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Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross
Kao-Ping Chua1, Michael A Fischer2, Jeffrey A Linder3
1Department of Pediatrics, Child Health Evaluation and Research Center, University of Michigan Medical School, 300 N Ingalls Street, SPC 5456 Room 6E18, Ann Arbor, MI 48109-5456, USA chuak@med.umich.edu.
Insights
Inappropriate antibiotic prescribing was common among privately insured US children and adults in 2016, with over 23% of outpatient prescription fills deemed inappropriate. This highlights a significant need for improved antibiotic stewardship in outpatient settings.
Area of Science:
- Health Services Research
- Infectious Diseases
- Pharmacology
Background:
- Antibiotic resistance is a growing global health threat, necessitating careful stewardship of antibiotic use.
- Accurate assessment of outpatient antibiotic prescribing appropriateness is crucial for combating resistance.
- The transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) in the US required updated methods for analyzing diagnosis codes.
Purpose of the Study:
- To evaluate the appropriateness of outpatient antibiotic prescribing for privately insured children and non-elderly adults in the United States.
- To develop and apply a comprehensive classification scheme for ICD-10-CM diagnosis codes to assess antibiotic prescribing patterns.
- To quantify the proportion of antibiotic prescription fills that were appropriate, potentially appropriate, or inappropriate.
Main Methods:
- A cross-sectional study was conducted using the 2016 MarketScan Commercial Claims and Encounters database, covering 19.2 million enrollees.
- A classification scheme was developed to categorize 91,738 ICD-10-CM diagnosis codes as "always," "sometimes," or "never" justifying antibiotic use.
- Antibiotic prescription fills were linked to diagnosis codes within a three-day look-back period to determine appropriateness categories: appropriate, potentially appropriate, inappropriate, or not associated with a recent diagnosis.
Main Results:
- Out of over 15.4 million outpatient antibiotic prescription fills, 12.8% were appropriate, 35.5% potentially appropriate, 23.2% inappropriate, and 28.5% lacked a recent diagnosis code.
- Inappropriate antibiotic prescriptions were most frequently associated with office-based settings (70.7%).
- Approximately 14.1% of all enrollees filled at least one inappropriate antibiotic prescription in 2016, affecting both children (10.6%) and adults (15.2%).
Conclusions:
- A significant proportion (23.2%) of outpatient antibiotic prescription fills were inappropriate for privately insured US children and non-elderly adults in 2016.
- The developed ICD-10-CM classification scheme provides a robust method for measuring outpatient antibiotic appropriateness.
- Findings underscore the need for targeted interventions to improve antibiotic prescribing practices and combat antimicrobial resistance in outpatient settings.
Objective:
To assess the appropriateness of outpatient antibiotic prescribing for privately insured children and non-elderly adults in the US using a comprehensive classification scheme of diagnosis codes in ICD-10-CM (international classification of diseases-clinical modification, 10th revision), which replaced ICD-9-CM in the US on 1 October 2015.
Design:
Cross sectional study.
Setting:
MarketScan Commercial Claims and Encounters database, 2016.
Participants:
19.2 million enrollees aged 0-64 years.
Main Outcome Measures:
A classification scheme was developed that determined whether each of the 91 738 ICD-10-CM diagnosis codes "always," "sometimes," or "never" justified antibiotics. For each antibiotic prescription fill, this scheme was used to classify all diagnosis codes in claims during a look back period that began three days before antibiotic prescription fills and ended on the day fills occurred. The main outcome was the proportion of fills in each of four mutually exclusive categories: "appropriate" (associated with at least one "always" code during the look back period, "potentially appropriate" (associated with at least one "sometimes" but no "always" codes), "inappropriate" (associated only with "never" codes), and "not associated with a recent diagnosis code" (no codes during the look back period).
Results:
The cohort (n=19 203 264) comprised 14 571 944 (75.9%) adult and 9 935 791 (51.7%) female enrollees. Among 15 455 834 outpatient antibiotic prescription fills by the cohort, the most common antibiotics were azithromycin (2 931 242, 19.0%), amoxicillin (2 818 939, 18.2%), and amoxicillin-clavulanate (1 784 921, 11.6%). Among these 15 455 834 fills, 1 973 873 (12.8%) were appropriate, 5 487 003 (35.5%) were potentially appropriate, 3 592 183 (23.2%) were inappropriate, and 4 402 775 (28.5%) were not associated with a recent diagnosis code. Among the 3 592 183 inappropriate fills, 2 541 125 (70.7%) were written in office based settings, 222 804 (6.2%) in urgent care centers, and 168 396 (4.7%) in emergency departments. In 2016, 2 697 918 (14.1%) of the 19 203 264 enrollees filled at least one inappropriate antibiotic prescription, including 490 475 out of 4 631 320 children (10.6%) and 2 207 173 out of 14 571 944 adults (15.2%).
Conclusions:
Among all outpatient antibiotic prescription fills by 19 203 264 privately insured US children and non-elderly adults in 2016, 23.2% were inappropriate, 35.5% were potentially appropriate, and 28.5% were not associated with a recent diagnosis code. Approximately 1 in 7 enrollees filled at least one inappropriate antibiotic prescription in 2016. The classification scheme could facilitate future efforts to comprehensively measure outpatient antibiotic appropriateness in the US, and it could be adapted for use in other countries that use ICD-10 codes.
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