Developing a quality measure to assess use of antibiotic medications for respiratory conditions

Implementing with intention: advantages, challenges, and tactics to optimally utilize the AXR metric

Antibiotic utilization for respiratory conditions (AXR) is a new Healthcare Effectiveness Data & Information Set ® (HEDIS®) measure designed to complement disease-specific metrics to improve outpatient antibiotic prescribing. Unique challenges include ensuring clinicians understand the metric and establishing appropriate goals within different health systems and service lines. Successful implementation requires awareness of the metric's limitations and may be enhanced by co-reporting with condition-specific antibiotic use metrics to prioritize local interventions.

Navigating performance measures for ambulatory antimicrobial stewardship: a review of HEDIS® and other metrics the steward should know

Ambulatory antimicrobial stewardship can be challenging due to disparities in resource allocation across the care continuum, competing priorities for ambulatory prescribers, ineffective communication strategies, and lack of incentive to prioritize antimicrobial stewardship program (ASP) initiatives. Efforts to monitor and compare outpatient antibiotic usage metrics have been implemented through quality measures (QM). Healthcare Effectiveness Data and Information Set (HEDIS®) represent standardized measures that examine the quality of antibiotic prescribing by region and across insurance health plans. Health systems with affiliated emergency departments and ambulatory clinics contribute patient data for HEDIS measure assessment and are directly related to value-based reimbursement, pay-for-performance, patient satisfaction measures, and payor incentives and rewards. There are four HEDIS® measures related to optimal antibiotic prescribing in upper respiratory tract diseases that ambulatory ASPs can leverage to develop and measure effective interventions while maintaining buy-in from providers: avoidance of antibiotic treatment for acute bronchitis/bronchiolitis, appropriate treatment for upper respiratory infection, appropriate testing for pharyngitis, and antibiotic utilization for respiratory conditions. Additionally, there are other QM assessed by the Centers for Medicare and Medicaid Services (CMS), including overuse of antibiotics for adult sinusitis. Ambulatory ASPs with limited resources should leverage HEDIS® to implement and measure successful interventions due to their pay-for-performance nature. The purpose of this review is to outline the HEDIS® measures related to infectious diseases in ambulatory care settings. This review also examines the barriers and enablers in ambulatory ASPs which play a crucial role in promoting responsible antibiotic use and the efforts to optimize patient outcomes.

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Importance

Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care).

Objective

To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs).

Design, Setting, and Participants

This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022.

Exposure

Setting of telemedicine visit as PCP vs DTC.

Main Outcomes and Measures

The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes.

Results

In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]).

Conclusions and Relevance

Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.