Changes in Outpatient Use of Antibiotics by Adults in the United States, 2006–2015
Numerous initiatives over the past decade have targeted the problem of antibiotic overuse in the US; however, the cumulative impact of such initiatives upon recent patterns of use is not known.
The aims of this study were to (1) describe general trends in outpatient antibiotic use among adults over the period 2006–2015; and (2) identify rapid shifts in use during this time period as potential indicators for key events.
This was an observational study set in the ambulatory setting. Patients ≥ 18 years of age were selected from the Optum Clinformatics Datamart™, a commercial insurance claims database. The outcome measures of interest were prescriptions filled/1000 enrolled individuals, by year or quarter. We used linear regression to identify trends in use over multiple years, and change-point regression to identify rapid shifts in use within individual years.
From 2006 to 2015, antibiotic use declined significantly, decreasing by 12% for adults younger than 65 years of age (913–807 prescriptions/1000 individuals, p = 0.0001) and by 5% for adults ≥ 65 years of age (991–943 prescriptions/1000 individuals, p = 0.018). With change-point regression, we identified a number of rapid shifts in the use of specific antibiotic classes, such as downward shifts in the use of quinolones and macrolides during the second quarter of 2008 and 2013, respectively.
Over the period 2006–2015 outpatient use of antibiotics decreased substantially among adults. Rapid shifts in use occurring in 2008 and 2013 may reflect the presence of key drivers of change, such as abrupt changes in access to care or perceived antibiotic safety.
MLM and EP were primarily responsible for the design of the study and drafting of the manuscript; MLM and JF were responsible for the statistical analyses; KH, MF, AK, and JL contributed to the design/manuscript revision; and JL performed extracts of the data from the Optum database.
Compliance with Ethical Standards
This study was supported by the Division of Pharmacoepidemiology and Pharmacoeconomics (Brigham and Women’s Hospital, Boston, MA, USA), the Agency for Healthcare Research and Quality R01HS024930 (MAF and JAL) and HHSP233201500020I (JAL). Dr. Kesselheim’s work in this area is supported by CeBIL (Collaborative Research Program for Biomedical Innovation Law), a scientifically independent collaborative research program supported by a Novo Nordisk Foundation Grant (NNF17SA0027784). Dr. Patorno was supported by a career development Grant (K08AG055670) from the National Institute on Aging.
Conflict of interest
Mallika L. Mundkur, Jessica Franklin, Krista Huybrechts, Michael A. Fischer, Aaron S. Kesselheim, Jeffrey A. Linder, Joan Landon, and Elisabetta Patorno have no conflicts of interest that are directly relevant to the content of this study.
- 20.Choosing Wisely, An initiative of the ABIM Foundation. “Antibiotics: When you need them—and when you don’t”. 2014. http://www.choosingwisely.org/patient-resources/antibiotics/. Accessed 3 Nov 2017.
- 21.Centers for Disease Control and Prevention. Get smart: know when antibiotics work. 2015. https://www.cdc.gov/getsmart/community/programs-measurement/national-activities/antibiotics-work.html. Accessed 19 Dec 2016.
- 22.National Committee for Quality Assurance. HEDIS 2006 patient-level file specifications. 2006. http://www.ncqa.org/portals/0/HEDISQM/DataSubmission/2006PatientLevelHEDISSubmissionSpecifications.pdf. Accessed 19 Dec 2016.
- 23.US FDA. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. 2016. http://www.fda.gov/Drugs/DrugSafety/ucm511530.htm. Accessed 19 Dec 2016.
- 24.US FDA. Information for Healthcare Professionals: Fluoroquinolone Antimicrobial Drugs [ciprofloxacin (marketed as Cipro and generic ciprofloxacin), ciprofloxacin extended-release (marketed as Cipro XR and Proquin XR), gemifloxacin (marketed as Factive), levofloxacin (marketed as Levaquin), moxifloxacin (marketed as Avelox), norfloxacin (marketed as Noroxin), and ofloxacin (marketed as Floxin)]. 2013. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm126085.htm#. Accessed 19 Dec 2016.
- 25.US FDA. Telithromycin (marketed as Ketek) Information. 2016. http://www.fda.gov/Drugs/DrugSafety/ucm107824.htm. Accessed 19 Dec 2016.
- 26.US FDA. Cleocin HCL (clindamycin hydrochloride) capsules. 2016. http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm194129.htm. Accessed 19 Dec 2016.
- 27.US FDA. Risk of fluoroquinolone-associated Myasthenia Gravis Exacerbation February 2011 Label Changes for Fluoroquinolones. 2011. http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm247115.htm. Accessed 19 Dec 2016.
- 30.Optum. Clinformatics data mart. 2014. https://www.optum.com/content/dam/optum/resources/productSheets/Clinformatics_for_Data_Mart.pdf. Accessed 19 Dec 2016.
- 31.Julious S. Inference and estimation in a changepoint regression problem. Statistician. 2001;50(1):51–61.Google Scholar
- 33.United States Department of Agriculture, Rocky Mountain Research Station. A tutorial on the piecewise regression approach applied to bedload transport data. 2007. http://www.fs.fed.us/rm/pubs/rmrs_gtr189.pdf. Accessed 19 Dec 2016.
- 34.Lopez BJ, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2016;46:348–55.Google Scholar
- 37.IMS Institute for Healthcare Informatics. HSRN Data Brief: Xponent™. 2011. https://www.imshealth.com/files/web/IMSH%20Institute/Xponent_Data_Brief_Final-.pdf. Accessed 13 Oct 2017.
- 42.Centers for Disease Control and Prevention. Outpatient Antibiotic Prescriptions—United States. 2014. https://www.cdc.gov/getsmart/community/pdfs/annual-reportsummary_2014.pdf. Accessed 13 Oct 2017.
- 43.Blue Cross Blue Shield. Antibiotic prescription fill rates declining in the US. 2017. https://www.bcbs.com/the-health-of-america/reports/antibiotic-prescription-rates-declining-in-the-US. Accessed 13 Oct 2017.
- 44.Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey [updated 21 Aug 2009; cited 13 Oct 2017]. Available at: https://meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp.
- 46.Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007;56(14):332–6.Google Scholar
- 47.Supermarket News. “Stop & Shop, Giant Foods Offer Free Antibiotics”. 2008. http://www.supermarketnews.com/latest-news/stop-shop-giant-foods-offer-free-antibiotics. Accessed 13 Oct 2017.
- 48.The Henry J. Kaiser Family Foundation. Health Coverage in an Economic Downturn: Impact of Tight Budgets on Families and States. 2008. https://www.kff.org/disparities-policy/fact-sheet/health-coverage-in-an-economic-downturn-impact/. Accessed 13 Oct 2017.
- 49.Medscape. “FDA Approves First Generic Versions of Levofloxacin”. 2011. https://www.medscape.com/viewarticle/745007. Accessed 13 Oct 2017.
- 50.Centers for Disease Control and Prevention. 2011–2012 Flu Season Draws to a Close. 2012. https://www.cdc.gov/flu/spotlights/2011-2012-flu-season-wrapup.htm. Accessed 13 Oct 2017.
- 52.United States Census Bureau. “Health Insurance Coverage in the United States: 2015”. 2016. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf. Accessed 16 May 2018.
- 53.European Center for Disease Prevention and Control. Antimicrobial consumption database (ESAC-Net). 2017. https://ecdc.europa.eu/en/antimicrobial-consumption/surveillance-and-disease-data/database. Accessed 1 Jun 2018.