Download - AOS Rx Trends Talk v5-final
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Provider and Patient Drivers of Ototopical Antibiotic Prescription Variability
Matthew G. Crowson, MDKristine C. Schulz, DrPHDebara L. Tucci, MD, MS, MBA
Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC USA
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Disclosures
• The authors have nothing to disclose
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Introduction• Otologic infections are among the most common disorders seen by
OHNS and PCPs• In North America 3 main classes of ototopical antibacterial agents in
use:– Aminoglycoside (e.g. tobramycin, gentamicin)– Fluoroquinolone (e.g. ciprofloxacin, ofloxacin) – Polymyxin combination products (e.g. cortisporin)
• The ototopical sales market in the U.S. is worth est. $310 million USD– Cost of individual prescriptions not uniform– Example: brand cortisporin $30; brand fluoroquinolone $100+
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Introduction• An emerging field of research within pharmaceutical utilization is
the study of variation in healthcare utilization and spending– Opiates, Antibiotics– OHNS regional variations in CRS, European antibiotic use in AOM
• Our Hypotheses: – Fluoroquinolone containing antibiotics are the most widely prescribed
ototopical antibiotic class– Providers prescribe more affordable topical therapy for patients who are
economically disadvantaged or come from economically disadvantaged communities
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Methods• Convenience sample of ototopical prescription records
– Provider centers: 3 general hospitals, 1 pediatric hospital, and 9 primary clinics in North Carolina
– Provider type was delineated by clinic type: Primary Care, Urgent Care, Non-OHNS specialist, OHNS
• Prescription, patient, provider, and institution variables analyzed– All prescriptions were the “first encounter” with respective providers– Diagnosis, prescription order type (agent; brand versus generic) – Demographics, health insurance status, healthcare provider type
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Results – Diagnoses Treated• First-time prescriptions of 2,416 adults and children presenting
with otologic infections from 2009-2013 • Non-OHNS providers served 82% of patients
• Primary Care most common setting (n = 1209; 50.0%)• 9.9% of pediatric patients received prescriptions from OHNS
providers versus 25.2% of adult patients (p < 0.0001)
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Results – Antibiotics Prescribed
• OHNS providers prescribed less fluoroquinolone compared to non-OHNS providers, 86.6% vs. 97.5% (p < 0.0001)
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Results – Demographics• OHNS providers prescribed more brand ototopical
agents to patients from "high poverty" counties than non-OHNS providers (72.3% versus 58.9%; p=0.0002).
• Fewer adult patients received brand prescriptions versus pediatric patients (58.4% versus 66.5%; p < 0.0001)
• Patients who identified as “non-white” received generic prescriptions at a frequency of 43.3% versus “white” patients at 38.0%, for all comers (p = 0.001).
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Results – Insurance Status
• Medicare patients had lowest proportion of fluoroquinolone antibiotic prescriptions, and were less likely to receive fluoroquinolone prescriptions versus commercial insurance (90% versus 96%; p = 0.004).
• 44% of non-insured patients received a generic prescription - highest proportion of all health plan types to receive generic
CommercialMedicaidMedicareSelf-Pay
OtherNo Data
No Insurance
0 200 400 600 800 1000 1200 1400 1600 1800
1600
374
140
111
75
62
54
Number of Patients
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Discussion Points• Fluoroquinolone agents are the most expensive and most
common antibiotics prescribed for these conditions.• Non-OHNS providers served the large majority of the patients
– Expected result, as simple otologic infections are frequently initially evaluated and managed by primary care providers before a referral to an OHNS physician is made.
• OHNS prescribed proportionally less fluoroquinolone and more brand name medications compared to non-OHNS providers.– Distribution of diagnoses for OHNS: chronic otologic conditions.
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Conclusions• Utilization analyses of our finite medical resource dollars are
urgently needed as we consider resource allocation in this new era of healthcare
• Fluoroquinolones are amongst the most expensive ototopical antibiotics available, and the patients treated in our system receive these most frequently
• One size fits all? Unclear if our providers are prescribing affordable topical antibiotic prescriptions if all receive the most expensive drug class
• These trends suggests directions for internal review, and may inform clinical guideline development
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Acknowledgements
• American Otologic Society
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References1. McCoy SI, Zell ER, Besser RE. Antimicrobial prescribing for otitis externa in children. Pediatr Infect Dis J. Feb 2004;23(2):181-183.
2. Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. Apr 2006;134(4 Suppl):S4-23.
3. Berenholz LP, Burkey JM, Farmer TL, Lippy WH. Topical otic antibiotics: clinical cochlear ototoxicity and cost consideration. Otolaryngol Head Neck Surg. Aug 2006;135(2):291-294.
4. McDonald DC, Carlson K, Izrael D. Geographic variation in opioid prescribing in the U.S. J Pain. Oct 2012;13(10):988-996.
5. Zhang Y, Steinman MA, Kaplan CM. Geographic variation in outpatient antibiotic prescribing among older adults. Arch Intern Med. Oct 22 2012;172(19):1465-1471.
6. Smith WM, Davidson TM, Murphy C. Regional variations in chronic rhinosinusitis, 2003-2006. Otolaryngol Head Neck Surg. Sep 2009;141(3):347-352.
7. Sanz E, Hernández MA, Kumari M, et al. Pharmacological treatment of acute otitis media in children. A comparison among seven locations: Tenerife, Barcelona and Valencia (Spain), Toulouse (France), Smolensk (Russia), Bratislava (Slovakia) and Sofia (Bulgaria). Eur J Clin Pharmacol. Mar 2004;60(1):37-43.
8. Assistance NCDoM. North Carolina Medicaid and Health Choice Preferred Drug List. http://www.nctracks.nc.gov. Accessed December 2 2015, 2015.
9. Services CfMM. Medicare Plan Coverage. http://www.medicare.gov/coverage/your-medicare-coverage.html. Accessed December 2 2014, 2014.
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Thank You