Academic detailing involves trained pharmacists who have thorough medication knowledge and who meet with prescribers to discuss the best prescribing practices.1 According to the National Resource Center for Academic Detailing, academic detailing is an effective way of communicating accurate, up-to-date information about comparative effectiveness, safety, and costs of a treatment.2 It is a method of outreach education that provides the one-on-one communication approach of industry detailers, without the commercial influence. This method has been used in different states and for varied purposes, such as drug class education (Idaho), disease state management education (New York), immunization promotion (Texas), and appropriate prescribing in the elderly (Pennsylvania).3 The goal of this study was to use academic detailing to reduce the inappropriate prescribing of cefixime and the associated cost.
We conducted this study at Community Health Choice, Inc, which is a local nonprofit HMO plan that offers the Medicaid State of Texas Access Reform program, the Children’s Health Insurance Program, and Health Insurance Marketplace Plans, with a network of 10,000 doctors and 70 hospitals.4
Overprescribing antibiotics is deemed inappropriate, because the risk for drug resistance is increased with the use of broad-spectrum antibiotics.5 Drug resistance happens when new strains of bacteria emerge, making it more difficult and more expensive to treat common infections, which can become life-threatening.5 When treating bacterial infections, it is important for physicians to give an adequate trial of antibiotics that are considered first-line therapy, which helps to keep patients and health plan costs down and decreases the time needed to treat the infection.
Cefixime is a broad-spectrum, bactericidal third-generation cephalosporin that works by inhibiting bacterial cell-wall synthesis by binding to ≥1 of the penicillin-binding proteins.6,7 Although cefixime is effective in treating community-acquired pneumonia (CAP), acute bacterial sinusitis, otitis media, pharyngitis, and urinary tract infections (UTIs), it is not the drug of choice for initial therapy. When treating CAP, the role of antibiotic therapy is debated, because of the increasing prevalence of viral and bacterial coinfections.8 The appropriate first-line antibiotic therapy for CAP is amoxicillin.9 Alternative treatments for CAP include second- or third-generation cephalosporin, including cefpodoxime, cefuroxime, and cefprozil. Cefixime should only be used when prescribers are certain that the causative microbial is Haemophilus influenzae.9
In the treatment of acute bacterial sinusitis, amoxicillin-clavulanate is the first-line treatment option.10 If the initial treatment fails, prescribers can initiate a round of doxycycline as a second-line option. Cefixime becomes a treatment option in children only when added to clindamycin after 2 previous treatment failures. In patients with penicillin allergies, levofloxacin and clindamycin with cefixime are treatment options.10
When treating otitis media, the first-line antibiotic should be amoxicillin or amoxicillin-clavulanate if amoxicillin has been used in the previous 30 days. Cefixime may be used in combination with clindamycin as a third-line option if the initial antibiotic treatment has failed. Patients with penicillin allergies may receive cefdinir, cefuroxime, cefpodoxime, or ceftriaxone as first-line therapy.11
The first-line antimicrobial option for the treatment of pharyngitis is oral penicillin V or amoxicillin. For individuals with penicillin allergies, cephalexin and cefadroxil, clindamycin, azithromycin, or clarithromycin can be used as first-line treatment options.12 Cefixime is appropriate to treat pharyngitis when Streptococcus pyogenes is the causative pathogen.13
When treating UTIs in children, amoxicillin has traditionally been the initial therapy of choice; however, increased resistance of Escherichia coli to amoxicillin has made it a less acceptable choice. Higher cure rates have been associated with trimethoprim/sulfamethoxazole.14 Other appropriate treatment options for UTIs in children include amoxicillin-clavulanate, cefixime, cefpodoxime, cephalexin, or cefprozil.15
The Table provides a comprehensive description of each infection along with its appropriate antimicrobial drug recommendations according to current treatment guidelines.16 Each recommended antibiotic is accompanied by the average cost of the drug therapy corresponding to the appropriate duration of therapy. The drug costs reflect the average wholesale price according to RED BOOK Online.16
The Director of Pharmacy Analytics at Community Health Choice identified and detailed the top physicians who prescribed cefixime to treat common pediatric infections by using claims data provided by the health plan. The purpose of the study was to ensure that physicians are prescribing appropriate antimicrobials based on the most recent pediatric guidelines. Utilizing only 1 pharmacist (the Director of Pharmacy Analytics) to conduct the detailing allowed for consistency and uniformity throughout the study. Preparation for the detailing included the pharmacist reviewing all pertinent guidelines, drug information, and prescribing patterns.
The pharmacist did not receive any formal training before performing the intervention; however, she does have more than 20 years of experience in pharmacy, a master’s degree in business administration, as well as a doctor of pharmacy degree. All prescribers were approached with the same information and methods to allow for uniform outcomes. The interventions took place between August 2014 and March 2015.
The pharmacist met with each prescriber in a one-on-one office-based meeting to execute the intervention. The physicians were provided with individualized prescribing patterns and compared them with other pediatricians. The pharmacist also provided copies of all American Academy of Pediatrics practice guidelines for the treatment of the most common childhood infections. The main goal for providing the practice guidelines was to ensure that prescribers would begin to utilize first-line antimicrobial therapies rather than broad-spectrum antimicrobials for initial therapy. The prescribers received a summary of all guidelines in a single chart and published an article for the Community Health Choice provider newsletter.
By having a discussion with the prescribers about why they chose cefixime as the initial therapy, the pharmacist found that the general consensus was that cefixime presented less gastrointestinal (GI) upset and diarrhea than the appropriate first-line therapy recommended by the practice guidelines. The pharmacist suggested to the physicians to counsel parents and patients about the possibility of GI upset and to ensure them that taking the antibiotic with food can help alleviate the potential for GI upset. For parents who are uncomfortable with the possibility of diarrhea, the physician should explain the potential for antibiotic resistance to first-line antibiotics.
In 2015, the number of cefixime prescriptions at Community Health Choice totaled 4906, which is a significant decrease of approximately 36% from 7708 prescriptions in 2014. The total cost to the health plan was $1.85 million spent in 2015, which was a significant decrease of approximately 20% compared with $2.3 million spent in 2014 (Figure 1).
Figure 2 shows the total number of cefixime prescriptions each physician prescribed 5 months before and after the intervention took place. Figure 2 also demonstrates the impact of the intervention on a larger scale, by looking at the total number of prescriptions prescribed. In 9 of 11 (82%) prescribers, the intervention was successful and resulted in fewer cefixime prescriptions.
However, prescribers B and G did not have the same outcomes as the other prescribers; the number of cefixime prescriptions prescribed actually increased after the intervention for these 2 physicians. The reason for the increase in cefixime prescriptions is unknown, because no additional follow-up was done with the 2 physicians.
Overall, 5 months before the intervention, the amount of cefixime prescriptions totaled 795; 5 months after the intervention, the number of cefixime prescriptions totaled 383, amounting to a decrease of approximately 52%.
The total cost of cefixime for 2015 was $1.85 million. The estimated cost-savings to the health plan totaled $500,000, which is an estimated 38% decrease in the total number of prescriptions and an estimated 22% decrease in total cost to the health plan when comparing the 2014 to 2015 data.
The time the pharmacist devoted to this research project included the time to review the literature, evaluate and prepare presentations, write an article for the Community Health Choice newsletter, and visit with the top 11 prescribers. Two prescribers did not respond to the academic detailing, and we were unsuccessful in our attempts to follow up with them.
The total time spent on the project was 50 hours, which translates to a cost-savings of $10,000 per 1 hour spent; this amount does not include the cost-savings from the reduction in antibiotic resistance. The Centers for Disease Control and Prevention has estimated that antibiotic resistance results in an excess of direct healthcare costs of $20 billion, with additional societal costs as high as $35 billion annually for lost productivity.17
The major limitation of this case study is that it solely addresses drug spending and did not capture outcomes, because most of the initial prescribing was deemed inappropriate. We could not review the patients’ outcomes, because it was not possible to determine which patients might have been prescribed cefixime without the academic detailing. It is difficult to ascertain if there were any treatment failures or an increase in complaints of side effects because of the decreased use of cefixime, which is a third-line antibiotic.
This case study evaluated the impact of academic detailing on prescribing and prescription drug costs of cefixime at Community Health Choice. Physician prescribing patterns indicated inappropriate prescribing of cefixime for common pediatric infections. Claims data provided by the health plan indicated that the intervention had a positive impact on prescribers, by decreasing the costs to the health plan through reduction of the number of cefixime prescriptions.
Source of Funding
This article was funded by a Texas Southern University Seed Grant.
Author Disclosure Statement
Dr Ndefo, Dr Norman, and Dr Henry reported no conflicts of interest.
Dr Ndefo is Associate Professor, Department of Pharmacy Practice, Texas Southern University, Houston; Dr Norman was a student at Texas Southern University, College of Pharmacy and Health Sciences, and is now Staff Pharmacist at CVS, Houston; Dr Henry is Director, Pharmacy Analytics, Medical Affairs, Community Health Choice, Houston, TX.
1. Ho K, Nguyen A, Jarvis-Selinger S, et al. Technology-enabled academic detailing: computer-mediated education between pharmacists and physicians for evidence-based prescribing. Int J Med Inform. 2013;82:762-771.
2. National Resource Center for Academic Detailing. Our story. www.narcad.org/about.html. Accessed October 1, 2016.
3. National Conference for State Legislators. What is academic detailing for medical treatments? www.ncsl.org/research/health/academic-detailing-marketing-facts-about-medical.aspx. Updated November 2015. Accessed October 1, 2016.
4. Community Health Choice. Annual report. 2014. www.communitycares.com/Portals/0/Downloads/AnnualReport-14.pdf. Accessed October 1, 2016.
5. Hildreth CJ, Burke AE, Glass RM. JAMA patient page. Inappropriate use of antibiotics. JAMA. 2009;302:816.
6. Cefixime. Drug Facts and Comparisons. Facts and Comparisons eAnswers. Philadelphia, PA: Wolters Kluwer Health. https://factsandcomparisons.com. Accessed October 2, 2016. (Requires paid subscription to access.)
7. Cefixime. Micromedex 2.0. Greenwood Village, CO: Truven Health Analytics. www.micromedexsolutions.com. Accessed October 2, 2016. (Requires paid subscription to access.)
8. Stuckey-Schrock K, Hayes BL, George CM. Community-acquired pneumonia in children. Am Fam Physician. 2012;86:661-667.
9. Bradley JS, Byington CL, Shah SS, et al; for the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-e76.
10. Chow AW, Benninger MS, Brook I, et al; for the Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:e72-e112.
11. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964-e999.
12. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infec Dis. 2012;55:1279-1282. Erratum in Clin Infec Dis. 2012;58:1496.
13. Suprax (cefixime) [prescribing information]. Baltimore, MD: Lupin Pharmaceuticals; March 2017.
14. White B. Diagnosis and treatment of urinary tract infections in children. Am Fam Physician. 2011;83:409-415.
15. Roberts KB; for the Subcommittee on Urinary Tract Infection; Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128:595-610.
16. RED BOOK Online. Micromedex 2.0. Greenwood Village, CO: Truven Health Analytics. www.micromedexsolutions.com. Accessed October 21, 2016. (Requires paid subscription to access.)
17. Centers for Disease Control and Prevention. Untreatable: report by CDC details today’s drug-resistant health threats: landmark report ranks threats, outlines four core actions to halt resistance. Press release. September 16, 2013. www.cdc.gov/media/releases/2013/p0916-untreatable.html. Accessed October 16, 2016.