SummaryAs part of a collaborative with four other California health plans, Health Net of California's Medi-Cal managed care plan provided physicians with a quarterly report that benchmarks individual performance related to prescribing of antibiotics to treat upper respiratory infection (i.e., the common cold) in children and adolescents versus that of peers, along with a list of child and adolescent patients of that physician who may have been inappropriately prescribed antibiotics for such an infection in the past year. The collaborative also provided an educational toolkit to network physicians that included copies of relevant adult and pediatric practice guidelines related to treatment of upper respiratory infection and other common viral infections not amenable to antibiotic treatment; posters, brochures, and other materials to educate patients and parents on appropriate prescribing; and pads that allow physicians to give parents a "prescription" consisting of instructions on how to treat their child's cold with over-the-counter medications and home-based therapies. The program significantly reduced inappropriate prescribing of antibiotics for upper respiratory infections in children and adolescents. The collaborative addressing appropriate prescription for those diagnosed with upper respiratory infections ended in 2010 when stated goals were achieved. However, collaborating health plans continue to implement specific activities within their population to sustain improved outcomes. Health Net continues to send the provider quarterly reports, and in 2012 began including patients 18 to 64 years old who were diagnosed with acute bronchitis and inappropriately prescribed with antibiotics.Moderate: The evidence consists of pre- and post-implementation trends in the prescribing habits of physicians for children and adolescent patients diagnosed with URI, along with post-implementation survey feedback from participating physicians.
Developing OrganizationsHealth Net of California, Inc.
Patient PopulationThe program targeted children between the ages of 3 months and 18 years old.Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Insurance Status > Medicaid; Age > Preschooler (2-5 years)
Problem AddressedPhysicians frequently prescribe antibiotics for patients, particularly children, with a cold or other common viral infections, even though these infections do not respond to such treatment. This practice leads to increased resistance to—and hence, reduced effectiveness of—such medications when used to treat future bacterial infections (which typically do respond to such treatment). Inappropriate prescribing frequently stems from lack of awareness among physicians and patients/parents about guidelines on use of antibiotics for viral infections, with many parents/patients remaining unaware or unconvinced that antibiotics provide no medical benefit (and could cause harm) in these situations.
- A common occurrence: A survey of more than 10,000 adults found that 12 percent had taken antibiotics in the past 4 weeks,1 with many having taken them for viral infections that do not respond to such treatment. Inappropriate use of antibiotics may be even more common in children and adolescents. Roughly 22 percent of children who visited a physician for an upper respiratory infection (URI) and 7.7 percent of those who visited for bronchitis received an antibiotic prescription.2 A study of five California health plans found that 31 percent of the 84,166 children and adolescents between the ages of 3 months and 18 years old who had an episode of URI or bronchitis received antibiotics. Prescribing rates varied widely across plans, from 2 to 75 percent.3
- Leading to increased resistance to antibiotics: Antimicrobial resistance is a large, rapidly growing problem in the United States and throughout the world, with recent antibiotic use being a primary risk factor for the development of such resistance.1 For people who become resistant, antibiotics will generally be less effective in treating future bacterial infections; such resistance is especially problematic for children, who need access to effective antibiotics throughout their lives.3
- Driven by lack of awareness among physicians, patients, parents: Despite efforts to educate physicians and the public, the message to avoid using antibiotics to treat viral infections has not fully reached its target audiences, as illustrated below:
- Patient misperceptions: In a survey of more than 10,000 adults, roughly one-fourth (27 percent) believed that taking antibiotics for a cold could prevent a more serious illness from developing, 32 percent believed that antibiotics accelerated recovery, and nearly half (48 percent) expected their physician to prescribe antibiotics for a cold. A slightly higher percentage of respondents with children shared each of these beliefs/attitudes. In addition, more than half of respondents (58 percent) did not know about the possible health dangers of inappropriate antibiotic use.1
- Parental pressure: Some physicians agree to prescribe antibiotics to children and adolescents because they lack the knowledge, educational materials, and/or time to convince parents that such a prescription is not necessary. For example, one study found that doctors prescribe antibiotics to children nearly two-thirds of the time (62 percent) if they believe parents expect them to do so, but only 7 percent of the time if they do not.4 Physician surveys conducted by Health Net have also identified parental pressure as a primary reason for inappropriate prescribing.
Description of the Innovative ActivityAs part of a five-plan collaborative, Health Net of California's Medi-Cal managed care plan provided physicians in its network with a quarterly report that benchmarked individual physician performance related to prescribing antibiotics for URI in children and adolescents versus that of peers, along with a list of patients who may have been inappropriately prescribed antibiotics for such an infection in the past year. The collaborative also provided an educational toolkit to network physicians in the top 20 percent of antibiotic prescribers that included copies of relevant adult and pediatric practice guidelines; posters, brochures, and other materials to educate patients and parents on appropriate prescribing; and pads that allowed physicians to give parents a "prescription" consisting of instructions on how to treat the child's cold. Appropriate antibiotic prescriptions improved with the initiatives. As a result, this collaborative has ended with each participating health plan continuing activities specific to their population. Key elements of the program include the following:
- Physician performance reports and education: Health Net provided physicians treating children and adolescents enrolled in its Medi-Cal managed care plan with regular performance reports and other support designed to educate them on appropriate prescribing habits, as outlined below:
- Quarterly provider performance report: Each quarter, Health Net sent a letter to every physician who, based on claims and encounter data, appeared to have inappropriately prescribed antibiotics for URI to a child or adolescent enrolled in its Medi-Cal managed care plan within the past year. (Due to delays in receiving such data, reports were sent out 2 to 3 months after the measurement period ended—for example, the letter sent in February 2010 covered calendar year 2009.) This letter, worded in a nonthreatening manner and signed by the plan's medical director (a physician), described the collaborative quality improvement project and the importance of prescribing antibiotics appropriately. The letter also included a table that displayed the individual physician's performance with respect to antibiotic prescribing compared with that of peers in the same specialty within the physician's group and within the Health Net Medi-Cal managed care plan provider network. The other four health plans in the collaborative sent similar letters/performance reports, using the same basic language, format, and content, to reinforce the message.
- List of patients receiving inappropriate prescriptions: Accompanying the letter was a list of the physician's Health Net patients (children and adolescents) who, based on claims and encounter data, appeared to have been inappropriately prescribed antibiotics sometime during the measurement period. According to information provided in April 2012, Health Net continues to send the quarterly mailings to providers. The mailing now includes a separate list of patients 18 to 64 years old who were diagnosed with acute bronchitis and were inappropriately prescribed with antibiotics (in addition to the table listing the children and adolescents).
- Relevant clinical practice guidelines: Through the AWARE (Alliance Working for Antibiotic Resistance Education) Project run by the California Medical Association Foundation, Health Net provided physicians in its Medi-Cal managed care plan network who were "heavy prescribers" of antibiotics (defined as those in the top 20 percent of all antibiotic prescribers) with copies of relevant adult and pediatric clinical practice guidelines related to the treatment of URI and other common viral infections. Health Net and the four other collaborating plans submitted the list of top prescribers to AWARE staff, which merged the lists to eliminate duplicate names (so as not to send multiple copies to individual physicians).
- Patient educational materials: Primarily through AWARE, Health Net and the other collaborating plans made patient educational materials available to the offices of primary care physicians and some specialists in Health Net's Medi-Cal and commercial plans. These materials included the following:
- Posters and brochures: AWARE mailed one copy of an educational poster and brochure that explained to patients/parents why it is important not to prescribe antibiotics for URI and other common viral infections. To supplement AWARE's efforts, Health Net distributed additional copies of these posters and brochures to the offices of physicians treating a high volume of patients with URI; these supplemental materials were distributed through the mail and in person during regularly scheduled visits made by Health Net's site review nurses and community health solutions specialists (who visited these offices once a month as part of their regular duties outside of this program). Providers were also advised that they could obtain additional copies of these materials from the AWARE Web site or by calling Health Net's health education information line.
- "Prescription" pads: The AWARE mailing included pads with checkoff boxes that physicians could use to write a "prescription" for over-the-counter medications and other home-based therapies for a cold, thus satisfying the many parents/patients who wanted the doctor to "prescribe" something to help them get better. Health Net had created an expanded version of this prescription pad (a half sheet rather than a quarter sheet) that included additional space for the doctor to write instructions, such as how to avoid catching a cold or the flu. Health Net staff distributed this version of the pad to physicians through the mail and during the aforementioned monthly visits.
- Newsletters: All participating plans produced member and physician newsletters that periodically included articles that discussed the importance of not prescribing antibiotics for URI and other common viral infections.
References/Related ArticlesMangione-Smith R, Wong L, Elliott MN, et al. Measuring the quality of antibiotic prescribing for upper respiratory infections and bronchitis in 5 US health plans. Arch Pedatric Adolesc Med. 2005;159:751-7.[PubMed]
Contact the InnovatorRosario J. Richards, RN, MSN
Senior Quality Improvement Specialist, State Health Programs
Health Net of California, Inc.
21281 Burbank Blvd, B5
Woodland Hills, CA 91367
Phone: (818) 676-7288
Fax: (818) 676-5454
Innovator DisclosuresMs. Richards has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsThe program significantly reduced inappropriate antibiotic prescribing among physicians in Health Net's Medi-Cal managed care plan network. In addition, appropriate antibiotic prescription goals for those diagnosed with URI were achieved among collaborating participants.
Moderate: The evidence consists of pre- and post-implementation trends in the prescribing habits of physicians for children and adolescent patients diagnosed with URI, along with post-implementation survey feedback from participating physicians.
- More physicians prescribing appropriately: The percentage of physicians treating a high volume of children and adolescent plan members (defined as 10 or more) who did not prescribe antibiotics to 80 percent or more of these patients on or within 3 days of a URI diagnosis rose from 49.4 percent during the baseline period (July 1, 2005 to June 30, 2006) to 69.9 percent during the same period 2 years later (July 1, 2007 to June 30, 2008). Improvements occurred in all seven counties where measurements took place. Many providers have eliminated inappropriate prescribing of antibiotics for URI altogether; in February 2008, Health Net's analysis of claims and encounter data identified 235 physicians who had written an inappropriate prescription within the previous 12 months, but by August 2009 that same analysis identified only 80. As a result of the initiative' success, Health Net expanded the initiative in 2012 to include adults inappropriately prescribed antibiotics for acute bronchitis, and hopes to experience similar declines in inappropriate antibiotic prescriptions for these patients as well.
- Fewer children receiving inappropriate antibiotics: The percentage of children age 3 months to 18 years old diagnosed with URI who did not receive an antibiotic prescription increased from 73.9 percent at baseline to 81.3 percent 2 years later. Improvements occurred in all seven counties included in the analysis, with six of the seven achieving the program's stated goal of performance at or above the 25th percentile as reported by the National Committee for Quality Assurance.
- Satisfied providers: Survey responses from a small sample of participating physicians suggest high levels of satisfaction with the educational materials.
Context of the InnovationHealth Net of California, Inc., offers a variety of managed care plans, including commercial health maintenance organization, preferred provider organization, and point-of-service plans; a Medicare plan; and a Medi-Cal plan (California's Medicaid program is known as "Medi-Cal") with roughly 675,000 enrollees, more than 70 percent of whom are under the age of 19 years old. The impetus for the program came from the California Department of Health Care Services, which monitors the quality of care provided to Medi-Cal enrollees by requiring all Medi-Cal plans to report performance on several quality measures, including the HEDIS® (Healthcare Effectiveness Data and Information Set) measure on appropriate antibiotic prescribing for children and adolescents diagnosed with URI. Minimum performance standards set by the department require all plans to meet or exceed the National Committee for Quality Assurance's national 25th percentile for reported measures. Department requirements also mandate that each plan with a Medi-Cal contract perform two quality improvement projects—a small-group collaborative with at least four participating Medi-Cal plans or a health plan–selected project, and a statewide collaborative among all Medi-Cal plans. Project results must be reported for a period of at least 2 years and show significant improvement. As part of their effort to meet these requirements, Health Net and four other Medi-Cal plans analyzed their performance on the HEDIS® antibiotic measure and found that several of the plans, including Health Net, did not consistently meet the 25th percentile threshold. In response to these findings and the mandate to participate in a small-group collaborative, the five plans collaboratively launched and implemented this program.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Periodic meetings: For 2 years, representatives from each participating plan met (usually on a monthly basis) to share experiences and lessons learned related to overcoming barriers and challenges to appropriate antibiotic prescribing. The department medical director and another senior-level colleague typically attended the meetings to provide guidance and advice to the plans. (The department requires the small-group collaborative to meet at least quarterly, but participants decided to meet more frequently.)
- Developing program elements: During the first few meetings, collaborative participants and department staff jointly agreed on the main interventions to be used to improve performance, including the quarterly provider reports and the distribution of AWARE educational materials. Each plan within the collaborative customized the program to meet its unique needs (e.g., Health Net decided to supplement distribution of AWARE materials, as noted earlier), although efforts were made to ensure that targeted physicians received consistent messages (e.g., same content, language, format), because provider panels overlap across participating plans.
- Selecting measures to gauge program impact: Collaborative participants decided to use the established HEDIS® measure to gauge the program's impact, along with a second measure suggested by the department medical director that tracks changes in prescribing habits among physicians who treat a high volume of child and adolescent health plan members.
- Sending consistent messages to providers and members: Consistent messages to providers and members may have helped in achieving improved outcomes.
- Continuing implementation to sustain improved outcomes: Although the collaborative addressing appropriate prescription for children and adolescents diagnosed with URIs ended in 2010, the collaborating health plans do continue to implement certain program activities. Health Net continues to send quarterly reports to providers, and in 2012 they expanded the initiative to include the HEDIS® measure on avoidance of antibiotic treatment in adults with acute bronchitis. The new reports now include a list of the provider's adult patients (ages 18 to 64) diagnosed with acute bronchitis who were inappropriately prescribed antibiotics in addition to the list of children and adolescents with URIs.
Resources Used and Skills Needed
- Staffing: Two Health Net staff—the senior quality improvement specialist for state health plans and an analyst—spent roughly 10 percent of their time on this project.
- Costs: Total program costs were unavailable but consist primarily of the allocated share of salary/benefits for the two staff members involved. Health Net also paid approximately $10,000 each year to cover its share of the costs of materials distributed to physicians through AWARE, and absorbed some additional minor program expenses related to periodic mailings and the printing of educational materials (as a supplement to those provided through AWARE).
Funding SourcesHealth Net of California, Inc.
The program is funded internally by Health Net of California, Inc.
Tools and Other ResourcesAWARE project materials, including the toolkit, guidelines, posters, and other educational materials for physicians and patients, can be downloaded at: http://www.aware.md/HealthCareProfessionals/ClinicalResources.aspx.
The template for the letter sent by Health Net to physicians each quarter can be obtained by contacting the innovator.
Information on the guidelines that underlie this program, including the organizations that contributed to their development, can be found at: http://www.aware.md/HealthCareProfessionals/materials/ToolKit2010/compendium_pediatric2010.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
HEDIS® (Healthcare Effectiveness Data and Information Set) measure: Appropriate treatment for children with upper respiratory infection (URI): percentage of children 3 months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. For more information, visit: http://www.qualitymeasures.ahrq.gov/content.aspx?id=38859.
Getting Started with This Innovation
- Secure physician leader support: A respected physician leader, often the medical director of the sponsoring organization, plays a critical role in ensuring that targeted physicians accept the credibility of the program and the associated data, and in responding to inevitable push-back from some physicians.
- Invest resources to ensure credible data: Those involved in developing the performance reports must have adequate resources to conduct their analysis as accurately and completely as possible. Physicians will ignore the reports if they do not believe they reflect their true performance.
- Collaborate on message content, format: If multiple insurers (or other kinds of organizations) participate in the program, ensure that each uses common language, messaging, and formatting for all materials sent to participating physicians. Physicians will quickly become disenchanted and disengaged if they receive inconsistent or contradictory messages.
- Craft friendly, respectful, peer-to-peer language for provider communications: All communications with physicians should come from a respected peer, usually the medical director. The tone should be friendly and nonthreatening, acknowledging that the information could potentially be inaccurate, particularly if it comes from claims and/or encounter data (which may miss cases in which diagnostic uncertainties likely make the prescribing of antibiotics appropriate). For example, Health Net's quarterly list of patients notes that the physicians "may" have prescribed antibiotics inappropriately for these patients, rather than declaring that they have done so.
Sustaining This Innovation
- Continue monitoring, reporting on program impact: Physicians will remain engaged if they see that the program produces meaningful improvements.
- Elicit feedback and refine program over time: Adopting organizations should continually review performance data and periodically consult with participating physicians to identify and address any problem areas.
Additional Considerations and Lessons
- Consider expansion to other populations, problems: A similar approach can be used with other patient populations for whom inappropriate antibiotic prescribing remains prevalent, such as adults and those enrolled in Medicare and commercial health plans. For example, Health Net expanded the scope of the quarterly reports in 2012 to include adults diagnosed with acute bronchitis who were inappropriately prescribed antibiotics. The same kind of education and performance feedback can also be used to address other areas in need of quality improvement, such as inappropriate use of the emergency department (ED). In fact, the statewide quality improvement collaborative project currently being pursued by all Medi-Cal managed care plans is using a similar approach to tackle "avoidable" ED visits. Under this program, physicians receive performance reports and lists of patients who have visited the ED within the past year for a condition that could have been treated elsewhere.
Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis. 2003;9(9):1128-35. [PubMed]
McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002; 287:3096-102. [PubMed]
Mangione-Smith R, Wong L, Elliott MN, et al. Measuring the quality of antibiotic prescribing for upper respiratory infections and bronchitis in 5 US health plans. Arch Pedatric Adolesc Med. 2005;159:751-7. [PubMed]
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Service Delivery Innovation Profile
Original publication: May 26, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.