TO THE EDITOR—Imprudent prescribing of antibiotics for acute bronchitis is of great concern in Taiwan [1] as in the United States [2]. We were interested to see whether the policy implications for antibiotic prescription would influence Taiwanese physicians’ prescribing behavior in the following years. We used Taiwan’s Bureau of National Health Insurance (BNHI) database of 1 million population cohort data from 1998 to 2011 to investigate the antibiotic prescribing trends for acute bronchitis. We selected subjects aged 18 to 64, by gender, who visited with acute bronchitis (International Classification of Diseases, Ninth Revision, code 466.0) and presence of antibiotics (Anatomical Therapeutic Chemical classification, first level of the code J; excluded J05–J07) prescriptions. We excluded patients who were admitted to the hospital or visits associated with chronic pulmonary disease, immunodeficiency, cancer, or concomitant infectious diagnoses. We found 258 049 visits for acute bronchitis meeting inclusion criteria. The overall antibiotic prescription rate was 33.0% (95% confidence interval [CI], 32.9%–33.3%). However, the actual antibiotic prescription rate was 57.0% (95% CI, 52.2%–61.5%) for the years 1998– 2001. From 2002, the results showed that there was a significant reduction in the
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Physicians’ Antibiotic Prescribing Behavior in Taiwan, 1998–2011
Antibiotic prescribing behavior for acute bronchitis in Taiwan, 1998–2011. Abbreviation: CI, confidence interval.
antibiotic prescription to 28.2% (95% CI, 24.9%–32.0; Figure 1). Thus, our findings would provide the evidence that the new regulations introduced for reimbursement purposes by the BNHI in 2001 related to upper respiratory tract infections discouraged physicians from prescribing antibiotics if not proven by a bacterial infection through blood examination [3]. Since 1995 the national health insurance system in Taiwan has been run by BNHI, which is a single payer to all the healthcare providers, and enrollment is mandatory for all citizens and legal residents. All public and private healthcare providers are affiliated with the program including medical centers, regional hospitals, and local clinics. It is surprising that over the 6 years from 2001 to 2006, irrational prescribing behavior changed in Taiwan. That is why we observed the multifactorial clustering effect that physicians became hesitant after 2001 when payment stopped (Figure 1).
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Therefore, the behavioral change for prescribing antibiotics was reduced up to 20% in patients with proven bacterial infection. It could be because of multifactorial effects such as national health insurance reimbursement, dissemination of knowledge, and peers’ pressure and behavior. We believe these 3 forces influenced the change in prescribing behavior [1, 4, 5]. Therefore, we believe that our findings would contribute to policy implications and serve as a lesson to other countries as well.
Note Potential conflicts of interest. All authors: No potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
CORRESPONDENCE
Usman Iqbal,1 Shabbir Syed-Abdul,1 Phung-Anh Nguyen,1 Wen-Shan Jian,2 and Yu-Chuan (Jack) Li1,3
1
Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, 2School of Health Care Administration, Taipei Medical University, and 3Department of Dermatology, Wan Fang Hospital, Taipei, Taiwan
References 1. Huang N, Chou Y-J, Chang H-J, Ho M, Morlock L. Antibiotic prescribing by ambulatory care physicians for adults with nasopharyngitis, URIs, and acute bronchitis in Taiwan: a multi-level modeling approach. Fam Pract 2005; 22:160–7. 2. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996–2010. JAMA 2014; 311: 2020–2. 3. Ho M, Hsiung CA, Yu H-T, Chi C-L, Chang H-J. Changes before and after a policy to restrict antimicrobial usage in upper respiratory infections in Taiwan. Int J Antimicrob Agents 2004; 23:438–45. 4. Arnold S, Straus S, Arnold S. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005; 4. 5. Little P, Stuart B, Francis N, et al. Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract
Downloaded from http://cid.oxfordjournals.org/ at University of Pittsburgh on June 22, 2015
Figure 1.
infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 2013; 382:1175–82. Correspondence: Yu-Chuan (Jack) Li, MD, PhD, College of Medicine Science and Technology, Taipei Medical University, 250-Wuxing St, Xinyi District, Taipei 11031, Taiwan (jack@ tmu.edu.tw). Clinical Infectious Diseases® 2015;60(9):1439–41 © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/civ038
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Physicians’ Antibiotic Prescribing Behavior in Taiwan, 1998–2011
Antibiotic prescribing behavior for acute bronchitis in Taiwan, 1998–2011. Abbreviation: CI, confidence interval.
antibiotic prescription to 28.2% (95% CI, 24.9%–32.0; Figure 1). Thus, our findings would provide the evidence that the new regulations introduced for reimbursement purposes by the BNHI in 2001 related to upper respiratory tract infections discouraged physicians from prescribing antibiotics if not proven by a bacterial infection through blood examination [3]. Since 1995 the national health insurance system in Taiwan has been run by BNHI, which is a single payer to all the healthcare providers, and enrollment is mandatory for all citizens and legal residents. All public and private healthcare providers are affiliated with the program including medical centers, regional hospitals, and local clinics. It is surprising that over the 6 years from 2001 to 2006, irrational prescribing behavior changed in Taiwan. That is why we observed the multifactorial clustering effect that physicians became hesitant after 2001 when payment stopped (Figure 1).
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Therefore, the behavioral change for prescribing antibiotics was reduced up to 20% in patients with proven bacterial infection. It could be because of multifactorial effects such as national health insurance reimbursement, dissemination of knowledge, and peers’ pressure and behavior. We believe these 3 forces influenced the change in prescribing behavior [1, 4, 5]. Therefore, we believe that our findings would contribute to policy implications and serve as a lesson to other countries as well.
Note Potential conflicts of interest. All authors: No potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
CORRESPONDENCE
Usman Iqbal,1 Shabbir Syed-Abdul,1 Phung-Anh Nguyen,1 Wen-Shan Jian,2 and Yu-Chuan (Jack) Li1,3
1
Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, 2School of Health Care Administration, Taipei Medical University, and 3Department of Dermatology, Wan Fang Hospital, Taipei, Taiwan
References 1. Huang N, Chou Y-J, Chang H-J, Ho M, Morlock L. Antibiotic prescribing by ambulatory care physicians for adults with nasopharyngitis, URIs, and acute bronchitis in Taiwan: a multi-level modeling approach. Fam Pract 2005; 22:160–7. 2. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996–2010. JAMA 2014; 311: 2020–2. 3. Ho M, Hsiung CA, Yu H-T, Chi C-L, Chang H-J. Changes before and after a policy to restrict antimicrobial usage in upper respiratory infections in Taiwan. Int J Antimicrob Agents 2004; 23:438–45. 4. Arnold S, Straus S, Arnold S. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005; 4. 5. Little P, Stuart B, Francis N, et al. Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract
Downloaded from http://cid.oxfordjournals.org/ at University of Pittsburgh on June 22, 2015
Figure 1.
infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 2013; 382:1175–82. Correspondence: Yu-Chuan (Jack) Li, MD, PhD, College of Medicine Science and Technology, Taipei Medical University, 250-Wuxing St, Xinyi District, Taipei 11031, Taiwan (jack@ tmu.edu.tw). Clinical Infectious Diseases® 2015;60(9):1439–41 © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/civ038
Downloaded from http://cid.oxfordjournals.org/ at University of Pittsburgh on June 22, 2015
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