Evaluating the impact of a novel restricted reimbursement policy for quinolone antibiotics: A time series analysis

Abstract

BackgroundPublicly-funded drug plans often use prior authorization policies to limit drug prescribing. To guide physician prescribing of a class of antibiotics with broad antimicrobial activity (quinolone antibiotics) in accordance with new prescribing guidelines, Alberta’s provincial health ministry implemented a new mechanism for formulary restriction entitled the optional special authorization (OSA) program. We conducted an observational study to determine the impact of this new formulary restriction policy on antimicrobial prescription rates as well as any clinical consequences.MethodsQuinolone antibiotic use, and adherence with quinolone prescribing guidelines, was assessed before and after implementation of the OSA program in patients with common outpatient infections using an administrative data cohort and a chart review cohort, respectively. At the same time this policy was implemented to limit quinolone prescribing, two new quinolone antibiotics were added to the formulary. Using administrative data, we analysed a total of 397,534 unique index visits with regard to overall antibiotic utilization, and through chart review, we analysed 1681 charts of patients with infections of interest to determine the indications for quinolone usage.ResultsUsing segmented regression models adjusting for age, sex and physician enrollment in the OSA program, there was no statistically significant change in the monthly rate of all quinolone use (−3.5 (95% CI −5.5, 1.4) prescriptions per 1000 index visits) following implementation of the OSA program (p = 0.74). There was a significant level change in the rate of quinolone antibiotic use for urinary tract infection (−33.6 (95% CI: -23.8, -43.4) prescriptions and upper respiratory tract infection (−16.1 (95%CI: -11.6, -20.6) prescriptions per 1000 index visits. Among quinolone prescriptions identified on chart review, 42.5% and 58.5% were consistent with formulary guidelines before and after the implementation of the OSA program, respectively (p = 0.002). There was no change in hospitalization, mortality or use of physician services after implementation of the OSA program.ConclusionsDespite the addition of two new quinolone antibiotics to the formulary, we found that there was no change in the use of quinolones after implementation of a new formulary restriction policy for outpatients with common outpatient infections.

Antimicrobial Stewardship in Outpatient Settings: A Systematic Review

“…Studies were conducted in the United States or Canada (N = 21), [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Europe or the United Kingdom (N = 24), the Middle East (N = 3), [65][66][67] and the Asia/ Pacific region (N = 2). 68,69 Of these, 14 studies that enrolled adults, 21,22,27,30,31,35,37,[48][49][50]52,56 5 enrolled children or adolescents, 18,20,57,65,68 In 16 studies of provider and/or patient education (5 RCTs, 38,43,44,67,68 6 CRCTs, 18,20,21,…”

“…– 69 Studies were conducted in the United States or Canada (N=21), 18 – 37 Europe or the United Kingdom (N=24), 38 – 64 the Middle East (N=3), 65 – 67 and the Asia/Pacific region (N=2) 68 69 Of these, 14 studies that enrolled adults, 21 , 22 , 27 , 30 , 31 , 35 , 37 , 48 – 50 , 52 , 56 5 enrolled children or adolescents, 18 , 20 , 57 , 65 , 68 and 31 enrolled all ages or did not specify age. Most enrolled patients with respiratory infections (29 trials).…”

“…In total, 20 studies reported return clinic visits, hospitalizations, and/or adverse events including mortality and only 3 found significant differences between intervention and control groups. 30,44,52 Implementation Facilitators…”

Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map

“…Along similar lines, 1 European country (Denmark) explored using reimbursement penalties targeting patients, where the national health insurance plan reimbursed patients a smaller proportion of the antibiotic cost than was previously reimbursed [41]. Three studies in Canada/US [34,36,38] and 1 each in Europe [31] and the Western Pacific [30] also tried reimbursement restrictions, where the patient was not reimbursed the cost of an antibiotic by their national health insurance plan unless the physician met particular guidelines such as proving the existence of an infection or consulting with an infectious disease specialist. In the African region, we found only 2 studies, both targeting the use of antimalarial drugs, and both employing published guidelines to change prescribing [50,51].…”

Inventory of antibiotic stewardship programs in general practice in France and abroad

“…If the request is accepted, the patient can be treated without having to pay for the drug [60]. The number of fluoroquinolone prescriptions has remained stable since this measure was implemented a few years ago, despite the marketing of 2 new agents of this family, and prescriptions seem to be more in line with the recommendations [61].…”