Download Impact of - WHO archives

Abstract
Decreased Inappropriate Antibiotic Use Following a
Korean National Policy to Prohibit Medication
Dispensing by Physicians
Sylvia Park, PhD; Stephen B. Soumerai, ScD; Alyce S. Adams, PhD;
Jonathan A. Finkelstein, MD,MPH; Sunmee Jang, PhD*; Dennis
Ross-Degnan, ScD
Department of Ambulatory Care and Prevention, Harvard Medical
School, USA;Health Insurance Review Agency, Korea*
Problem Statement: Korean government introduced a new policy in July 2000 that prohibited
physicians from dispensing and pharmacists from prescribing medication.
Objectives: To evaluate the impact of the new policy on antibiotic prescribing for cases of
viral disease, in which antibiotic prescribing was likely inappropriate, compared to bacterial
disease, where antibiotic prescribing could be appropriate; to determine provider factors
associated with reductions in inappropriate antibiotic prescribing for viral illness following the
policy change.
Design: Retrospective, before/after study.
Setting and Population: National health insurance claims data on monthly episodes of care
for patients with viral or bacterial illness, collected for January 2000 and January 2001.
Nationally representative sample consisted of 50,999 cases from 1,372 primary care clinics.
Intervention: As of July 2000, physicians were prohibited from dispensing and pharmacists
were prohibited from prescribing.
Outcome Measures: Rate of antibiotic prescribing; average number of different antibiotics
per case.
Results: After the dispensing restriction, antibiotic prescribing declined for both patients with
viral illness (from 80.8% to 72.8%, adjusted relative risk (RR)= 0.89, [95% confidence interval:
0.86, 0.91], p<0.0001) and patients with bacterial illness (from 91.6% to 89.7%, adjusted RR=
0.98, [0.97, 0.99], p=0.0171). Reductions in antibiotic prescribing were significantly larger
(adjusted RR=0.90, [0.87, 0.93], p<0.0001) for patients with viral illness. The number of
different antibiotics prescribed per episode also decreased significantly after the policy, but
there were no significant differences in these reductions between viral and bacterial illness.
The dispensing restriction also reduced prescribing of non-antibiotic drugs, with no difference
by diagnosis. Provider factors found to be associated with reduced inappropriate antibiotic
prescribing were young age and practice location in an urban area.
Conclusions: Prohibiting doctors from dispensing drugs reduced prescribing overall and
selectively reduced inappropriate antibiotic prescribing for patients with viral diagnoses. Since
our findings were based on single observations before and after the policy intervention,
further study using longitudinal data is needed to evaluate the long-term effects of such
policies.
Introduction
Research on Dispensing Doctors
• Dispensing Doctors were found to
- prescribe greater numbers of drugs
- prescribe more antibiotics and injections
- have higher prescribing costs.
• Little is known about whether incentives
related to dispensing affect the quality of
prescribing.
• Most of previous research has been crosssectional.
New Policy in Korea (July, 2000)
• Prohibiting doctors from dispensing drugs
and pharmacists from prescribing drugs
Antibiotics in Korea
• Antibiotics accounted for 20% of
ambulatory drug expenditures in 2000.
• Korea has very high resistance rates, with
86% of Streptococcus pneumoniae
resistant to penicillin in 2001.
Objectives
•
To evaluate the impact of the dispensing
restriction policy in Korea on the quantity
and quality of physician prescribing
- selectivity in the decrease of antibiotic
prescribing in cases with viral illness, in
which antibiotic prescribing was likely
inappropriate, compared to bacterial
illness, where antibiotic prescribing could
be appropriate
•
To investigate provider characteristics
related to the decrease of inappropriate
antibiotic prescribing in viral illness
Methods
Data Collection
NHI monthly claims data(patient level)
- monthly episodes
- diagnosis, prescription, patient information
Jan. 2000
Jan. 2001
(6 months before policy) (6 months after policy)
Viral Illness
Common Cold /
Upper respiratory
tract infection /
Bronchiolitis
Bacterial Illness
Penumonia/ Otitis media/
Tonsilitis/ Strep. Sore
throat/ Sinusitis/ Urinary
tract infection/ Skin and
soft tissue infection
Sampling: 10% of all clinics (1476 clinics)
 20% of claims with above diagnoses in
sampled clinics
Including cases with no commorbidity
From 1372 clinics,
Viral: 18,656(pre), 16,736(post) cases
Bacterial: 7758(pre), 7849(post) cases
Analysis
: Impact of the Policy on Prescribing
 Prescription Variables (patient level)
• Antibiotics
- antibiotic prescribing
- number of different antibiotics
• Non-antibiotics
- gastrointestinal drug prescribing
- number of different non-antibiotic drugs
 Generalized Estimating Equations
Y = ß0 + ß1×Policy + ß2×Illness
+ ß3×Policy × Illness
(+ ß4 Patient or provider char. + ß5 … ) + 
- Y: Prescription Variables (patient level)
- X : Policy: after policy=1 / before policy=0
: Illness: viral=1 / bacterial=0
: Policy × illness: Interaction
(different policy effect between illnesses)
: Patient or provider characteristics
: gender, age, location, size, type
- Cluster effect : clinic
Analysis
: Provider Characteristics Related
to Decrease of Inappropriate
Antibiotic Prescribing in Viral Illness
 Data Rearrangement
• Only clinics having >= 10 cases in each
period in viral illness
• Aggregating data to clinic level
• Adjusting to patient gender, age
distribution and diagnosis mix of total
sample in Jan. 2001
 Multiple Regression
Y= ß0 + ß1 Location + ß2 Type + ß3 Size
(+ ß4 Age + ß5 Gender) + 
Y: Antibiotic prescribing rate
: Average # of different antibiotics per case
(baseline & pre/post change) (clinic level)
X: Location : Urban / Rural
Type : Group / Solo
Size : <= 150 pt / 151 - 250 pt / >= 251 pt
Age : <= 39 / 40 - 49 / >= 50
Gender : Male / Female
Results
Characteristics of Cases
Characteristics (n= 50 999)
Gender of patient
Age of patient
Location of clinic
Practice size
Type of practice
Gender of physician
Age of physician
%
Male
46.4
Female
53.6
≤2
18.7
3 – 18
34.3
19 – 64
42.6
≥ 65
4.4
Urban
89.4
Rural
10.6
≤ 150 patients
151 – 250 patients
22.7
34.0
≥ 251 patients
43.3
Solo
89.2
Group
10.8
Male
90.9
Female
9.1
≤ 39
30.5
40 – 49
47.4
≥ 50
22.1
Impact of the Policy
on Antibiotic Prescribing
100%
91.6
89.7
90
80.8
80
72.8
70
60
50
Bef ore
Af ter
Viral illness
Explanatory variables
Policy effect
in bacterial illness
Additional policy effect
in viral illness
Bacterial illness
Adjusted relative risk
0.98
(95% CI)
(0.97, 0.99)
P value
0.0171
0.90
(0.87, 0.93)
< 0.0001
• Antibiotic prescribing decreased after
the policy in both illness groups.
• Reduction of antibiotic prescribing was
significantly larger in viral illness than in
bacterial illness.
Impact of the Policy
on the Number of Different
Antibiotics
2
1.7
1.8
1.6
1.6
1.4
1.5
1.4
1.2
1
Before
After
Viral illness
Explanatory variables
Bacterial illness
Adjusted rate of change
(95% CI)
P value
Policy effect
in bacterial illness
-6.38%
(- 8.25%, - 4.47%) < 0.0001
Additional policy effect
in viral illness
-1.28%
(- 3.95%, 1.46%)
• Number of different antibiotics
decreased after the policy, with no
difference between illness groups.
0.3571
Impact of the Policy on
Gastrointestinal Drug Prescribing
Explanatory variables
Adjusted relative risk
(95% CI)
P value
Policy effect
in bacterial illness
0.96
(0.93, 0.98)
< 0.0001
Additional policy effect
in viral illness
0.97
(0.93, 1.01)
0.1243
• Gastrointestinal drug prescribing
decreased after the policy, with no
difference between illness groups.
Impact of the Policy
on the Number of Different
Non-antibiotic Drugs
Explanatory variables
Policy effect
in bacterial illness
Additional policy effect
in viral illness
Adjusted rate of change
(95% CI)
P value
-7.55%
(- 10.37%, - 4.63%) < 0.0001
0.65%
(- 3.19%, 4.64%)
0.7450
• Number of different non-antibiotic drugs
decreased after the policy, with no
difference between illness groups.
Provider Characteristics
Related to Decrease
of Inappropriate Antibiotic
Prescribing in Viral Illness
Provider variable
Estimate
95% CI
P value
Baseline antibiotic prescribing rate (n= 435)
Type (Group)
-14.3% (- 23.4%, - 5.2%)
0.0021
Changes in number of antibiotics (n= 307)
Age (≤ 39)
-0.13
(- 0.24, - 0.02)
0.0235
Age (40 – 49)
-0.16
(- 0.26, - 0.06)
0.0022
Location (Urban)
-0.14
(- 0.27, - 0.01)
0.0298
• At baseline, physicians in group practice
were less likely to prescribing antibiotics
for viral illness than those in solo practice
by 14.3 percentage points.
• After the policy, younger physicians were
more likely to decrease antibiotic
polypharmacy than those age 50 and older.
• Physicians in urban area were more likely
to reduced prescribing per patient by 0.14
antibiotics than those in rural area.
Conclusion
• Prohibiting doctors from dispensing drugs
reduced prescribing overall, both
antibiotics and other drugs, and selectively
reduced inappropriate antibiotic
prescribing for patients with viral diagnosis.
• There was no evidence of diagnosis shift
or change in the proportion with bacterial
or possibly bacterial diagnoses as either
primary or secondary diagnosis.
• Data on pre-intervention trends supports
the validity of our findings: antibiotic
prescribing had not decreased before
intervention in 1994-2000.
• Still high rate of antibiotic prescribing for
viral illness after policy indicates the need
for further targeted interventions.
• Further study using longitudinal data is
needed to evaluate whether these
reductions in prescribing and
improvements in quality are maintained.
• Removing the financial motivation to
prescribe can contribute significantly to
quality use of medicines.