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 BY WILLIAM E. GOLDEN, MD, 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 A 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% 68.4% 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 64.3% cost-effective than treating all patients Southwest 67.7% with antibiotics. The reliance on pre- 68.5% Southeast 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 7.3% 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 4.9% 32.1% 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.