Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017

Abstract

Background In most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level. Aim Our objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs’ performance scores and their clinimetric properties using a large regional reimbursement database. Methods A recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties). Results The 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential. Conclusions The set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases

“…To overcome the absence of indications/diagnoses in the Health Insurance databases, Thilly et al developed 10 PIs estimating the appropriateness of antibiotic prescriptions at GP level, calculable J o u r n a l P r e -p r o o f from routine Health Insurance databases. [6] These PIs were based on a literature review and used national guidelines as a reference. [12] Each PI was associated with targets set to reflect the appropriateness of antibiotic prescriptions: the optimal target aims at 100% compliance with national guidelines, while the acceptable target is less restrictive and takes into account that guidelines are not applicable to all patients.…”

“…[5] In this context, we recently developed 10 proxy indicators (PIs) calculable from routine databases, estimating the appropriateness of antibiotic prescriptions at GP level without requiring indications/diagnoses. [6] Identifying factors associated with the appropriateness of antibiotic prescriptions is useful to guide AMS interventions. However, in the literature, few studies aimed at identifying such factors in general practice.…”

Surveillance: a prerequisite for effective antimicrobial stewardship

“…Quantitative metrics can also have another application. So-called proxy indicators can be derived from data on the volume of antibiotic use without using data on clinical indication [17]. These indicators share characteristics of both quantity metrics and quality indicators and can indirectly reflect the appropriateness of antibiotic use if associated with a clear target [17].…”

“…So-called proxy indicators can be derived from data on the volume of antibiotic use without using data on clinical indication [17]. These indicators share characteristics of both quantity metrics and quality indicators and can indirectly reflect the appropriateness of antibiotic use if associated with a clear target [17]. Examples are a seasonal variation of quinolone prescriptions for general practitioners [17] and the percentage of antibiotic prescriptions with a duration of >8 days in nursing homes [18].…”

“…These indicators share characteristics of both quantity metrics and quality indicators and can indirectly reflect the appropriateness of antibiotic use if associated with a clear target [17]. Examples are a seasonal variation of quinolone prescriptions for general practitioners [17] and the percentage of antibiotic prescriptions with a duration of >8 days in nursing homes [18]. The advantage of proxy indicators is that they are derived from data that can be easily extracted from electronic systems compared to measuring quality indicators, which requires a large time investment, while proxy indicators provide a clearer direction to improve performance in daily practice (i.e.…”