肯塔基州医疗补助计划中急性呼吸道感染的抗生素处方：管理干预的机会

文献信息

中文摘要

背景： 急性呼吸道感染（ARI）的不当抗生素处方是抗菌药物管理的主要目标。我们考察了2022年至2024年肯塔基州医疗补助计划中的抗生素处方情况，并识别与不当ARI处方相关的因素，以为管理干预的靶向提供依据。
方法： 对肯塔基州医疗补助计划中关联的药房和医疗索赔数据进行回顾性分析。对于在配药后七天内具有门诊ARI诊断的受益人，其处方采用三层诊断分类框架进行适当性分类，其中第3层被视为不适当。采用以处方者为聚类标准误的多变量logistic回归评估患者、提供者和情境因素。
结果： 在2,386,291份ARI抗生素处方中，437,193份（18.3%）为不适当。四种疾病占87.0%：病毒性上呼吸道感染、支气管炎、非化脓性中耳炎、哮喘和过敏。阿奇霉素占不适当处方的38.3%，并且是病毒性上呼吸道感染和支气管炎中最常见的抗生素。高级实践提供者占抗生素处方量的67%和不适当处方的65%，尽管其校正后比值比低于成人初级保健医生。农村居住与更高的不适当处方比值比相关[校正比值比（AOR）：1.25]。不适当处方总体下降21%，主要由2022年至2023年间26%的下降驱动，2024年略有增加。
结论： 肯塔基州医疗补助计划中不适当的ARI抗生素处方集中在少数几种疾病和抗生素上。区分处方量与适当性对管理干预的靶向具有直接影响，而此处建立的纵向监测基础设施可被其他州卫生部门复制。

英文摘要

BACKGROUND: Inappropriate antibiotic prescribing for acute respiratory infections (ARIs) is a major stewardship target. We examined antibiotic prescribing in Kentucky Medicaid from 2022 to 2024 and identified factors associated with inappropriate ARI prescribing to inform stewardship targeting.
METHODS: Retrospective analysis of linked pharmacy and medical claims in Kentucky Medicaid. Prescriptions for beneficiaries with an outpatient ARI diagnosis within seven days of dispensing were classified for appropriateness using a three-tiered diagnostic classification framework, with Tier 3 considered inappropriate. Multivariable logistic regression with prescriber-clustered standard errors assessed patient, provider, and contextual factors.
RESULTS: Of 2,386,291 ARI antibiotic prescriptions, 437,193 (18.3%) were inappropriate. Four conditions accounted for 87.0%: viral upper respiratory infection, bronchitis, non-suppurative otitis media, asthma and allergy. Azithromycin accounted for 38.3% of inappropriate prescriptions and was the most common antibiotic for both viral upper respiratory infection and bronchitis. Advanced practice providers accounted for 67% of antibiotic volume and 65% of inappropriate prescriptions despite lower adjusted odds than adult primary care physicians. Rural residence was associated with higher odds of inappropriate prescribing [Adjusted Odds Ratio (AOR): 1.25]. Inappropriate prescribing declined 21% overall, driven by a 26% reduction between 2022 and 2023 with a modest increase in 2024.
CONCLUSIONS: Inappropriate ARI antibiotic prescribing in Kentucky Medicaid is concentrated in a small set of conditions and antibiotics. Distinguishing prescribing volume from appropriateness has direct implications for stewardship targeting, and the longitudinal surveillance infrastructure developed here is replicable by other state health departments.