AFMC Closer Look MAR dd

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					                        A                   AR   L LOOK AT A T
                                   C L O S E CLOSERO O K QUALITY Q U A L I T Y
                                                               EDITORIAL PANEL: WILLIAM E. GOLDEN, MD;
                                                            NANCY ARCHER, RN, BS, CPHQ; NENA SANCHEZ, MS

                             Antibiotic prescribing
                                 in Arkansas:
             Compliance with national standards varies widely
                                                          alization for prescribing antibiotics                      URI therapy
     and CLAYTON WELLS, MS                                for pharyngitis without confirma-                               AFMC examined claims data
                                                          tion of streptococcal infection.                           for ARKids First A and B recipients
       ntibiotic resistance is now a                          Several years ago, AFMC                                between the ages of 3 months and
        subject of international con-                     embarked on statewide data collec-                         18 years from January 1, 2003, to
         cern and even mainstream                         tion on antibiotic prescribing and                         December 31, 2003. Claims included
media coverage. Yet in many parts                         launched a multimedia educational                          for analysis contained only the diagno-
of Arkansas, patients presenting                          campaign under the tagline, “Save                          sis of URI, a negative 30-day medica-
with upper respiratory symptoms                           the Antibiotic.” Clinical and com-                         tion history prior to the office visit
or sore throat are likely to receive                      munications staff collaborated on a                        and continuous enrollment during the
antibiotics without further testing,                      toolkit for outpatient offices to offer                    30 days surrounding the visit for URI.
according to Medicaid data ana-                           patients alternative therapies for                              Overall, more than two-thirds
lyzed by the Arkansas Foundation                          respiratory conditions. The campaign                       (70.4%) of patients appropriately did
for Medical Care (AFMC).                                  also included outreach education to                        not receive antibiotics for their upper
    Increasing resistance to antibiotics                  schools and daycare centers, as well as                    respiratory tract infection. Performance
by community-acquired pathogens has                       public service messages for statewide                      on this measure varied widely; how-
been a focus of public health policy for                  media outlets.                                             ever, more than 90% of patients in
the past 10 to 15 years. Efforts have                         The AFMC project predated the                          Crittenden and Faulkner counties did
concentrated on educating physicians                      development of related clinical per-                       not receive antibiotics for upper respira-
and patients about the dangers of                         formance measures by the National                          tory tract infection, while patients in
overprescribing antibiotics, particularly                 Committee on Quality Assurance                             Garland, Hempstead, Jefferson, Miller,
for conditions for which they are inef-                   (NCQA). The NCQA now bench-                                Pope, Pulaski and Union counties
fective: most notably, viral upper respi-                 marks managed care companies, as                           received appropriate care in more than
ratory tract infections and sore throats.                 well as state Medicaid programs, on                        80% of episodes. In contrast, patients
    Nearly all URI conditions in oth-                     system-wide compliance with clinical                       in Calhoun and Drew counties received
erwise healthy ambulatory patients                        standards to reduce inappropriate pre-                     antibiotics inappropriately in more than
reflect viral disease not responsive                      scribing of antibiotics. The measures                      40% of clinical episodes of upper respi-
to antimicrobial therapy. Moreover,                       use claims data to determine whether                       ratory tract infection.
the vast majority of sore throats                         patients with common respiratory tract                          Overall, care of patients in central
are not caused by Group A strep.                          diagnoses received antibiotics associ-                     Arkansas complied with standards 82%
Antibiotics offer no more than a                          ated with an office visit for such com-                    of the time, while the northeast section
half-day improvement in symptom                           plaints, and whether patients received                     of the state had the lowest compliance
reduction for strep throat and serve                      antibiotics for a sore throat without an                   with 64.4%. Young children were less
mainly to prevent post-streptococcal                      associated claim for pharyngeal testing                    likely to receive antibiotics than older
rheumatic fever. There is no ration-                      for streptococcal disease.                                 adolescents. Nearly 80% of patients

The Arkansas Foundation for Medical Care is the Quality Improvement Organization for Medicare and Medicaid in Arkansas. AFMC works collaboratively with providers, community
groups and other stakeholders to promote the quality of care in Arkansas through evaluation and education. For more information about AFMC quality improvement projects,
call 1-877-375-5700.
          A                       L O O K      A T
                   C L O S E R CLOSER LOOK AT QUALITY Q U A L I T Y

under 12 months of age did not receive
antibiotics, whereas only 60% of teen-          Rate of appropriate URI treatment                                    State Fiscal Year 2000
agers between 15 and 18 years old were
                                                (ARKids First A and B), by region                                    State Fiscal Year 2004
not treated with antimicrobial therapy
for URI symptoms.                                            0.0%                                   50.0%                             100.0%
                                                 Northwest                                                            70.7%
Pharyngitis                                                                                                     61.0%
     The clinical literature supports            Northeast                                                        64.4%
pretreatment diagnostic testing for the                                                                                   77.7%
                                                 Central                                                                    81.5%
presence of strep pharyngitis as more
cost-effective than treating all patients        Southwest                                                          67.7%
with antibiotics. The reliance on pre-                                                                              68.5%
treatment testing reflects disease preva-                                                                          66.8%
lence, risk of allergic reactions, and the       STATEWIDE                                                          67.5%
                                                 TOTAL                                                                70.4%
problems of antimicrobial resistance.
For patients with positive cultures,             SOURCE: AFMC Department of Projects and Analysis

guidelines recommend the use of peni-
cillin to treat Group A strep.
     The NCQA performance measure
examines care for children between              Rate of appropriate pharyngitis testing                                            SFY 2000
2 and 18 years of age and requires              for children (ARKids First A and B), by region                                     SFY 2004
administrative claims for strep testing                      0.0%                                   50.0%                             100.0%
if the illness episode is connected with
provision of an antibiotic. Performance          Northwest                                     38.9%
on this clinical measure is low in the                              2.6%
                                                 Northeast                                 32.5%
ARKids First A and B programs but has
shown steady improvement over the                                    5.2%
                                                 Central                                            43.4%
past five years. For calendar year 2003,                            2.7%
approximately one-third of patients              Southwest                          24.4%
received strep testing prior to receipt of       Southeast
antibiotics. While low, this rate com-
                                                 STATEWIDE           4.8%
pares favorably to care in 1998, when            TOTAL                                      35.0%
less than 5% of patients received diag-
                                                 SOURCE: AFMC Department of Projects and Analysis
nostic testing prior to treatment.
     Again, performance across the
state varied widely. Faulkner, Carroll,
Izard, and Newton counties tested at          Both measures are currently under                     mine when antibiotics are appropriate
least 60% of children presenting with         review by the National Quality Forum,                 and communicate clearly with patients
symptoms of pharyngitis. Yet, patients        and will likely be adopted by other pay-              and families. For more information, call
rarely received testing in Bradley,           ers and become candidates for national                1-877-375-5700. ▲
Clark, White and Yell counties, where         reporting for physician clinical care.
the rate was 5% or less. Statewide, the           In the interest of public health and              Dr. William E. Golden is vice president
highest rates of pretreatment testing         the well-being of our patients — as                   for clinical quality improvement for the
were in central Arkansas at 43%, and          well as meeting nationally accepted                   Arkansas Foundation for Medical Care
the lowest was in the southwest sector        standards of care — we must refrain                   and professor of medicine and public
of the state at 24%.                          from prescribing antibiotics in situa-                health at the University of Arkansas for
     AFMC will follow up the results of       tions where they are not effective or                 Medical Sciences.
this data with office detailing of clinical   not needed, regardless of pressure from
standards and toolkits, particularly in       patients, parents or other caretakers.                Clayton Wells is the Medicaid data
counties with low clinical performance        AFMC offers free tools and assistance                 analysis manager for the Arkansas
on these national standards for care.         to help clinicians in Arkansas deter-                 Foundation for Medical Care.