The more antibiotics are used, the less effective they become—which is why ensuring appropriate use is essential to slowing the emergence of multidrug-resistant bacteria. Although there has been encouraging progress in recent years in the collection and availability of data regarding antibiotic use in human health care, inappropriate use persists, and enhanced information about antibiotic prescribing practices is needed to drive further progress.
One leading source of such indicators is the National Committee for Quality Assurance (NCQA), which evaluates health insurance plans using a set of performance measures known as the Healthcare Effectiveness Data and Information Set (HEDIS). These measures assess the quality of care provided to members of major insurance plans for a wide range of health issues, allowing stakeholders to compare the performance of health plans and identify opportunities for improvement. Additionally, public and private payers are increasingly using HEDIS measures, including those that assess antibiotic use, to systematically factor quality of care delivered by providers in their network into reimbursement calculations.
Earlier this year, NCQA proposed improvements to HEDIS measures that assess antibiotic use associated with three common acute respiratory conditions: bronchitis, upper respiratory infections (URI), and pharyngitis (sore throat). Bronchitis and URI are almost always caused by viruses—not bacteria—and therefore will not respond to antibiotic treatment. Pharyngitis is caused by a number of pathogens but should be treated with antibiotics only when tests show that the condition is caused by group A Streptococcus. Understanding prescribing practices for these illnesses is particularly useful for stewardship efforts, because the conditions are associated with a large proportion of unnecessary outpatient antibiotic prescribing in the U.S.
The Pew Charitable Trusts’ antibiotic resistance project submitted comments in support of NCQA’s proposed updates, which would take effect in 2020, and further improve the ability of health care stakeholders to assess antibiotic prescribing through the following changes:
Expansion of the observed patient population. NCQA wants to include both adult and pediatric patients in the population captured by its measures for the three conditions, providing a more comprehensive assessment of antibiotic use. The bronchitis measure currently includes only adults ages 18-64, and the URI and pharyngitis measures include only the pediatric population (health plan members 3 months to 18 years old and those ages 3 to 18 years, respectively). Additionally, NCQA would report the data by age group, allowing health care stakeholders to identify changes in prescribing trends and better target antibiotic stewardship activities. For example, a recent study found that decreases in antibiotic prescribing rates were being driven primarily by decreased prescribing for pediatric patients. NCQA’s proposed approach to data reporting would help illuminate these kinds of nuances behind population-level change. Finally, NCQA proposed including telehealth visits in the eligible episodes captured by the URI and pharyngitis measures, which would allow for a more comprehensive picture of antibiotic prescribing for those conditions.
Improved accounting of inappropriate prescribing episodes. Currently, NCQA’s measures use a member-based denominator, with each health plan member counted only once, even for multiple diagnoses of the associated condition through the year. Its proposal to change to an episode-based denominator—with each eligible visit counted, even if for the same member—would result in a more accurate count of visits that lead to inappropriate antibiotic prescribing. Additionally, tightening up the criteria under which patients are included in the count— such as excluding patients with comorbid conditions for which antibiotic use may be warranted—would further improve the relevance of visits captured for these diagnoses.
Pew’s antibiotic resistance team urges NCQA to finalize these proposed changes to existing appropriate antibiotic use measures for HEDIS 2020 and looks forward to working with other stakeholders to leverage this and other data to drive improvements to antibiotic stewardship in the U.S.—a critical component of the fight against antibiotic-resistant bacteria.
David Hyun, M.D., is a senior officer and Rachel Zetts, M.P.H, is an officer with The Pew Charitable Trusts’ antibiotic resistance project.