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Decline in oral antimicrobial prescription in the outpatient setting after nationwide implementation of financial incentives and provider education: An interrupted time-series analysis

Published online by Cambridge University Press:  06 April 2022

Kazuaki Jindai Open the ORCID record for Kazuaki Jindai [Opens in a new window] ,
Takahiro Itaya ,
Yusuke Ogawa Open the ORCID record for Yusuke Ogawa [Opens in a new window] ,
Tsukasa Kamitani Open the ORCID record for Tsukasa Kamitani [Opens in a new window] ,
Shunichi Fukuhara ,
Michihiko Goto Open the ORCID record for Michihiko Goto [Opens in a new window]  and
Yosuke Yamamoto Open the ORCID record for Yosuke Yamamoto [Opens in a new window]
Kazuaki Jindai
Affiliation:
Department of Healthcare Epidemiology, School of Public Health, Kyoto University, Japan Department of Virology, Tohoku University Graduate School of Medicine, Japan
Takahiro Itaya
Affiliation:
Department of Healthcare Epidemiology, School of Public Health, Kyoto University, Japan
Yusuke Ogawa
Affiliation:
Department of Healthcare Epidemiology, School of Public Health, Kyoto University, Japan
Tsukasa Kamitani
Affiliation:
Section of Education for Clinical Research, Kyoto University Hospital, Japan
Shunichi Fukuhara
Affiliation:
Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University, Japan Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Japan Shirakawa STAR for General Medicine, Fukushima Medical University, Japan
Michihiko Goto
Affiliation:
Iowa City VA Medical Center, Iowa City, Iowa, United States Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
Yosuke Yamamoto*
Affiliation:
Department of Healthcare Epidemiology, School of Public Health, Kyoto University, Japan
*
Author for correspondence: Yosuke Yamamoto MD, PhD, E-mail: yamamoto.yosuke.5n@kyoto-u.ac.jp
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Abstract

Objectives:

To assess the impact of nationwide outpatient antimicrobial stewardship interventions in the form of financial incentives for providers and provider education when antimicrobials are deemed unnecessary for uncomplicated respiratory infections and acute diarrhea.

Methods:

We collected data from a large claims database from April 2013 through March 2020 and performed a quasi-experimental, interrupted time-series analysis. The outcome of interest was oral antimicrobial prescription rate defined as the number of monthly antimicrobial prescriptions divided by the number of outpatient visits each month. We examined the effects of financial incentive to providers (ie, targeted prescriptions for those aged ≤2 years) and provider education (ie, targeted prescriptions for those aged ≥6 years) on the overall antimicrobial prescription rates and how these interventions affected different age groups before and after their implementation.

Results:

In total, 21,647,080 oral antimicrobials were prescribed to 2,920,381 unique outpatients during the study period. At baseline, prescription rates for all age groups followed a downward trend throughout the study period. Immediately after the financial incentive implementation, substantial reductions in prescription rates were observed among only those aged 0–2 years (−47.5 prescriptions per 1,000 clinic visits each month; 95% confidence interval, −77.3 to −17.6; P = .003), whereas provider education immediately reduced prescription rates in all age groups uniformly. These interventions did not affect the long-term trend for any age group.

Conclusion:

These results suggest that the nationwide implementation of financial incentives and provider education had an immediate effect on the antimicrobial prescription but no long-term effect.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 44 , Issue 2 , February 2023 , pp. 253 - 259
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Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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Footnotes

a

Authors of equal contribution.

PREVIOUS PRESENTATION: Part of this study was presented at Society for Clinical Epidemiology Fourth Annual Meeting, on October 30, 2021, in Tokyo, Japan.

References

The national action plan on antimicrobial resistance (AMR) 2016–2020. Government of Japan website. http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000138942.pdf. Published 2016. Accessed January 13, 2022.Google Scholar
Muraki, Y, Yagi, T, Tsuji, Y, et al. Japanese antimicrobial consumption surveillance: first report on oral and parenteral antimicrobial consumption in Japan (2009–2013). J Glob Antimicrob Resist 2016;7:19–23.CrossRefGoogle ScholarPubMed
Surveillance of antimicrobial use based on national database for prescription and national health check-up. AMR Clinical Reference Center website. http://amrcrc.ncgm.go.jp/surveillance/010/20181128172333.html. Published 2020. Accessed January 13, 2022.Google Scholar
Jindai, K, Kusama, Y, Gu, Y, Honda, H, Ohmagari, N. Narrative review: the process of expanding the manual of antimicrobial stewardship by the government of Japan. Intern Med 2021;60:181–190.CrossRefGoogle ScholarPubMed
Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.CrossRefGoogle ScholarPubMed
FY 2018 revision of medical fee. (Japanese only.) Ministry of Health, Labor, and Welfare website. https://www.mhlw.go.jp/file/06-Seisakujouhou-12400000-Hokenkyoku/0000198532.pdf. Accessed January 13, 2022.Google Scholar
Infectious Diseases Control Division, Health Service Bureau. Manual of antimicrobial stewardship, first edition. (Japanese only.) Ministry of Health, Labour and Welfare website. https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000193504.pdf. Published 2017. Accessed January 13, 2022.Google Scholar
Balinskaite, V, Johnson, AP, Holmes, A, Aylin, P. The impact of a national antimicrobial stewardship program on antibiotic prescribing in primary care: an interrupted time series analysis. Clin Infect Dis 2019;69:227–232.CrossRefGoogle ScholarPubMed
Ellegård, LM, Dietrichson, J, Anell, A. Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? Health Econ 2018;27:e39–e54.CrossRefGoogle ScholarPubMed
The JMDC claims database. JMDC website. https://www.jmdc.co.jp/en/jmdc-claims-database. Accessed January 3, 2022.Google Scholar
Nagai, K, Tanaka, T, Kodaira, N, Kimura, S, Takahashi, Y, Nakayama, T. Data resource profile: JMDC claims databases sourced from medical institutions. J Gen Fam Med 2020;21:211–218.CrossRefGoogle ScholarPubMed
Kimura, Y, Fukuda, H, Hayakawa, K, et al. Longitudinal trends of and factors associated with inappropriate antibiotic prescribing for nonbacterial acute respiratory tract infection in Japan: a retrospective claims database study, 2012–2017. PLoS One 2019;14:e0223835.CrossRefGoogle ScholarPubMed
Sato, D, Goto, T, Uda, K, Kumazawa, R, Matsui, H, Yasunaga, H. Impact of national guidelines for antimicrobial stewardship to reduce antibiotic use in upper respiratory tract infection and gastroenteritis. Infect Control Hosp Epidemiol 2021;42:280–286.CrossRefGoogle ScholarPubMed
Anatomical therapeutic chemical (ATC) classification. World Health Organization website. https://www.who.int/tools/atc-ddd-toolkit/atc-classification. Accessed March 20, 2021.Google Scholar
Shadish, WR, Cook, TD, Campbell, DT. Experimental and Quasi-experimental Designs for Generalized Causal Inference. Boston: Houghton Mifflin; 2002.Google Scholar
Saito, H, Noda, H, Takakura, S, Jindai, K, Takahashi McLellan, R, Asanuma, K. First major practical step toward appropriate antimicrobial use by the government of Japan. Jpn J Infect Dis 2019;72:56–57.CrossRefGoogle ScholarPubMed
Infectious Diseases Control Division, Health Service Bureau. Manual of antimicrobial stewardship, first edition, digest version. (Japanese only.) Ministry of Health, Labor, and Welfare website. https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/tebiki_1.pdf. Published 2017. Accessed October 31, 2020.Google Scholar
Gillings, D, Makuc, D, Siegel, E. Analysis of interrupted time series mortality trends: an example to evaluate regionalized perinatal care. Am J Public Health 1981;71:38–46.CrossRefGoogle ScholarPubMed
Wagner, AK, Soumerai, SB, Zhang, F, Ross-Degnan, D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002;27:299–309.CrossRefGoogle ScholarPubMed
BigQuery: Cloud Data Warehouse. Google Cloud website. https://cloud.google.com/bigquery. Accessed January 13, 2022.Google Scholar
Wise, J. Hospitals and GPs are offered incentives to reduce antibiotic prescribing. BMJ 2016;352:i1499.CrossRefGoogle ScholarPubMed
Bou-Antoun, S, Costelloe, C, Honeyford, K, et al. Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis. J Antimicrob Chemother 2018;73:2883–2892.CrossRefGoogle ScholarPubMed
Jindai, K, Goto, M, MacKay, K, et al. Improving fluoroquinolone use in the outpatient setting using a patient safety initiative. Infect Control Hosp Epidemiol 2018;39:1108–1111.CrossRefGoogle ScholarPubMed
Persell, SD, Doctor, JN, Friedberg, MW, et al. Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial. BMC Infect Dis 2016;16:373.CrossRefGoogle ScholarPubMed
FY 2020 revision of medical fee (Japanese only). Ministry of Health, Labor, and Welfare website. https://www.mhlw.go.jp/content/12400000/000605493.pdf. Accessed January 13, 2022.Google Scholar
Infectious Diseases Control Division, Health Service Bureau. Manual of antimicrobial stewardship, second edition. (Japanese only). Ministry of Health, Labor, and Welfare website. https://www.mhlw.go.jp/content/10900000/000573655.pdf. Published 2019. Accessed March 20, 2021.Google Scholar
Gerber, JS, Prasad, PA, Fiks, AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013;309:2345–2352.CrossRefGoogle ScholarPubMed
Gerber, JS, Prasad, PA, Fiks, AG, et al. Durability of benefits of an outpatient antimicrobial stewardship intervention after discontinuation of audit and feedback. JAMA 2014;312:2569–2570.CrossRefGoogle ScholarPubMed
Yamamoto, S, Gu, Y, Fujitomo, Y, et al. Development and efficacy of a clinician-targeted refresher course for treating nonpneumonia respiratory tract infections. J Gen Fam Med 2018;19:127–132.CrossRefGoogle ScholarPubMed
Muraki, Y, Kusama, Y, Tanabe, M, et al. Impact of antimicrobial stewardship fee on prescribing for Japanese pediatric patients with upper respiratory infections. BMC Health Serv Res 2020;20:399–399.CrossRefGoogle ScholarPubMed
Hashimoto, H, Saito, M, Sato, J, et al. Indications and classes of outpatient antibiotic prescriptions in Japan: a descriptive study using the national database of electronic health insurance claims, 2012–2015. Int J Infect Dis 2019;91:1–8.CrossRefGoogle ScholarPubMed
van Walraven, C, Bennett, C, Forster, AJ. Administrative database research infrequently used validated diagnostic or procedural codes. J Clin Epidemiol 2011;64:1054–1059.CrossRefGoogle ScholarPubMed
Yamana, H, Moriwaki, M, Horiguchi, H, Kodan, M, Fushimi, K, Yasunaga, H. Validity of diagnoses, procedures, and laboratory data in Japanese administrative data. J Epidemiol 2017;27:476–482.CrossRefGoogle ScholarPubMed
Koram, N, Delgado, M, Stark, JH, Setoguchi, S, de Luise, C. Validation studies of claims data in the Asia-Pacific region: a comprehensive review. Pharmacoepidemiol Drug Saf 2019;28:156–170.CrossRefGoogle ScholarPubMed
Horsky, J, Drucker, EA, Ramelson, HZ. Accuracy and completeness of clinical coding using ICD-10 for ambulatory visits. AMIA Annu Symp Proc 2018;2017:912–920.Google ScholarPubMed
Kontopantelis, E, Doran, T, Springate, DA, Buchan, I, Reeves, D. Regression based quasi-experimental approach when randomisation is not an option: interrupted time series analysis. BMJ 2015;350:h2750.CrossRefGoogle Scholar
Hicks, LA, Bartoces, MG, Roberts, RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015;60:1308–1316.Google ScholarPubMed
Uda, K, Kinoshita, N, Morisaki, N, Kasai, M, Horikoshi, Y, Miyairi, I. Targets for optimizing oral antibiotic prescriptions for pediatric outpatients in Japan. JJID 2019;72:149–159.Google ScholarPubMed
Bernal, JL, Cummins, S, Gasparrini, A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol 2016;46:348–355.Google Scholar
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