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enrolled members who received antibiotics was higher than the proportion of those in the main analysis during the study, but their utilization also decreased. The recent literature on antibiotic utilization in the United States
varies by study period and age of the study population. One group examined outpatient pharmacy dispensing data in 2013–2015 and found no significant changes in individual or overall rates of antibi- otics dispensed during that time.2 In our study, the proportion of members who received no antibiotics from 2013 to 2015 was also modest (73%to 74%), suggesting the importance of looking at longer periods to detect more subtle trends. Likewise, the CDC reported a decline in rates of outpatient antibiotics dispensed among chil- dren 19 and younger from 2011 to 2015 (908 to 788 per 1,000, respectively), but the report also revealed a constant rate of anti- biotic use among those 20 and older.6 An earlier study reported a decline in outpatient antibiotic prescribing from 2006 to 2010 (892 prescriptions per 1,000 to 867 prescriptions per 1,000, respectively) in IMSHealth data.7 From 2002 to 2010, the number of dispensed antibiotics captured in large prescription databases decreased by 14% among children 17 and younger.8 Among children 3 months to 18 years of age in 3 health plans, rates of outpatient antibiotic dispensings were lower in 2009–2010 than in 2000–2001.9 The major strength of our analysis is the long duration of the
study period. The study, based within a single commercial health plan in New England, also has several other strengths and limita- tions. Although our results may not be generalizable to other geographic areas or other patient populations, the relative homo- geneity of the population, especially in the continuously enrolled cohort in the sensitivity analysis, provides estimates that may be less affected by demographic and/or other sources of variation. An important limitation of the study is that inpatient (hospital) antibiotic use was not included. In addition, we did not examine appropriateness of use. Finally, the way we assessed comorbidities was more sensitive than specific; we included all patients with ≥1 pertinent diagnosis code and therefore may have overestimated those with comorbidities. On the other hand, we did not require members to have at least 1 year of enrollment history for comor- bidity assessment, so we may have underestimated the prevalence of some comorbidities. In conclusion, over a 17-year study period in a single commer- cial health plan based in New England, we observed a decrease in
Noelle M. Cocoros et al
the proportion of members receiving antibiotics across age, sex, race/ethnicity, and comorbidities.
Author ORCIDs. Noelle Cocoros, 0000-0001-7090-2761
Acknowledgments. The authors would like to thank Elizabeth Dee, Megha Bhattarai, Robert Jin, Zhonghe Li, and Jessica Young for their contribu- tions to this work.
Financial support. This work was supported by a grant from the Harvard Pilgrim Health Care Institute to M. Klompas.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Antibiotic use in the United States, 2017: progress and opportunities. Centers for Disease Control and Prevention website.
https://www.cdc. gov/antibiotic-use/stewardship-report/pdf/stewardship-report.pdf. Published 2017. Accessed December 17, 2018.
2. Durkin MJ, Jafarzadeh SR, Hsueh K, et al. Outpatient antibiotic prescription trends in the united states: a national cohort study. Infect Control Hosp Epidemiol 2018;39:584–589.
3. Grigoryan L, Zoorob R, Shah J, Wang H, Arya M, Trautner BW. Antibiotic prescribing for uncomplicated acute bronchitis is highest in younger adults. Antibiotics (Basel) 2017;6(4):22.
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5. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130–1139.
6. Patient safety atlas, Xponent database from Quintiles IMS, 2011-2015, 2017. Centers for Disease Control and Prevention website.
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7. SudaKJ,HicksLA, RobertsRM,Hunkler RJ, TaylorTH. Trends and seasonal variation in outpatient antibiotic prescription rates in the United States, 2006 to 2010. Antimicrob Agents Chemother 2014;58:2763–2766.
8. Chai G, Governale L, McMahon AW, Trinidad JP, Staffa J, Murphy D. Trends of outpatient prescription drug utilization in US children, 2002–2010. Pediatrics 2012;130:23–31.
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