At first glance, a for-profit health insurer and the United States’ leading national public health institute may not seem to have that much in common.
But while Aetna and the Centers for Disease Control and Prevention play two very different roles in the healthcare world, they have recently begun working toward one common goal: reducing the frequency of unnecessary antibiotic prescriptions.
Aetna got the partnership started by reaching out to the CDC to explore ways to better educate its network of providers about antibiotic stewardship, said Daniel Knecht, M.D., the company’s head of clinical strategy.
“This is an area where we feel that we can leverage our data analytics and our ability to partner with our provider community, as well as collaborate with a group like the CDC,” he said.
So far, the partnership between Aetna and the CDC has resulted in targeted outreach to select clinicians who, according to the data, aren’t following the CDC’s guidelines for prescribing antibiotics for acute bronchitis in adults. But while the focus so far has been somewhat narrow, the problem that the two organizations are taking on is a powerful one.
A health issue with high stakes
The overuse of antibiotics in clinical settings contributes to antibiotic resistance, which according to Knecht is “one of the biggest threats to our collective health across the globe.”
In biological terms, it’s simply a natural evolutionary adaptation by bacteria in which they “flip a switch” to turn on an antibiotic-resistance gene when exposed to such drugs.
But not only does antibiotic resistance make conditions like skin infections, pneumonia and tuberculosis harder to treat, it has also given rise to dangerous multidrug-resistant infections. Those infections, Knecht noted, often must be treated with “backup drugs” that must be administered intravenously, putting patients at risk for further infections.
Antibiotic resistance has other serious consequences in the medical world, as well.
“It’s not just that we can’t treat infections, there’s a whole slew of amazing medical technologies that we wouldn’t be able to use if the antibiotics stopped working,” Knecht said. These include C-sections, organ transplantation and chemotherapy, all of which would be too dangerous to implement without antibiotics.
“There are so many compelling reasons why we have to be thoughtful and prudent when we use antibiotics,” he added.
Data-driven provider outreach
The CDC and Aetna decided to focus on one specific quality measure from the Healthcare Effectiveness Data and Information Set (HEDIS)—antibiotic avoidance in adults with acute bronchitis—because of the “sheer number” of antibiotics prescribed for respiratory conditions, according to Knecht.
Indeed, 44% of antibiotics prescribed in an outpatient setting are for acute respiratory conditions that include bronchitis, and 50% of them are unnecessary, according to a report from The Pew Charitable Trusts. Such conditions are largely caused by viral illnesses or allergies, neither of which respond to antibiotics.
Looking specifically at the HEDIS data, doctors appropriately avoid antibiotic misuse for acute bronchitis only a little under 30% of the time. That’s a metric that has “perennially been difficult to budge,” Knecht pointed out.
When Aetna dug into its own data, a similar pattern emerged. Among its in-network providers in four select specialties, 1,115 were outliers who fell under the “high avoidance failure” category, meaning they prescribed antibiotics 50% of the time or more to treat adult acute bronchitis. Meanwhile, just 127 providers met the criteria for “high avoidance success,” or avoiding prescribing antibiotics 100% of the time for that condition.
Those in the former category received a letter from Aetna that lets them know how their prescribing patterns measure up to those of their peers; outlines the threat of antibiotic resistance; and offers them an email address where they can reach Aetna to learn more.
“We really want this to be an opportunity to engage with our provider community in a productive dialog, and by no means is this punitive,” Knecht said.
A "cordial and collaborative" response
So far, it appears the letters are having their intended effect—at least on a small scale—as a handful of providers have taken Aetna up on its offer to learn more.
“They really wanted to better understand the data,” Knecht said. So Aetna obliged by reviewing their individual prescribing data in a HIPAA-compliant manner, as well as patients’ clinical data, and then discussing those findings with the interested clinicians.
Most generally agreed their prescribing habits could improve, he said, and the interactions have all been “cordial and collaborative.” As many clinicians have encountered antibiotic-resistant bacteria, they know how hard it is to treat, “so they understand the implications and they sincerely want to play a positive role,” he added.
As for why antibiotic prescribing habits are so misaligned with CDC guidelines in the first place, Knecht said that as a physician, he knows the answer is complicated. Part of the problem, he said, is that antibiotics are “victims of their own success,” since they are so effective at treating certain infections.
Human psychology, of course, also plays a role.
“It’s very validating and comforting for patients to receive an antibiotic prescription when they’re not feeling well,” Knecht noted. And because doctors are trained to alleviate pain and suffering, “it’s sort of a confluence of us wanting to help and the patient wanting to get the prescription.”
Ultimately, changing providers’ prescribing habits is only one small part of the fight against antibiotic resistance, as the majority of antibiotics are used in the agricultural sector on animals like pigs and chickens.
While Knecht acknowledged that Aetna has no influence in that domain, he said the insurer and the CDC still feel it’s important to make a difference in how antibiotics are used clinically for humans.
And for the time being, Aetna is focused primarily on changing provider behavior, “because they have the power of the pen and the prescription pad,” he said.
But the letter sent to providers also directed them to the CDC’s “Get Smart” campaign, which offers a host of member-facing and educational materials aimed at improving antibiotic stewardship.
“Something in the future we’d consider is educational outreach to our members as well,” Knecht said.