EDITORIAL PANEL : Chad T . Rodgers , MD , FAAP | Elena M . Davis , MD , MPH | Shannon Edwards , MD | William L . Mason , MD | J . Gary Wheeler , MD , MPS | Beth Milligan , MD , FAAFP , CHCQM , CPE
Outpatient Antibiotic Stewardship
WILLIAM GOLDEN , MD , MACP , LARRY BALLARD , CPC +, PCCM , E . J . SHOPTAW , MS , AND MARLO HARRIS , MS
Reducing the overuse of antibiotics has been a focus for quality improvement in the hospital and longterm care settings . Facilities have instituted structured reviews and protocols to avoid lengthy durations of treatment and utilization of inappropriate broad-spectrum agents .
Outpatient antibiotic stewardship is less well-developed and effective . Antimicrobials are prescribed routinely for common respiratory conditions , despite evidence to the contrary . The Arkansas Medicaid episodes of care initiative successfully reduced antibiotic prescribing from 50 % of viral URIs to the low 30s . It was not effective in lessening the 90 % antibiotic use for acute sinusitis visits that warrant such treatment infrequently . Pharyngitis , bronchitis , and otitis are other conditions with substantial overuse of antibiotics .
Two years ago , Arkansas Medicaid joined with the Arkansas Department of Health ( ADH ) to participate in a CDC initiative promoting outpatient antibiotic stewardship in the state . ADH has pursued an academic detailing effort with primary care offices , distributing posters and educational fliers for physicians and patients .
Arkansas Medicaid has developed a new data-driven approach for its Patient-Centered Medical Home ( PCMH ) program . The PCMH program has developed a report card for each medical home in Arkansas by determining the number of antibiotic prescriptions per 100 patients who were in a practice panel for at least six months . The practice variation in medical home performance is substantial and provides an opportunity for all prescribers to benchmark their practice style to peers in the state .
The PCMH program modeled its report card after the national IQVIA analysis provided to the CDC . Using all-payer pharmacy claims , the IQVIA mapped each state by its antibiotic outpatient prescribing . In 2018 , the national rate was 76 prescriptions per 100 patients . The western United States prescribed antibiotics the lowest , 55 per 100 patients while the southern US had a rate of 86 per 100 patients , over 50 % higher .
The Arkansas rate was 101 filled prescriptions per 100 patients , over 25 % higher than the national average . While 7th highest in the country , Arkansas was not as pronounced as Kentucky that had nearly 113 antibiotic prescriptions per 100 patients .
Table 1 displays the practice variation in Arkansas medical homes . Some practices prescribed at a rate over three times higher than sites with more selective use of antibiotics . The Arkansas Medicaid prescribing values were very similar to the all-payer IQVIA prescription data , so it appears that payer source does not affect antibiotic utilization .
This practice variation sends an interesting message : if the antibiotics were clinically necessary , practices with the lowest rates of prescribing should have had complications from under treatment . Such adverse clinical outcomes are not prevalent . On the other hand , practices with higher rates of prescribing could safely consider reducing the use of antibiotics without systemic risk .
252 • The Journal of the Arkansas Medical Society www . ArkMed . org