropriate ences. Accessed from https://www.cdc.gov/antibiotic-use/community/materi- antibiotic prescribing among primary care practices: a randomized clinical als-references/index.html trial. JAMA. 2016 Feb 9;315(6):562-70. 25.University of Louisville. About Kentucky Antibiotic Awareness. Accessed from 8. Hicks LA, Bartoces MG, Roberts RM, Suda KJ, Hunkler RJ, Taylor TH, Schrag uofl.edu/ky-antibiotic-awareness SJ. US outpatient antibiotic prescribing variation according to geography, 26.CDC. Antibiotic Stewardship Framework for Health Departments. Accessed patient population, and provider specialty in 2011. Clin Infect Dis. 2015 May from https://www.cdc.gov/antibiotic-use/community/programs-measurement/ 1;60(9):1308-16. state-local-activities/framework.html?CDC_AA_refVal=https%3A%2F%2F- 9. Palms DL, Hicks LA, Bartoces M, Hersh AL, Zetts R, Hyun DY, Fleming-Dutra www.cdc.gov%2Fantibiotic-use%2Fcommunity%2Fprograms-measure- KE. Comparison of antibiotic prescribing in retail clinics, urgent care centers, ment%2Fstate-local-activities%2Fstate-activities.html emergency departments, and traditional ambulatory care settings in the United 27.IDSA. CMS Takes a significant step against antimicrobial resistance with hos- States. JAMA Intern Med. 2018 Sep 1;178(9):1267-1269. pital stewardship requirement. 2019. Accessed from https://www.idsociety.org/ 10.Zetts R, Hyun D. To fight superbugs, health insurers play an important role. news--publications-new/articles/2019/cms-takes-a-significant-step-against-an- Pew Charitable Trusts. 2020 Accessed from https://www.pewtrusts.org/en/ timicrobial-resistance-with-hospital-stewardship-requirement/ research-and-analysis/articles/2020/04/02/to-fight-superbugs-health-insurers- 28.NCQA. HEDIS and Performance Measurement. Accessed from https://www. play-an-important-role ncqa.org/hedis/ 11.Barlam TF, et al. Implementing an antibiotic stewardship program: Guidelines 29.Staub MB, Ouedraogo Y, Evans CD, Katz SE, Talley PP, Kainer MA, Nelson by the Infectious Diseases Society of America and the Society for Healthcare GE. Analysis of a high-prescribing state's 2016 outpatient antibiotic prescrip- Epidemiology of America. Clin Infect Dis. 2016 May 15;62(10)e51-77. tions: Implications for outpatient antimicrobial stewardship interventions. 12.The Joint Commission. Antimicrobial Stewardship in Ambulatory Health Infect Control Hosp Epidemiol. 2020 Feb;41(2):135-142. Care. R3 Report. 2019 June 20; Accessed from https://www.jointcommission. 30.Katz SE, Staub M, Ouedraogo Y, Evans CD, Kainer MA, Griffin MR, Banerjee org/-/media/tjc/documents/standards/r3-reports/r3_23_antimicrobial_stew- R. Population-based assessment of patient and provider characteristics influ- ardship_amb_6_14_19_final2.pdf?db=web&hash=81604D26AD039EA9ABB- encing pediatric outpatient antibiotic use in a high antibiotic-prescribing state. FBBA8907F8430 Infect Control Hosp Epidemiol. 2020 Mar;41(3):331-336. 13.Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions 31.Winders HR, Royer J, Younas M, Justo JA, Bookstaver PB, Weissman SB, Bell - United States, 2018. Accessed from https://www.cdc.gov/antibiotic-use/ L, Waites KS, Plante J, Al-Hasan MN. Temporal trends in ambulatory antibi- community/programs-measurement/state-local-activities/outpatient-antibiot- otic prescription rates in South Carolina: Impact of age, gender and resident ic-prescriptions-US-2018.html location. Infect Control Hosp Epidemiol. 2020 Jun 5;1-4. 14.Ray MJ, Tallman GB, Bearden DT, Elman MR, McGregor JC. Antibiotic pre- 32.Lake J, Frydrich V, Gonzales V, Alonso EM, LaFleur J. Antibiotic Utilization scribing without documented indication in ambulatory care clinics: national in Pediatric Patients. Utah Medicaid DUR Report. September 2017. Accessed cross sectional study. BMJ. 2019 Dec 11;367:I6461. from https://medicaid.health.utah.gov/pharmacy/drugutilization/files/Crite- 15.Watson JR, Wang L, Klima J, et al. Healthcare Claims Data: An Underutilized ria%20Review%20Documents/2017/2017.09%20Pediatric%20Codeine%20 Tool for Pediatric Outpatient Antimicrobial Stewardship. Clin Infect Dis. Jun 1 &%20Tramadol%20Use.pdf 2017;64(11):1479-1485. 33.Kaiser Family Foundation (KFF). Medicaid State Fact Sheets. 2020. Accessed 16.Chua KP, Fischer MA, Linder JA. Appropriateness of outpatient antibiotic from https://www.kff.org/interactive/medicaid-state-fact-sheets/ prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ. 2019 Jan 16;364:k5092. 4