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

Disclosures

• The authors have nothing to disclose

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+

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

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

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)

Results – Antibiotics Prescribed

• OHNS providers prescribed less fluoroquinolone compared to non-OHNS providers, 86.6% vs. 97.5% (p < 0.0001)

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).

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

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.

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

Acknowledgements

• American Otologic Society

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