Conformity of antibiotic pack sizes with guideline recommendations:
an analysis of healthcare claims data

Sereina Graber
Department of Health Sciences, Helsana Insurance Group

Health care system of Switzerland: good, expensive and intransparent

  • All swiss residents are subject to mandatory basic insurance.

  • Mandatory insurance is financed mainly by premiums and to a small extent by taxes.

  • Premiums are determined by:

    • choice of provider (~ 50 health insurers)
    • choice of deductible
    • insurance model (e.g. managed care model)

  • Mandatory insurance covers all relevant medical services

  • Supplementary benefits can be covered via supplementary insurance

  • High quality, high availability, but also high (and continuously rising) costs

  • Lack of transparency

Data on the swiss health care system


  • Health insurance claims data

Source of health insurance data


Health insurance data

  • Healthcare utilization based on tariffs applied for the billing of the services
  • Service providers
    • categorization of prescribing and performing providers (SASIS Super-and Subgroups )
  • Individuals’ socio-demographics & health insurance plan
    • age, sex, geographic region
    • deductible, managed care program

Advantages and limits of health insurance data


Advantages

  • “Real World Evidence”
  • (Largely) without study bias
  • Treatment data from all sectors (utilization patterns, care histories, transfers)
  • Large cohorts in long time series
  • Continuity of data (longitudinal and cross-sectional studies)
  • Personal reference (prevalence, incidence, follow-up)
  • Physician/institution reference
  • Cost data (cost-of-illness studies)
  • Cost-effective collection (process-produced, comprehensive information collection)

Limits

  • Data only on compulsorily insured services (underestimation of self-medication or Out-of-Pocket payments)
  • Only billing-relevant data available:
    • no diagnosis
    • no clinical data
    • no data on quality of life
    • no socio-economic information
  • Blurry on flat rate tariffs (DRG, ambulatory flat rates)
  • Only data on Helsana group (16% market share, 1.4 Mio insured persons)




Antimicrobial resistance poses a major threat


  • analysis of 471 million records in 204 countries (2019)

  • 4.95 million deaths associated with antimicrobial resistance

  • …including 1.27 million deaths attributable to antimicrobial resistance

Antibiotic use leads to resistance


Finish the pack! (too) short-term antibiotic treatment leads to resistence

  • increasing evidence that the risk of resistance highly correlates with the duration of the therapy1-7

  • In Switzerland (& other countries): dispension of prepacked antibiotics

    • left-over pills -> self-medication/ abuse8, improper waste disposal to the sewerage9

  • Modelling studies indicate that discrepancies between pack sizes and guideline recommendations are common9-11. Switzerland: suitable pack sizes in 36-47% of recommendations.

  • Real world data?

Study aim

Assess the proportion of prescribed antibiotic pack sizes that were potentially non-conform with guideline recommendations and to determine the corresponding proportion of potential over and under prescriptions.


Collaboration with USZ, UNIBE and ANRESIS

Dr. med. Sbarina Stollberg, Dr. Sereina Graber, Prof. Dr. Andreas Kronenberg, Prof. Dr. med. Oliver Senn, Prof. Dr. med. Stefan Neuner-Jehle, Dr. Catherine Plüss-Suard, Dr. Carola A. Huber, Dr. med. Andreas Plate

Guidelines


  • 5 most frequent indications for antibiotic treatments in the Swiss general practice1-3
    • acute bacterial rhinosinusitis (ABRS) (“infection of nasal cavity and sinuses”)
    • community acquired pneumonia (CAP)
    • streptococcal pharyngitis (SP) (“strep throat”)
    • acute otitis media (OM) (“middle ear infection”)
    • uncomplicated urinary tract infection (UTI) in women
  • national 1st- and 2nd-line treatment recommendations4 for the 5 included infections…
  • …encompassing 11 antimicrobial substances.

Data

  • Healthcare claims data from the Helsana Group
  • Identification of antibiotic substances based on Anatomical Therapeutic Chemical (ATC) Code by the World Health Organization (WHO)
  • included prescriptions:
    • by General Practitioners (GP)
    • issued in outpatient setting in 2022
    • for patients ≥ 18 yrs
    • antibiotics for UTI: only prescriptions for women
    • for main analyses: prescriptions of single pack
  • Challenges data preparation!

Calculations


  • Total dosage per prescribed pack
    • tablet dosage x no. of tablets in pack
  • Total dosage recommended guidelines
    • tablet dosage x no. doses per day x recommended duration
  • extrapolation based on a stratification into cantons, year, sex and 16 age classes (total of 26 x 2 x 16 = 832 strati) as used in the Swiss risk equalization statistics


Antibiotic prescriptions 2022




  • ~ 1 Mio prescriptions
  • ~ 600’000 patients
    • mean age 55 years
    • 65% women


Guideline recommendations vs. prescribing practice


Guideline recommendations vs. prescribing practice

Single indications

Guideline recommendations vs. prescribing practice

Multiple indications

Guideline recommendations vs. prescribing practice



  • For 10 out of 23 substance/ indication combinations none of the prescribed packs aligned with the respective guideline
  • Weighted mean across all substances resulted in potentially non-conform prescriptions in 32%
  • Taking into account all substances: total of 2.7 Mio overprescribed tablets!

Conclusions


  • First study to analyse real world data considering appropriateness of pack sizes

  • Limitation: indication for prescribed antibiotic unknown!

  • Many indications lack appropriate pack sizes and that one third of all prescriptions are potentially non-conform with guidelines

  • Mismatch leads predominantly to overprescriptions

  • Inadequate pack sizes undermine antibiotic stewardship interventions aimed at improving the quality of prescribing in outpatient medicine

  • How about dispensing partial packs or specific number of tablets?

  • Routine data from compulsory health insurance as a valid basis for generating insights into health care

  • Healthcare research as an important basis for political discussions and initiatives




Thank you!



Questions?

Supplementary | Infections (ANRESIS Report 2022)


Supplementary | Infections (ANRESIS Report 2022)


Supplementary | Infections (ANRESIS Report 2022)


Supplementary | Political point of view

BAG Medienmitteilung, Nov 2022


  • Motion «Einzelverkauf von Medikamenten: Wagen wir den Versuch!» (17.3942), 2017

  • Machbarkeitsstudie im Auftrag des Bundesamtes für Gesundheit (BAG), 2022:

    • Fehlende Übereinstimmung zwischen Packungsgrösse und Therapiemenge kommt relativ häufig vor
    • Einzelabgabe von Antibiotika grundsätzlich realisierbar und von Patientinnen und Patienten mehrheitlich akzeptiert wird
    • Herausforderungen:
      • ein von der Originalverpackung abweichender Verkauf von Medikamenten aktuell rechtlich nicht geregelt
      • Für Arztpraxen und Apotheken entsteht zudem bei der Einzelabgabe ein Mehraufwand, weil die Tabletten abgezählt, die Abgabe dokumentiert und der Restbestand aufbewahrt werden muss. Die Leistungserbringer fordern deshalb, dass sie für diesen Mehraufwand entschädigt werden.
    • Empfehlungen:
      • Erstens sollen weitere Erkenntnisse zur fehlenden Übereinstimmung von Therapiemenge und Packungsgrösse auf Ebene einzelner Antibiotika gewonnen werden.
      • Zweitens sollen alternative und/oder ergänzende Massnahmen zur Einzelabgabe geprüft werden.
      • Drittens müsste für die Umsetzung der Einzelabgabe in Arztpraxen Rechtssicherheit geschaffen werden.

  • Der Bundesrat beauftragt das eidgenössische Departement des Innern, die offenen Fragen zur Einzelabgabe von Antibiotika im Rahmen der nationalen Strategie gegen Antibiotikaresistenzen vertieft zu prüfen – insbesondere die Frage, welche gesetzliche Anpassungen nötig sind.

  • Seit März 2023 ist die Teilabgabe von vier Antibiotika (Amoxicillin, Amoxicillin/Clavulansäure, Cefuroxim und Levofloxacin) aufgrund der Medikamentenknappheitssituation in der Schweiz erstmals gesetzlich möglich und könnte den Weg für weitere Teilmengenabgaben ebnen.

    1. Mai 2024: Zustimmung des Nationalrats zur Motion (22.4245): Festlegung des Preises, dass er nur den tatsächlich benötigten Packungsinhalt berücksichtigt. Anreiz für kleinere Packungen, die günstiger sind. Import aus kleineren Packungen aus dem Ausland möglich, wenn es sie nicht in der Schweiz gibt. Einsparpotential: CHF 300-600 Mio.