New research suggests large proportions of antibiotic prescriptions to Medicaid recipients are not infection-related.
Part of the problem: Many of the patients in question often didn't receive their prescriptions in the doctor’s office.
A study in the latest issue of Health Affairs found nearly half of antibiotics dispensed to Medicaid recipients are missed by existing U.S. antibiotic stewardship policies. Specifically, the study found 28% of antibiotic prescriptions filled for Medicaid patients between 2004 and 2013 were dispensed without a clinical assessment, and another 17% were associated with clinician visits that did not yield an infection-related diagnosis.
That’s a problem, given most antibiotic stewardship efforts have focused on the appropriateness of a prescription when a patient presents with a diagnosis clearly related to an infection.
The blind spot among current stewardship efforts results from physicians’ widespread underestimation of the number of these prescriptions that have historically been written, according to the study’s lead author, Michael Fischer, M.D., associate professor of medicine at Harvard Medical School. He is also an associate physician in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital.
“When we designed the policies, we were thinking in the framework of a patient and a doctor sitting together in the office, making the decision about antibiotics,” Fischer told FierceHealthcare. “What we didn’t realize was just how common it is that patients are getting an antibiotic prescription without actually seeing the doctor in person—and so the stewardship interventions we designed weren’t designed for that kind of scenario.”
Where were these patients getting the prescriptions? Researchers said the interactions took place between patients and prescribing clinicians that were not captured as an encounter billable to Medicaid. But, the study said, researchers assume most of those prescriptions were associated with a telephone interaction or email, electronic health record patient portals or informal, uncaptured visits. In a small percentage of cases, antibiotics may be used chronically, for instance such as suppressive therapy in the setting of an infected prosthetic joint or for dental prophylaxis.
While prescribing antibiotics to a patient outside the office setting doesn’t necessarily make the prescription inappropriate, Fischer says the volume of prescriptions raises worries. “We definitely worry that there are a lot of those prescriptions where either the patient could have been managed without an antibiotic or we can’t be sure they’re getting the right antibiotic,” he said.
Because the study’s analysis relied on a comprehensive set of Medicaid claims data, researchers warn it’s impossible to say exactly how doctors and patients communicated in the process of the medical encounters that led to antibiotic prescriptions. For example, the study notes that some prescriptions could easily have been appropriate responses to lab tests ordered in response to patient complaints delivered via phone, email or home care services.
Fischer points out that antibiotic stewardship interventions can be difficult, because, at any given moment in time, it can be much easier for a physician to err on the side of potentially helping an individual patient versus creating an incremental additional risk to the general population. With the rising use of telehealth services and virtual doctor visits, he sees a valuable opportunity to redirect stewardship efforts. That push will require designing new interventions that fit those new models of interaction between physicians and patients.
“I try to think of it as an opportunity, that we’ve said, ‘Hey, if we’re going to try to do this, and we’re going to try to get better at it over time, at least now we can shine a light on one important population that was potentially being missed before and make the interventions better,'” explains Fischer.
The study’s findings also point out how the key to progress could be flying just under the radar, waiting for a different approach to existing data.
“If this stimulates other people to think creatively, either about identifying potential problems that we didn’t think of or to think of creative solutions to this specific challenge that might be useful for antibiotic stewardship generally, that would be a really useful outcome of all this, too,” Fischer said.