Overprescribing antibiotics is a major health concern in the U.S.  It has been directly linked to the prevalence of antibiotic resistance, with 2.8 million antibiotic-resistant infections and 35,000 deaths occurring annually.1

Acute bronchitis/bronchiolitis almost always gets better on its own; therefore, patients without other health problems should not usually be prescribed an antibiotic.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to joining you in ensuring the appropriate use of antibiotics for patients with acute bronchitis/bronchiolitis to help them avoid harmful side effects and possible resistance to antibiotics over time.

Key Points 

• Based on Blue Cross NC data, a high percentage of our members with a diagnosis of bronchitis/bronchiolitis are being prescribed antibiotics within three days of diagnosis, which is outside of HEDIS guidelines
  
• These guidelines apply to Fully Insured, Administrative Services Only (ASO), State Health Plan, Inter-Plan Program Host (IPP Host) and FEP members

HEDIS Quality Measure for AAB 

Rather than ordering antibiotics within three days of diagnosis, follow the guidelines outlined in the AAB HEDIS chart below. If patients meet any of the exclusion criteria listed in the chart below, please include applicable codes when submitting claims so that patients who are medically inappropriate are correctly excluded from this measure.  

Additionally, you can also refer to the Choosing Wisely respiratory illnesses and antibiotic use report from the Infectious Disease Society of America as an educational resource to share with patients.

HEDIS Quality Measure
AAB Administrative measure

• The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis / bronchiolitis that did NOT result in an antibiotic dispensing event.
• The Intake Period captures eligible episodes of treatment.
• The intake period begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year.

Clinical Goal

• Diagnosis of acute bronchitis/bronchiolitis in patients ages 3 months or older will NOT result in an antibiotic dispensing event on or within 3 days of the Episode Date.
• Episode Date – date of service for any outpatient, telephone, observation or ED visit, e-visit or virtual check-in with a diagnosis of acute bronchitis/bronchiolitis.
  

Criteria to Meet the Goal

Claims: 

When submitting claims for diagnosis bronchitis or bronchiolitis, if antibiotics were also ordered, be sure to submit any applicable claims which meet exclusion criteria for this measure.

Exclusions – if any of the below scenarios are applicable to your patient, please include the appropriate code(s) when submitting claims:

1. Visit that resulted in inpatient admission

2. Episode dates when patients had a claim/encounter with any diagnosis for a comorbid condition during the 12 months prior to the episode date.  A code from any of the following condition categories meet criteria for a comorbid condition history

a. HIV
b. HIV Type 2
c. Malignant Neoplasms
d. Other Malignant Neoplasm of Skin
e. Emphysema
f. COPD
g. Comorbid Conditions
h. Disorders of the Immune System

3. Episode Dates where patient had a claim/encounter with a competing diagnosis on or 3 days after the Episode Date.  A code from either of the following condition categories meet criteria for a competing diagnosis

a. Pharyngitis
b. Competing Diagnosis

1 Centers for Disease Control and Prevention.  2019. Antibiotic Resistance Threats in the United States. https://www.cdc.gov/drugresistance/biggest-threats.html

If you have questions, please contact Sharon Gee Brown.