Assessment of the quality of antibiotics prescription in a regional health system

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AC: abdominal circumference; BMI: body mass index; MH: medical history." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Carretero Gómez, J. Ena, J.C. Arévalo Lorido, J.M. Seguí Ripoll, F.J. Carrasco-Sánchez, R. Gómez-Huelgas, M.I. Pérez Soto, J. Delgado Lista, P. Pérez Martínez" "autores" => array:10 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Carretero Gómez" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Ena" ] 2 => array:2 [ "nombre" => "J.C." "apellidos" => "Arévalo Lorido" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Seguí Ripoll" ] 4 => array:2 [ "nombre" => "F.J." "apellidos" => "Carrasco-Sánchez" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Gómez-Huelgas" ] 6 => array:2 [ "nombre" => "M.I." "apellidos" => "Pérez Soto" ] 7 => array:2 [ "nombre" => "J." "apellidos" => "Delgado Lista" ] 8 => array:2 [ "nombre" => "P." "apellidos" => "Pérez Martínez" ] 9 => array:1 [ "colaborador" => "on behalf of the Diabetes, Obesity and Nutrition Workgroup of the Spanish Society of Internal Medicine" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256520301806" "doi" => "10.1016/j.rce.2020.06.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256520301806?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887421000631?idApp=WRCEE" "url" => "/22548874/0000022100000009/v3_202201140544/S2254887421000631/v3_202201140544/en/main.assets" ] "en" => array:22 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Assessment of the quality of antibiotics prescription in a regional health system" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "497" "paginaFinal" => "508" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Rojas García, F. Antoñanzas Villar" "autores" => array:2 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Rojas García" "email" => array:1 [ 0 => "paula.rojas@unirioja.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Antoñanzas Villar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Economía y Empresa, Área de Economía Aplicada, Universidad de La Rioja, Logroño, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de la calidad de la prescripción de antibióticos en un sistema regional de salud" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1760 "Ancho" => 2412 "Tamanyo" => 375827 ] ] "descripcion" => array:1 [ "en" => "Cost (€/DDD) per active ingredient and use (DID) by contribution groups. J01CA (penicillins): includes amoxicillin (J01CA04) and ampicillin (J01CA01). J01CR (combinations of penicillins): includes amoxicillin and beta-lactamase inhibitors (J01CR02). Prescription quality evaluation parameters: (<14.42%) dark green “very high”; (14.42–22.70%) light green “high”; (22.71–33.98%) yellow “low”; (>33.98%) red “very low”. J01MA (fluoroquinolones): includes ciprofloxacin (J01MA02), levofloxacin (J01MA12), moxifloxacin (J01MA14) and norfloxacin (J01MA06). Prescription quality evaluation parameters (<4.82%) dark green “very high”; (4.82–7.28%) light green “high”; (7.29–9.06%) yellow “low”; (>9.06%) red “very low”. J01FA (macrolides): includes azithromycin (J01FA10), clarithromycin (J01FA09), erythromycin (J01FA01) and spiramycin (J01FA02). J01DD (third generation cephalosporins): includes cefditoren (J01DD16) and cefixime (J01DD08). Prescription quality evaluation parameters (<0.04%) dark green “very high”; (0.04–0.51%) light green “high”; (0.52–1.88%) yellow “low”; (>1.88%) red “very low”. J01XX (others antibacterials): includes fosfomycin (J01XX01). *Significant differences compared to the other TSI groups with a significance level of p=0.020. **Significant differences compared to the other TSI groups with a significance level of p=0.051. ***Significant differences compared to the other TSI groups with a significance level of p=0.024. ****Significant differences compared to the other TSI groups with a significance level of p=0.053. Own draft based on Coenen et al.<a class="elsevierStyleCrossRef" href="#bib0250">11</a>" ] ] ] "textoCompleto" => "IntroductionAntibiotics have been fundamental to the treatment of bacterial infections ever since they were first introduced into clinical practice in the 1940s. Currently, the main threats society faces are the epidemiological, microbiological, and economic consequences of the development of antibiotic resistance.<a class="elsevierStyleCrossRef" href="#bib0200">1</a> These threats are enhanced, among other causes, by excessive and inappropriate use not only in humans, but also in veterinary practices, limited awareness of the problem among the general population and insufficient hospital measures for preventing infection.<a class="elsevierStyleCrossRef" href="#bib0205">2</a>The European Centre for Disease Prevention and Control lists initiatives<a class="elsevierStyleCrossRef" href="#bib0210">3</a> from multiple European countries to raise awareness about the risks of inappropriate antibiotic use. In Spain, the surveillance of antibiotics consumption is a strategic line of the National Plan against Antibiotics Resistance (PRAN) promoted by the Spanish Agency of Medicines and Medical Devices. The PRAN publishes annual reports<a class="elsevierStyleCrossRefs" href="#bib0205">2,4</a> detailing the work performed within its six strategic lines. One of its initiatives within the human health care field is to promote the creation of antibiotic consumption studies in local geographic contexts with the aim of acting in a disaggregated manner and to draft specific actions plans for each case.One of these regional studies is that of Lázaro et al.,<a class="elsevierStyleCrossRef" href="#bib0220">5</a> which analysed the differences in antibiotic consumption among autonomous communities, making the conclusion in the year 2000 that there were differences between regions of up to 10.4 defined daily doses per 1000 inhabitants (DID).Ripoll et al.<a class="elsevierStyleCrossRef" href="#bib0225">6</a> analysed antibiotic consumption in rural and urban areas of the Ávila province in 2005. In this region, consumption varied according to area, and was much higher in urban areas and much lower in rural areas.Vázquez et al.<a class="elsevierStyleCrossRef" href="#bib0230">7</a> also analysed the pharmaceutical cost of antibiotic prescribing in paediatrics in Castile and León between 2001 and 2005, finding a decrease in cost and consumption in the last year.Serna et al.<a class="elsevierStyleCrossRef" href="#bib0235">8</a> studied antibiotic consumption and distribution by age and sex in Lérida between 2002 and 2007, finding higher consumption rates in children and older individuals (over the age of 74).Lallana-Alvarez et al.<a class="elsevierStyleCrossRef" href="#bib0240">9</a> described outpatient antibiotic prescribing according to epidemiological variables (age, sex, and overuse patients) in the Community of Aragón using data from 2008. Their results showed that women presented higher antibiotic consumption than men, that penicillins were the most frequently prescribed antibiotic up to age 80, and that quinolones were the dominant group for patients aged 80 and above.Sánchez-Núñez et al.<a class="elsevierStyleCrossRef" href="#bib0245">10</a> analysed outpatient use of antibiotics in hospitals in Asturias between 2006 and 2015 in the rural, urban, and suburban population. They highlighted the need for new measures to reduce antibiotic prescribing since those that had been implemented (cost control, fundamentally) had not had the desired effect on consumption.In 2007, the European Surveillance of Antimicrobial Consumption (ESAC) published a set of indicators<a class="elsevierStyleCrossRef" href="#bib0250">11</a> to describe antibiotic use, evaluate the quality of prescribing patterns, assess national rankings compared to other countries, and to design actions aimed at promoting rational use of these drugs.<a class="elsevierStyleCrossRef" href="#bib0255">12</a> Adriaenssens et al.<a class="elsevierStyleCrossRef" href="#bib0260">13</a> calculated these quality indicators for 32 European countries. In their study, they stressed that the individuals responsible for formulating policies as well as health care professionals required this information on consumption quality in order to select improvement actions for antibiotic consumption. Klein et al.<a class="elsevierStyleCrossRef" href="#bib0265">14</a> analysed data from 76 countries, concluding that those with lower income had higher mortality rates related to infectious diseases and lower rates of antibiotic consumption and they believed that policies to reduce consumption in high income countries were necessary.Ultimately, all of these regional, national, and international studies have contributed to expanding knowledge and understanding of antibiotic consumption, identifying trends, and highlighting how significant consumption in developed countries strengthens the advance of antibiotic resistance. Nevertheless, in the battle against antibiotic resistance, actions targeted at prevention, control, and consumption awareness are not the only necessary measures. Evaluating results is a fundamental yet barely addressed aspect.<a class="elsevierStyleCrossRef" href="#bib0270">15</a> This study addresses the need to have performance indicators for action plans against antibiotic resistance.The objectives of this study are framed within the PRAN recommendations on setting up regional consumption studies to provide information that will facilitate the creation of policies that better fit the characteristics of the population. Specifically, the aim of this project was to define the quality of antibiotic prescribing in the autonomous community of La Rioja, taking into account epidemiological variables (age, sex, and seasonality) and economic variables (price of active ingredients, percent of co-payment contribution, and income level).Material and methodsThe data for this retrospective study came from the dispensation records of ordinary official prescriptions and pharmacies from the autonomous community of La Rioja, from the autonomic delegations in La Rioja from the Armed Forces Social Institute (ISFAS) and the General Mutual Benefit Fund for Civil Servants (MUFACE), which provided the primary data, while prescriptions that were not publicly funded, such as those prescribed by private dentists, were left out of the study. Data from private prescriptions were not included in the analysis as there is no detailed database like the public prescription registers of each health ministry in each autonomous community. Even the Ministry of Health, Consumer Affairs and Social Welfare, in order to create antibiotics consumption maps, must estimate medication dispensing through private prescribing based on sampling (the most recent with 6065 pharmacies, with a 27.5% coverage of the total).<a class="elsevierStyleCrossRef" href="#bib0275">16</a> Another data source would be pharmaceutical distributors, but as they are not public access, this option has been ruled out.The analysis was based on an observational study using the database, on a monthly basis, for all antibiotics dispensing (subgroup J01 of the Anatomical Therapeutic Chemical [ATC] classification)<a class="elsevierStyleCrossRef" href="#bib0280">17</a> carried out in 2017 in La Rioja. The included variables were as follows: dispensing date (month), name and code of the active ingredient (ATC classification), dose, prescription cost (recommended retail price), age, sex, and type of contribution of the patient prescribed the prescription.Population rates for antibiotic prescribing are expressed in defined daily doses (DDD) per 1000 inhabitants and day (DID) and number of prescriptions written per 1000 inhabitants. Using these population rates, the prescribing quality was evaluated using nine quality indicators (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) defined by the ESAC<a class="elsevierStyleCrossRef" href="#bib0250">11</a>: four on prescribing expressed in DID (total J01, of penicillins J01C, of cephalosporins J01D and of quinolones J01M), three on relative prescribing expressed as a percent compared to the total (of penicillins and beta-lactamase inhibitors J01CR, of third generation cephalosporins J01DD, and fluoroquinolones J01MA), a ratio of broad-spectrum antibiotic prescription (J01B/N) and an indicator for seasonal variation applied to the total prescribing (J01SV).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>To evaluate prescribing quality, the prescribing rates were grouped in quartiles and their intervals listed from smallest to greatest, similar to the approach used in the ESAC study.<a class="elsevierStyleCrossRef" href="#bib0250">11</a> The values separating each quartile are identified as the limits of each interval in the ESAC study and served as a quality pattern for this study; specifically, those from 2017 were used, the most recent available year. Prescribing quality was thus established, according to the location of the prescribing rates in the quartiles and, for analytical ease, a colour scale was used for each one: a dark green colour indicates “very high” prescribing quality, light green is “high”, yellow is “low”, and red is “very low”.Note that the population data for the calculations comes from the number of individual health cards (Spanish acronym: TSI) provided by the Directorate General of Benefits and Pharmacy and the number of members of medical insurance companies. The WHO estimates defined daily doses based on adult consumption, so prescriptions for patients under the age of 15 were not considered.For patient classification according to contribution types and income level, the Royal Decree-Law 16/2012<a class="elsevierStyleCrossRef" href="#bib0285">18</a> was referenced, whereby there are six patient groups according to the type of TSI assigned. In this study, data was used from the groups TSI 002 (low- and middle-income pensioners), TSI 003 (low-income active workers), TSI 004 (middle-income active workers) and TSI 005 (high-income pensioners and active workers), with the aim of facilitating inferential analysis. Based on the cost of each active ingredient (expressed in euros per DDD), the cost relationship with the prescription was analysed. This phenomenon was called the “price effect”. It was then estimated whether the income variable had any impact on consumption, which in this study we called the “income effect”.Calculations were made with and without single dose fosfomycin prescriptions following the PRAN recommendation to use narrow spectrum antibiotic prescriptions as a relative indicator, as these are largely used for respiratory and urinary tract infections.To establish the existence of significant differences in antibiotic prescribing by sex, age, and contribution type, the Chi-squared test was used with a 95% confidence interval. IBM SPSS 20, 2011 (Armonk, New York) predictive analysis software was used. A table of acronyms and abbreviations is included as additional material.ResultsBy epidemiological variables (age, sex, and seasonality)Antibiotic prescribing through official prescription in La Rioja was estimated to be 18.55DID (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a), presenting “high” quality (prescribing rate within the second quartile, classified as “high quality” between 14.52 and 20.31DID), according to the standards established by ESAC. Antibiotic prescribing through a prescription issued by medical insurance in La Rioja was 21.79DID (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a), presenting “low” quality (prescribing rates within the third quartile, classified as “low” quality between 20.32 and 23.77DID), according to the standards established by ESAC.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The differences in total antibiotic prescribing between men and women, for the 20 to 64 age range, were statistically significant (p<0.05). The age group with the highest doses of prescribed antibiotics was women aged 85 to 89 with 35.38DID, while the lowest amount prescribed was for men aged 30 to 34, with 9.19DID. In the group of men aged 15 to 64, prescribing quality was “very high” (prescribing rates within the first quartile, under 14.52 DID). As age increased, total prescribing quality (J01) fell, presenting as “low” for those aged 65 to 79 and “very low” (prescribing rates higher than 23.77DID) from 80 years and above. In the group of women aged between 15 to 29 and between 35 to 54, the prescribing quality was “very high”. From 30 to 34 and from 55 to 69 years of age, prescribing quality was “high”. Starting at age 69, quality shifted to “low” and in women over 75 years it became “very low”.Penicillins prescribing (J01C) met the standards defined for “high” quality (prescribing rates between 6.80 and 9.94DID), with the exception of women aged 25 to 39 and individuals of both sexes over the age of 70 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b). A “very low” prescribing quality for the group of women aged 85 to 89 stood out (12.83DID). The amount of penicillins prescribed to women was higher for all age ranges than that prescribed to men. The group with the lowest doses of prescribed penicillins was men aged 50 to 54 (5.58DID). The penicillin prescribing differences between men and women were statistically significant (p<0.05) in the age range of 15 to 69.Cephalosporins prescribing quality (J01D) remained “very high” (prescribing rates of less than 0.64DID) in women aged 15 to 34 and 40 to 54, in men aged 15 to 59, and “high” (prescribing rates between 0.64 and 1.60DID) in both sexes up to the age of 74 Significant differences were found (p<0.05) between men and women aged 20 to 59 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>c).Quinolones prescribing (J01M) stopped meeting the predetermined “high” quality standards (prescribing rates between 0.80 and 1.23DID) in men and women aged 45 and above, reaching 11.55DID and 9.41DID in the groups of women and men aged 85 to 89, respectively (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>d). With the exception of this age range, no significant differences were detected between sexes.The prescribing rates for every 1000 patients were calculated, allowing us to confirm these differences by sex. For every 1000 inhabitants, 588 antibiotic prescriptions were written; 674.37 prescriptions for every 1000 women and 499.41 for every 1000 men. Statistically significant differences were found between both prescribing rates (p=0.031). After applying the calculations to the database without the prescription records of dispensed fosfomycin, 589.48 prescriptions were recorded for every 1000 women and 491.54 prescriptions for every 1000 men, and this difference was not statistically significant. In this manner, any bias in the results between the number of prescriptions and the prescribed load (DID) by sex was avoided, since 80.29% of the fosfomycin prescriptions written for women corresponded to prescriptions for single-dose packs, while in men the percentage was 49.21%.<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>e shows the ratio for wide-spectrum antibiotics prescribing compared to narrow-spectrum antibiotics (J01B/N). Wide-spectrum antibiotics should be used in situations in which narrow-spectrum antibiotics have not been effective. Therefore, starting at 17.09 points, wide-spectrum antibiotics prescribing is considered “low” quality. With a ratio of more than 49.17 points, prescribing is considered to be “very low” quality according to ESAC, this being the case of the group of men over the age of 45 and women aged 50 to 54 and over 65.The weight of prescriptions for penicillins and beta-lactamase inhibitors (J01CR, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>f) compared to total prescribing (J01) exceeded the defined standards for “high” quality (between 14.42% and 22.70%) in men aged 20 to 49.In third generation cephalosporins (J01DD, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>g) and fluoroquinolones (J01MA, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>h), high prescribing rates were also recorded in both sexes from the age of 40.<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows the seasonal variation of total prescribing in the winter months compared to the summer months. In agreement with the ESAC, a percentage of more than 32.78% suggests overuse of antibiotics in the winter months compared to the summer, meaning it is considered a “very low” prescribing quality. This was the case in the group of women aged 50 to 89, which reached seasonal variations of up to 52.24% (21.36 DID in winter and 14.03DID in summer, p=0.023) in the 85 to 89 age range. This was also the case in the group of men aged 65 to 89, reaching seasonal variations of up to 41.98% (12.75 DID in winter and 8.98DID in summer, p=0.046) in the 75 to 79 age range.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>A higher number of prescriptions were written (mainly amoxicillin with and without inhibitors, azithromycin, and cefuroxime) in the winter months as compared to the summer months. Fosfomycin was the only ingredient for which prescribing increased in the summer months compared to winter months.By economic variables (income levels and treatment cost)<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> shows the quality indicators for prescribing by contribution groups. In the pensioners group, the total prescriptions (28.89 DID) of cephalosporins (4.80 DID) and quinolones (5.26 DID) received a “very low” prescribing quality.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>In the group of low-income active workers, the quality of total prescribing (17.60DID) and of quinolones (0.98DID) was “high” according to the ESAC criteria, while prescribing of penicillins (11.37DID) and cephalosporins (1.85 DID) was “low” quality.In middle-income active workers, total prescribing (17.44DID) and that of quinolones (0.94DID) was “high” quality and prescribing of penicillins (10.92DID) and cephalosporins (1.93DID) was “low” quality.In high-income active workers, total prescribing (10.43DID) and that of penicillins (4.68DID) was “high” quality, while prescribing of cephalosporins (1.74DID) and quinolones (1.50DID) was “low” quality.<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a> lists the various active ingredients, grouped according to therapeutic-pharmacological subgroup (fourth level of the ATC classification), according to their cost (expressed in euros per DDD). The penicillins subgroup (J01CA), which includes the active ingredients amoxicillin (J01CA04) and ampicillin (J01CA01), presented a lower cost per DDD (0.14€/DDD). The subgroup of other antibacterials (J01XX), which includes fosfomycin (J01XX01), presented the highest cost per DDD (7.07€/DDD). The amount prescribed (expressed in DID) is also included in each contribution group.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>As the cost of the active ingredients increased, the amount of antibiotics prescribed fell (“price effect”). With the exception of penicillins, the pensioner group (TSI 002) presented higher consumption than the other groups (attributable to epidemiological reasons) with statistically significant differences in fluoroquinolones (p=0.024) and macrolides (p=0.053).The amount of penicillins prescribed (J01CA and J01CR) to high-income active workers was significantly lower (p=0.020 and p=0.051, respectively) than the amount prescribed to the other contribution groups (“income effect”). While no statistically significant differences were detected, a larger number of fluoroquinolones, macrolides, third generation cephalosporins, and fosfomycins were prescribed to high-income active workers than to the other actively working groups.<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a> also includes prescribing quality according to the relative consumption indicators (J01CR, J01MA and J01DD). All the contribution groups received a “very low” prescribing quality in third generation cephalosporins, and the pensioner and high-income active worker groups did in fluoroquinolones.DiscussionThe analysis of prescribing quality has been a fundamental topic of public health for years.<a class="elsevierStyleCrossRefs" href="#bib0290">19,20</a> It has currently gained relevance in the field of antibiotics<a class="elsevierStyleCrossRef" href="#bib0300">21</a> due to the relationship between their elevated use and the appearance of resistances to these drugs.<a class="elsevierStyleCrossRefs" href="#bib0305">22,23</a> Understanding how not only epidemiological, but also economic variables impact antibiotic prescribing habits enables actions to be carried out to control resistance in clinical practice<a class="elsevierStyleCrossRef" href="#bib0315">24</a> and, by extension, allows healthcare costs to be managed more effectively. This study addresses the need<a class="elsevierStyleCrossRef" href="#bib0270">15</a> to have performance indicators and to evaluate the results of action plans against antibiotic resistance.To improve antibiotic resistance rates, prescribing quality must also be measured outside the European context. Local and regional data provide information about the setting where management decisions are made and facilitate the acquisition, use, and return of information.<a class="elsevierStyleCrossRef" href="#bib0205">2</a> In addition, the comparative evaluation methodology<a class="elsevierStyleCrossRef" href="#bib0320">25</a> used gives validity to regional studies like this one.In this analysis, antibiotic prescribing in adults (from the age of 15) during 2017 via official prescription was estimated to be 18.55DID. The number of TSIs was used as the population value for calculations. The Ministry of Health, Consumer Affairs and Social Welfare estimated said prescribing volume to be 18.45DID, a difference attributable to the fact that said Ministry used the number of inhabitants. Both values indicated a “high” quality of antibiotic prescribing with official prescription according to the standards defined by ESAC.Antibiotic prescribing in patients belonging to medical insurance companies was 21.79DID. This figure indicated a prescribing quality for medical insurance companies that is also “low”, as per the ESAC standards. The number of policy holders was used as the population value for calculations (from MUFACE and ISFAS). Nevertheless, the Ministry of Health, Consumer Affairs and Social Welfare estimated this figure using the number of total inhabitants, thereby obtaining a prescription rate in medical insurance of 0.99DID. In this study, it was seen that the prescribing habits of medical insurance companies with a higher number of affiliates (MUFACE and ISFAS, which represent 93% of this population) was 0.95 DID.In addition, antibiotics consumption via private prescription was 6.58DID, according to estimates from the Ministry of Health, Consumer Affairs and Social Welfare. In this study, no results have been presented for this value due to the absence of these records in the database. Therefore, total antibiotic consumption, or the sum or DID dispensed as official prescriptions (18.45DID taking the number of inhabitants as the population value and 18.55DID the number of health cards), as prescriptions from various medical insurance companies (0.99DID), and from private prescriptions (6.58 DID), for adults in La Rioja in 2017 would be estimated to be between 26.02 and 26.12DID. This result would correspond to a “very low” prescribing quality.Some authors<a class="elsevierStyleCrossRef" href="#bib0325">26</a> have pointed out that antibiotic prescribing in the private sector is less normalised than it is in the public sector, with there being a deviation in antibiotic prescribing from official prescriptions to private prescriptions. By way of estimation, if we put into context the value that the Ministry of Health, Consumer Affairs and Social Welfare provides for La Rioja, 6.58DID<a class="elsevierStyleCrossRef" href="#bib0275">16</a> for private prescriptions compared to 26DID (result obtained in this study for the sum of official, medical insurance, and private prescriptions), we would see that approximately 25% of the DID would be attributable to private prescriptions. In any event, this estimate is a subject for future analysis.The patient groups and antibiotic families that rational antibiotic use policies could impact were identified. The highest consumption rates were found in the groups over the age of 60. One possible explanation is that age is an influential factor in the immune status of the patient (infections are more easily contracted and additionally are harder to resolve without the aid of drugs).<a class="elsevierStyleCrossRef" href="#bib0330">27</a> Therefore, antibiotics consumption is higher starting with this age group.As with previous studies<a class="elsevierStyleCrossRefs" href="#bib0240">9,28</a> significant differences were detected in the number of prescriptions written to women and to men. As per the quality indicators, quinolones prescribing for groups over the age of 60 and penicillins prescribing for women aged 25 to 39 exceeded the standards that the ESAC classified as “high” quality (>2.42DID and >9.95DID, respectively).Differences were found regarding prescribing quality by type of contribution according to the TSI group assigned to the patients, this being “high” in the active workers group and “low” in pensioners. The contribution groups showed a wide margin for improvement in the indicators for relative consumption of third generation cephalosporins and, with the exception of low- and middle-income active workers, in the consumption of fluoroquinolones.Regarding seasonality, it was detected that fosfomycin did not meet the characteristic seasonality<a class="elsevierStyleCrossRef" href="#bib0340">29</a> of antibiotics (higher consumption in winter months), as it increased by 12.15% in the summer months compared to the winter. This active ingredient is mainly prescribed for urinary tract infections which are more common in the summer and in women. Despite this characteristic of the antibiotics, the quality indicators showed overuse of antibiotics in women over the age of 60 in the winter months as compared to the summer.As for economic variables, a “price effect” was detected that could potentially signal the choice of lower-priced active ingredients. Antibiotic prescribing seems to follow a pattern similar to that of the consumption of other goods: higher demand for lower-priced items, and vice versa, as can be deduced from the observation in <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>, which mirrors the typical demand curve.Significant differences were found in prescribing for pensioners (TSI 002) compared to the other groups (TSI 003, TSI 004 and TSI 005) of fluoroquinolones and macrolides, whose costs were 1.32€/DDD and 1.87€/DDD, respectively. These differences may be attributable to epidemiological issues. What's more, statistically significant differences were found in prescriptions for antibiotic subgroups with the lowest prices, penicillins (J01CA with 0.14€/DDD and J01CR with 1.22€/DDD) in high-income active workers compared to other groups, with a lower amount prescribed to high-income active workers, thereby detecting an “income effect” that seemed to indicate, in economic terms, that penicillins would be an inferior good with respect to income.While the prescribed amount of the active ingredient with the highest cost (other antibacterials, such as fosfomycin, 7.07€/DDD) was higher in high-income active workers, no significant differences were found in the amounts prescribed between contribution groups. Therefore, no lack of equity was detected in access to high-cost antibiotics due to the purchasing power of the patients, which is desirable from a healthcare policy perspective. Nevertheless, it is the patient who makes the decision to withdraw the prescription from the pharmacy, which may be influenced by his or her purchasing power, something which was not investigated in this study.It must be kept in mind that the data source did not include a series of aspects that affect the obtained results, such as real consumption (different from dispensing of multiple packages of antibiotics in one prescription) and the paediatric population.It is necessary to consider the differences between the volume of antibiotics prescribed, dispensed, and consumed. While it would have been ideal to study the effective consumption of the population of La Rioja in 2017, it is worth pointing out that the available data does not allow us to accurately know said consumption.As some studies<a class="elsevierStyleCrossRef" href="#bib0245">10</a> indicated, bias can appear in the results for the same period and population depending on whether prescribing or dispensing is observed. Some authors<a class="elsevierStyleCrossRef" href="#bib0345">30</a> have quantified the percent of antibiotic prescriptions that are written but not dispensed to be 30% (based on a comparison of prescribing data with reimbursement data for the 2002 to 2005 period in Spain). In addition, once a patient obtains the antibiotic, it is his or her choice to consume it or not, either partially or fully, perhaps contemplating future self-medication. In this sense, the newspaper El Global, on 24 May 2018,<a class="elsevierStyleCrossRef" href="#bib0350">31</a> highlighted that 63% of Spanish adults admitted to having used the same medication that in the past had cured the same or similar symptoms and without prior prescription from their doctor.This study has used data from official prescriptions that were prescribed and dispensed, whose content may or may not have ultimately been consumed by the patient, as this information is difficult to know from the available data. Therefore, the previously mentioned bias of 30% difference between volume prescribed and dispensed would not affect this study, though the bias regarding final consumption of the antibiotic would, which is hard to estimate. In this vein, the results of the 2016 Eurobarometer on citizen awareness of antibiotics, published by the European Commission<a class="elsevierStyleCrossRef" href="#bib0355">32</a> and analysed by the Ministry of Health, Consumer Affairs and Social Welfare,<a class="elsevierStyleCrossRef" href="#bib0360">33</a> indicated that 5% of the Spaniards surveyed admitted to self-medicating with antibiotics.One study<a class="elsevierStyleCrossRef" href="#bib0365">34</a> analysed irregular private prescriptions for J01 oral antibacterials in 247 pharmacies across all of Spain (except Ceuta and Melilla) between 2016 and 2017. It concluded that 29% of private prescriptions did not follow regulations, mainly for being issued through emergency reports, verbal or telephone prescriptions, prescriptions for insufficient dosages, medical discharge reports, and deferred prescriptions.Another cross-sectional study<a class="elsevierStyleCrossRef" href="#bib0370">35</a> using a sample of 977 pharmacies from northwest Spain and carried out between 2016 and 2017 estimated that a fifth of said pharmacies had dispensed antibiotics without a prescription to the “actors” who attempted to obtain them, supplying antibiotics at 18.83% of visits. The rural setting was a deciding factor in the study results.In addition, in a literature review<a class="elsevierStyleCrossRef" href="#bib0375">36</a> from 2018 on determinants in antibiotics dispensing without prescription, it was pointed out that Internet purchases constituted a risk factor for access to these drugs. Nevertheless, it concluded that pharmacies were the main means for obtaining antibiotics without a prescription.The WHO assures that, for practical reasons, the DDD indicator has been constructed according to adult consumption, with the exception of certain drugs used exclusively in children. To prevent bias in the results due to this fact, all records prescribed to the paediatric population (up to and including age 14) have been excluded from the study.In conclusion, the overall rate of antibiotic prescribing (official, medical insurance, and private prescriptions) in La Rioja during 2017 (26.02DID as per population data and 26.12 DID as per the number of health cards) presented “very low” quality, according to the intervals defined by the ESAC. According to data from the European Centre for Disease Prevention and Control, the community sits in the higher consumption bracket of the European ranking<a class="elsevierStyleCrossRef" href="#bib0380">37</a> and has a large margin for improvement for reducing prescribing volume.This study has identified which population groups and antibiotic families should be the focus of prescribing improvement measures, including quinolones for patients over the age of 45, fluoroquinolones for those over 30, penicillins for women aged 25 to 39 and for men and women over the age of 70, and third generation cephalosporins for pensioners and active workers.Therefore, the various healthcare proposals and policies designed to reduce antibiotic consumption, such as antimicrobial administration programmes in hospital settings<a class="elsevierStyleCrossRef" href="#bib0385">38</a> and in primary care,<a class="elsevierStyleCrossRef" href="#bib0390">39</a> campaigns for restrained use and personalised diagnosis programmes, can use these results and more effectively fight the threat that the appearance of antibiotic resistance poses to public health.<elsevierMultimedia ident="tb0005"></elsevierMultimedia>FundingThis paper was funded by a predoctoral contract FPI-CAR 2018.Conflicts of interestThe authors declare that they do not have any conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1646184" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1466588" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1646185" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1466587" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "By epidemiological variables (age, sex, and seasonality)" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "By economic variables (income levels and treatment cost)" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack581362" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-01-22" "fechaAceptado" => "2020-04-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1466588" "palabras" => array:5 [ 0 => "Antibiotics" 1 => "Prescription" 2 => "Primary care" 3 => "Pharmacoepidemiology" 4 => "Patient identification card" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1466587" "palabras" => array:5 [ 0 => "Antibióticos" 1 => "Prescripción" 2 => "Atención Primaria" 3 => "Farmacoepidemiología" 4 => "Tarjeta sanitaria individual" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesThe inappropriate and indiscriminate use of antibiotics is one of the main factors contributing to the onset of antimicrobial resistance. In 2007, the European Surveillance of Antimicrobial Consumption (ESAC) project established certain indicators to assess the quality of antibiotic use. We analysed the quality of antibiotic prescription in La Rioja (Spain) in 2017, using epidemiological (age, sex, seasonal nature) and financial variables (price of the antibiotic and income level). Material and methodsUsing data on monthly distributions of antibiotics (J01) through official prescriptions and prescriptions from medical insurance companies, we calculated the population rates for the number of prescriptions per 1000 inhabitants, as well as the values of 9 quality indicators (by antibiotic family, age group, sex and income), defined by ESAC, classifying the prescription quality as “very high”, “high”, “low” and “very low”. ResultsThe quality of antibiotic prescriptions in La Rioja in 2017 was “high” for antibiotics dispensed through official prescriptions (18.55 daily defined doses per 1000 inhabitants [DID]) and “low” for those dispensed through medical insurance companies (21.79 DID). When we included private prescriptions (26.02 DID), the quality was “very low”, taking into account the margins indicated by ESAC. We detected high rates of prescription for broad-spectrum antibiotics for men older than 45 years, penicillins for women aged 25 to 39 years, quinolones for pensioners and cephalosporins for high-income patients. ConclusionsThe quality of antibiotic prescription is determined not only by epidemiological variables, such as age and sex, but also by financial variables, such as patient income and antibiotic price." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosEl uso inadecuado e indiscriminado de los antibióticos es uno de los principales factores que contribuye a la aparición de resistencias bacterianas. En 2007 el Proyecto europeo de vigilancia del consumo de antimicrobianos (ESAC) estableció unos indicadores para evaluar la calidad de uso de los antibióticos. Se analiza la calidad de la prescripción de antibióticos en La Rioja en 2017, por variables epidemiológicas (edad, sexo y estacionalidad) y económicas (precio del antibiótico y nivel de renta). Material y métodosDispensaciones mensuales de antibióticos (J01) mediante receta oficial y mutuas, con los que se calcularon tasas poblacionales de número de recetas prescritas por cada 1.000 habitantes y los valores de 9 indicadores de calidad (por familias de antibióticos, grupos de edad, sexo y renta), definidos por el ESAC, calificando como «muy alta», «alta», «baja» y «muy baja» la calidad de prescripción. ResultadosLa calidad de la prescripción de antibióticos en La Rioja en 2017 resultó «alta» en antibióticos dispensados mediante receta oficial (18,55 dosis diarias definidas por 1.000 habitantes –DHD–) y «baja» mediante mutuas (21,79 DHD). Al incluir la receta privada (26,02 DHD) la calidad fue «muy baja» atendiendo a los márgenes indicados por el ESAC. Se detectaron altas tasas de prescripción de, entre otros: antibióticos de amplio espectro para hombres de más de 45 años, penicilinas para mujeres entre 25 y 39 años, quinolonas para pensionistas y cefalosporinas en renta alta. ConclusionesLa calidad de la prescripción de antibióticos está determinada no solo por variables epidemiológicas, como la edad o el sexo, sino también por variables económicas, como la renta del paciente y el precio del antibiótico." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "Please cite this article as: Rojas García P, Antoñanzas Villar F. Evaluación de la calidad de la prescripción de antibióticos en un sistema regional de salud. Rev Clín Esp. 2021;221:497–508." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0060" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2296 "Ancho" => 2466 "Tamanyo" => 499897 ] ] "descripcion" => array:1 [ "en" => "Formulas used. ESAC methodology. The population data are expressed in the number of health cards and/or number of policy holders." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4144 "Ancho" => 2824 "Tamanyo" => 1286525 ] ] "descripcion" => array:1 [ "en" => "Indicators for antibiotic prescription quality by age groups and sex. Own draft based on Coenen et al.<a class="elsevierStyleCrossRef" href="#bib0250">11</a>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1832 "Ancho" => 2500 "Tamanyo" => 471361 ] ] "descripcion" => array:1 [ "en" => "Seasonal variation of total prescribing (J01SV). Own draft based on Coenen et al.<a class="elsevierStyleCrossRef" href="#bib0250">11</a>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1757 "Ancho" => 2504 "Tamanyo" => 288854 ] ] "descripcion" => array:1 [ "en" => "Indicators for antibiotic prescription quality by contribution groups. J01: prescription quality evaluation parameters (<14.52DID) dark green “very high”; (14.52DID-20.31DID) light green “high”; (20.32DID-23.77DID) yellow “low”; (>23.77DID) red “very low”. J01C: prescription quality evaluation parameters (<6.80DID) dark green “very high”; (6.80DID-9.94DID) light green “high”; (9.95DID-12.83DID) yellow “low”; (>12.83DID) red “very low”. J01D: prescription quality evaluation parameters (<0.64DID) dark green “very high”; (0.64DID-1.60DID) light green “high”; (1.61DID-2.42DID) yellow “low”; (>2.42DID) red “very low”. J01M: prescription quality evaluation parameters (<0.80DID) dark green “very high”; (0.80DID-1.23DID) light green “high”; (1.24DID-2.29DID) yellow “low”; (>2.30DID) red “very low”. Own draft based on Coenen et al.<a class="elsevierStyleCrossRef" href="#bib0250">11</a>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1760 "Ancho" => 2412 "Tamanyo" => 375827 ] ] "descripcion" => array:1 [ "en" => "Cost (€/DDD) per active ingredient and use (DID) by contribution groups. J01CA (penicillins): includes amoxicillin (J01CA04) and ampicillin (J01CA01). J01CR (combinations of penicillins): includes amoxicillin and beta-lactamase inhibitors (J01CR02). Prescription quality evaluation parameters: (<14.42%) dark green “very high”; (14.42–22.70%) light green “high”; (22.71–33.98%) yellow “low”; (>33.98%) red “very low”. J01MA (fluoroquinolones): includes ciprofloxacin (J01MA02), levofloxacin (J01MA12), moxifloxacin (J01MA14) and norfloxacin (J01MA06). Prescription quality evaluation parameters (<4.82%) dark green “very high”; (4.82–7.28%) light green “high”; (7.29–9.06%) yellow “low”; (>9.06%) red “very low”. J01FA (macrolides): includes azithromycin (J01FA10), clarithromycin (J01FA09), erythromycin (J01FA01) and spiramycin (J01FA02). J01DD (third generation cephalosporins): includes cefditoren (J01DD16) and cefixime (J01DD08). Prescription quality evaluation parameters (<0.04%) dark green “very high”; (0.04–0.51%) light green “high”; (0.52–1.88%) yellow “low”; (>1.88%) red “very low”. J01XX (others antibacterials): includes fosfomycin (J01XX01). *Significant differences compared to the other TSI groups with a significance level of p=0.020. **Significant differences compared to the other TSI groups with a significance level of p=0.051. ***Significant differences compared to the other TSI groups with a significance level of p=0.024. ****Significant differences compared to the other TSI groups with a significance level of p=0.053. Own draft based on Coenen et al.<a class="elsevierStyleCrossRef" href="#bib0250">11</a>" ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 53226 ] ] 6 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "What do we know?In 2018, the World Health Organisation pointed to the development of antibiotic resistance as one of the 10 major threats to public health. The action plans against antibiotic resistance focus their strategies on prevention and consumption control, while evaluation of the results is a fundamental yet barely addressed issue.What does this study offer?This study addresses the need to evaluate antibiotics prescribing patterns in primary care, including epidemiological variables (age, sex, and seasonality) and economic variables (income level and price of the antibiotic). The patient groups and active ingredients that rational antibiotic use policies could impact were identified." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Día europeo para el uso prudente de los antibióticos, 2017. 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Assessment of the quality of antibiotics prescription in a regional health system

Evaluación de la calidad de la prescripción de antibióticos en un sistema regional de salud

P. Rojas García

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paula.rojas@unirioja.es

Corresponding author.

, F. Antoñanzas Villar

Departamento de Economía y Empresa, Área de Economía Aplicada, Universidad de La Rioja, Logroño, Spain

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        "titulo" => "Evaluaci&#243;n de la calidad de la prescripci&#243;n de antibi&#243;ticos en un sistema regional de salud"
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Cost &#40;&#8364;&#47;DDD&#41; per active ingredient and use &#40;DID&#41; by contribution groups&#46;</p> <p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">J01CA &#40;penicillins&#41;&#58; includes amoxicillin &#40;J01CA04&#41; and ampicillin &#40;J01CA01&#41;&#46; J01CR &#40;combinations of penicillins&#41;&#58; includes amoxicillin and beta-lactamase inhibitors &#40;J01CR02&#41;&#46; Prescription quality evaluation parameters&#58; &#40;&#60;14&#46;42&#37;&#41; dark green &#8220;very high&#8221;&#59; &#40;14&#46;42&#8211;22&#46;70&#37;&#41; light green &#8220;high&#8221;&#59; &#40;22&#46;71&#8211;33&#46;98&#37;&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;33&#46;98&#37;&#41; red &#8220;very low&#8221;&#46;</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">J01MA &#40;fluoroquinolones&#41;&#58; includes ciprofloxacin &#40;J01MA02&#41;&#44; levofloxacin &#40;J01MA12&#41;&#44; moxifloxacin &#40;J01MA14&#41; and norfloxacin &#40;J01MA06&#41;&#46; Prescription quality evaluation parameters &#40;&#60;4&#46;82&#37;&#41; dark green &#8220;very high&#8221;&#59; &#40;4&#46;82&#8211;7&#46;28&#37;&#41; light green &#8220;high&#8221;&#59; &#40;7&#46;29&#8211;9&#46;06&#37;&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;9&#46;06&#37;&#41; red &#8220;very low&#8221;&#46; J01FA &#40;macrolides&#41;&#58; includes azithromycin &#40;J01FA10&#41;&#44; clarithromycin &#40;J01FA09&#41;&#44; erythromycin &#40;J01FA01&#41; and spiramycin &#40;J01FA02&#41;&#46;</p> <p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">J01DD &#40;third generation cephalosporins&#41;&#58; includes cefditoren &#40;J01DD16&#41; and cefixime &#40;J01DD08&#41;&#46; Prescription quality evaluation parameters &#40;&#60;0&#46;04&#37;&#41; dark green &#8220;very high&#8221;&#59; &#40;0&#46;04&#8211;0&#46;51&#37;&#41; light green &#8220;high&#8221;&#59; &#40;0&#46;52&#8211;1&#46;88&#37;&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;1&#46;88&#37;&#41; red &#8220;very low&#8221;&#46;</p> <p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">J01XX &#40;others antibacterials&#41;&#58; includes fosfomycin &#40;J01XX01&#41;&#46;</p> <p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;020&#46;</p> <p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;051&#46;</p> <p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42;&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#46;</p> <p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42;&#42;&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;053&#46;</p> <p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Own draft based on Coenen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Antibiotics have been fundamental to the treatment of bacterial infections ever since they were first introduced into clinical practice in the 1940s&#46; Currently&#44; the main threats society faces are the epidemiological&#44; microbiological&#44; and economic consequences of the development of antibiotic resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a> These threats are enhanced&#44; among other causes&#44; by excessive and inappropriate use not only in humans&#44; but also in veterinary practices&#44; limited awareness of the problem among the general population and insufficient hospital measures for preventing infection&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The European Centre for Disease Prevention and Control lists initiatives<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> from multiple European countries to raise awareness about the risks of inappropriate antibiotic use&#46; In Spain&#44; the surveillance of antibiotics consumption is a strategic line of the National Plan against Antibiotics Resistance &#40;PRAN&#41; promoted by the Spanish Agency of Medicines and Medical Devices&#46; The PRAN publishes annual reports<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;4</span></a> detailing the work performed within its six strategic lines&#46; One of its initiatives within the human health care field is to promote the creation of antibiotic consumption studies in local geographic contexts with the aim of acting in a disaggregated manner and to draft specific actions plans for each case&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">One of these regional studies is that of L&#225;zaro et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> which analysed the differences in antibiotic consumption among autonomous communities&#44; making the conclusion in the year 2000 that there were differences between regions of up to 10&#46;4 defined daily doses per 1000 inhabitants &#40;DID&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ripoll et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">6</span></a> analysed antibiotic consumption in rural and urban areas of the &#193;vila province in 2005&#46; In this region&#44; consumption varied according to area&#44; and was much higher in urban areas and much lower in rural areas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">V&#225;zquez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> also analysed the pharmaceutical cost of antibiotic prescribing in paediatrics in Castile and Le&#243;n between 2001 and 2005&#44; finding a decrease in cost and consumption in the last year&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Serna et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> studied antibiotic consumption and distribution by age and sex in L&#233;rida between 2002 and 2007&#44; finding higher consumption rates in children and older individuals &#40;over the age of 74&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Lallana-Alvarez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a> described outpatient antibiotic prescribing according to epidemiological variables &#40;age&#44; sex&#44; and overuse patients&#41; in the Community of Arag&#243;n using data from 2008&#46; Their results showed that women presented higher antibiotic consumption than men&#44; that penicillins were the most frequently prescribed antibiotic up to age 80&#44; and that quinolones were the dominant group for patients aged 80 and above&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">S&#225;nchez-N&#250;&#241;ez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> analysed outpatient use of antibiotics in hospitals in Asturias between 2006 and 2015 in the rural&#44; urban&#44; and suburban population&#46; They highlighted the need for new measures to reduce antibiotic prescribing since those that had been implemented &#40;cost control&#44; fundamentally&#41; had not had the desired effect on consumption&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In 2007&#44; the European Surveillance of Antimicrobial Consumption &#40;ESAC&#41; published a set of indicators<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> to describe antibiotic use&#44; evaluate the quality of prescribing patterns&#44; assess national rankings compared to other countries&#44; and to design actions aimed at promoting rational use of these drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a> Adriaenssens et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> calculated these quality indicators for 32 European countries&#46; In their study&#44; they stressed that the individuals responsible for formulating policies as well as health care professionals required this information on consumption quality in order to select improvement actions for antibiotic consumption&#46; Klein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a> analysed data from 76 countries&#44; concluding that those with lower income had higher mortality rates related to infectious diseases and lower rates of antibiotic consumption and they believed that policies to reduce consumption in high income countries were necessary&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ultimately&#44; all of these regional&#44; national&#44; and international studies have contributed to expanding knowledge and understanding of antibiotic consumption&#44; identifying trends&#44; and highlighting how significant consumption in developed countries strengthens the advance of antibiotic resistance&#46; Nevertheless&#44; in the battle against antibiotic resistance&#44; actions targeted at prevention&#44; control&#44; and consumption awareness are not the only necessary measures&#46; Evaluating results is a fundamental yet barely addressed aspect&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> This study addresses the need to have performance indicators for action plans against antibiotic resistance&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The objectives of this study are framed within the PRAN recommendations on setting up regional consumption studies to provide information that will facilitate the creation of policies that better fit the characteristics of the population&#46; Specifically&#44; the aim of this project was to define the quality of antibiotic prescribing in the autonomous community of La Rioja&#44; taking into account epidemiological variables &#40;age&#44; sex&#44; and seasonality&#41; and economic variables &#40;price of active ingredients&#44; percent of co-payment contribution&#44; and income level&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0060" class="elsevierStylePara elsevierViewall">The data for this retrospective study came from the dispensation records of ordinary official prescriptions and pharmacies from the autonomous community of La Rioja&#44; from the autonomic delegations in La Rioja from the Armed Forces Social Institute &#40;ISFAS&#41; and the General Mutual Benefit Fund for Civil Servants &#40;MUFACE&#41;&#44; which provided the primary data&#44; while prescriptions that were not publicly funded&#44; such as those prescribed by private dentists&#44; were left out of the study&#46; Data from private prescriptions were not included in the analysis as there is no detailed database like the public prescription registers of each health ministry in each autonomous community&#46; Even the Ministry of Health&#44; Consumer Affairs and Social Welfare&#44; in order to create antibiotics consumption maps&#44; must estimate medication dispensing through private prescribing based on sampling &#40;the most recent with 6065 pharmacies&#44; with a 27&#46;5&#37; coverage of the total&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> Another data source would be pharmaceutical distributors&#44; but as they are not public access&#44; this option has been ruled out&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The analysis was based on an observational study using the database&#44; on a monthly basis&#44; for all antibiotics dispensing &#40;subgroup J01 of the Anatomical Therapeutic Chemical &#91;ATC&#93; classification&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a> carried out in 2017 in La Rioja&#46; The included variables were as follows&#58; dispensing date &#40;month&#41;&#44; name and code of the active ingredient &#40;ATC classification&#41;&#44; dose&#44; prescription cost &#40;recommended retail price&#41;&#44; age&#44; sex&#44; and type of contribution of the patient prescribed the prescription&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Population rates for antibiotic prescribing are expressed in defined daily doses &#40;DDD&#41; per 1000 inhabitants and day &#40;DID&#41; and number of prescriptions written per 1000 inhabitants&#46; Using these population rates&#44; the prescribing quality was evaluated using nine quality indicators &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; defined by the ESAC<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a>&#58; four on prescribing expressed in DID &#40;total J01&#44; of penicillins J01C&#44; of cephalosporins J01D and of quinolones J01M&#41;&#44; three on relative prescribing expressed as a percent compared to the total &#40;of penicillins and beta-lactamase inhibitors J01CR&#44; of third generation cephalosporins J01DD&#44; and fluoroquinolones J01MA&#41;&#44; a ratio of broad-spectrum antibiotic prescription &#40;J01B&#47;N&#41; and an indicator for seasonal variation applied to the total prescribing &#40;J01SV&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">To evaluate prescribing quality&#44; the prescribing rates were grouped in quartiles and their intervals listed from smallest to greatest&#44; similar to the approach used in the ESAC study&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> The values separating each quartile are identified as the limits of each interval in the ESAC study and served as a quality pattern for this study&#59; specifically&#44; those from 2017 were used&#44; the most recent available year&#46; Prescribing quality was thus established&#44; according to the location of the prescribing rates in the quartiles and&#44; for analytical ease&#44; a colour scale was used for each one&#58; a dark green colour indicates &#8220;very high&#8221; prescribing quality&#44; light green is &#8220;high&#8221;&#44; yellow is &#8220;low&#8221;&#44; and red is &#8220;very low&#8221;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Note that the population data for the calculations comes from the number of individual health cards &#40;Spanish acronym&#58; TSI&#41; provided by the Directorate General of Benefits and Pharmacy and the number of members of medical insurance companies&#46; The WHO estimates defined daily doses based on adult consumption&#44; so prescriptions for patients under the age of 15 were not considered&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For patient classification according to contribution types and income level&#44; the Royal Decree-Law 16&#47;2012<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> was referenced&#44; whereby there are six patient groups according to the type of TSI assigned&#46; In this study&#44; data was used from the groups TSI 002 &#40;low- and middle-income pensioners&#41;&#44; TSI 003 &#40;low-income active workers&#41;&#44; TSI 004 &#40;middle-income active workers&#41; and TSI 005 &#40;high-income pensioners and active workers&#41;&#44; with the aim of facilitating inferential analysis&#46; Based on the cost of each active ingredient &#40;expressed in euros per DDD&#41;&#44; the cost relationship with the prescription was analysed&#46; This phenomenon was called the &#8220;price effect&#8221;&#46; It was then estimated whether the income variable had any impact on consumption&#44; which in this study we called the &#8220;income effect&#8221;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Calculations were made with and without single dose fosfomycin prescriptions following the PRAN recommendation to use narrow spectrum antibiotic prescriptions as a relative indicator&#44; as these are largely used for respiratory and urinary tract infections&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">To establish the existence of significant differences in antibiotic prescribing by sex&#44; age&#44; and contribution type&#44; the Chi-squared test was used with a 95&#37; confidence interval&#46; IBM SPSS 20&#44; 2011 &#40;Armonk&#44; New York&#41; predictive analysis software was used&#46; A table of acronyms and abbreviations is included as additional material&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">By epidemiological variables &#40;age&#44; sex&#44; and seasonality&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Antibiotic prescribing through official prescription in La Rioja was estimated to be 18&#46;55<span class="elsevierStyleHsp" style=""></span>DID &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#41;&#44; presenting &#8220;high&#8221; quality &#40;prescribing rate within the second quartile&#44; classified as &#8220;high quality&#8221; between 14&#46;52 and 20&#46;31<span class="elsevierStyleHsp" style=""></span>DID&#41;&#44; according to the standards established by ESAC&#46; Antibiotic prescribing through a prescription issued by medical insurance in La Rioja was 21&#46;79<span class="elsevierStyleHsp" style=""></span>DID &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#41;&#44; presenting &#8220;low&#8221; quality &#40;prescribing rates within the third quartile&#44; classified as &#8220;low&#8221; quality between 20&#46;32 and 23&#46;77<span class="elsevierStyleHsp" style=""></span>DID&#41;&#44; according to the standards established by ESAC&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The differences in total antibiotic prescribing between men and women&#44; for the 20 to 64 age range&#44; were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The age group with the highest doses of prescribed antibiotics was women aged 85 to 89 with 35&#46;38<span class="elsevierStyleHsp" style=""></span>DID&#44; while the lowest amount prescribed was for men aged 30 to 34&#44; with 9&#46;19<span class="elsevierStyleHsp" style=""></span>DID&#46; In the group of men aged 15 to 64&#44; prescribing quality was &#8220;very high&#8221; &#40;prescribing rates within the first quartile&#44; under 14&#46;52 DID&#41;&#46; As age increased&#44; total prescribing quality &#40;J01&#41; fell&#44; presenting as &#8220;low&#8221; for those aged 65 to 79 and &#8220;very low&#8221; &#40;prescribing rates higher than 23&#46;77<span class="elsevierStyleHsp" style=""></span>DID&#41; from 80 years and above&#46; In the group of women aged between 15 to 29 and between 35 to 54&#44; the prescribing quality was &#8220;very high&#8221;&#46; From 30 to 34 and from 55 to 69 years of age&#44; prescribing quality was &#8220;high&#8221;&#46; Starting at age 69&#44; quality shifted to &#8220;low&#8221; and in women over 75 years it became &#8220;very low&#8221;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Penicillins prescribing &#40;J01C&#41; met the standards defined for &#8220;high&#8221; quality &#40;prescribing rates between 6&#46;80 and 9&#46;94<span class="elsevierStyleHsp" style=""></span>DID&#41;&#44; with the exception of women aged 25 to 39 and individuals of both sexes over the age of 70 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#46; A &#8220;very low&#8221; prescribing quality for the group of women aged 85 to 89 stood out &#40;12&#46;83<span class="elsevierStyleHsp" style=""></span>DID&#41;&#46; The amount of penicillins prescribed to women was higher for all age ranges than that prescribed to men&#46; The group with the lowest doses of prescribed penicillins was men aged 50 to 54 &#40;5&#46;58<span class="elsevierStyleHsp" style=""></span>DID&#41;&#46; The penicillin prescribing differences between men and women were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; in the age range of 15 to 69&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Cephalosporins prescribing quality &#40;J01D&#41; remained &#8220;very high&#8221; &#40;prescribing rates of less than 0&#46;64<span class="elsevierStyleHsp" style=""></span>DID&#41; in women aged 15 to 34 and 40 to 54&#44; in men aged 15 to 59&#44; and &#8220;high&#8221; &#40;prescribing rates between 0&#46;64 and 1&#46;60<span class="elsevierStyleHsp" style=""></span>DID&#41; in both sexes up to the age of 74 Significant differences were found &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; between men and women aged 20 to 59 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>c&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Quinolones prescribing &#40;J01<span class="elsevierStyleHsp" style=""></span>M&#41; stopped meeting the predetermined &#8220;high&#8221; quality standards &#40;prescribing rates between 0&#46;80 and 1&#46;23<span class="elsevierStyleHsp" style=""></span>DID&#41; in men and women aged 45 and above&#44; reaching 11&#46;55<span class="elsevierStyleHsp" style=""></span>DID and 9&#46;41<span class="elsevierStyleHsp" style=""></span>DID in the groups of women and men aged 85 to 89&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>d&#41;&#46; With the exception of this age range&#44; no significant differences were detected between sexes&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The prescribing rates for every 1000 patients were calculated&#44; allowing us to confirm these differences by sex&#46; For every 1000 inhabitants&#44; 588 antibiotic prescriptions were written&#59; 674&#46;37 prescriptions for every 1000 women and 499&#46;41 for every 1000 men&#46; Statistically significant differences were found between both prescribing rates &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;031&#41;&#46; After applying the calculations to the database without the prescription records of dispensed fosfomycin&#44; 589&#46;48 prescriptions were recorded for every 1000 women and 491&#46;54 prescriptions for every 1000 men&#44; and this difference was not statistically significant&#46; In this manner&#44; any bias in the results between the number of prescriptions and the prescribed load &#40;DID&#41; by sex was avoided&#44; since 80&#46;29&#37; of the fosfomycin prescriptions written for women corresponded to prescriptions for single-dose packs&#44; while in men the percentage was 49&#46;21&#37;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>e shows the ratio for wide-spectrum antibiotics prescribing compared to narrow-spectrum antibiotics &#40;J01B&#47;N&#41;&#46; Wide-spectrum antibiotics should be used in situations in which narrow-spectrum antibiotics have not been effective&#46; Therefore&#44; starting at 17&#46;09 points&#44; wide-spectrum antibiotics prescribing is considered &#8220;low&#8221; quality&#46; With a ratio of more than 49&#46;17 points&#44; prescribing is considered to be &#8220;very low&#8221; quality according to ESAC&#44; this being the case of the group of men over the age of 45 and women aged 50 to 54 and over 65&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The weight of prescriptions for penicillins and beta-lactamase inhibitors &#40;J01CR&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>f&#41; compared to total prescribing &#40;J01&#41; exceeded the defined standards for &#8220;high&#8221; quality &#40;between 14&#46;42&#37; and 22&#46;70&#37;&#41; in men aged 20 to 49&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In third generation cephalosporins &#40;J01DD&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>g&#41; and fluoroquinolones &#40;J01MA&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>h&#41;&#44; high prescribing rates were also recorded in both sexes from the age of 40&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the seasonal variation of total prescribing in the winter months compared to the summer months&#46; In agreement with the ESAC&#44; a percentage of more than 32&#46;78&#37; suggests overuse of antibiotics in the winter months compared to the summer&#44; meaning it is considered a &#8220;very low&#8221; prescribing quality&#46; This was the case in the group of women aged 50 to 89&#44; which reached seasonal variations of up to 52&#46;24&#37; &#40;21&#46;36 <span class="elsevierStyleHsp" style=""></span>DID in winter and 14&#46;03<span class="elsevierStyleHsp" style=""></span>DID in summer&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41; in the 85 to 89 age range&#46; This was also the case in the group of men aged 65 to 89&#44; reaching seasonal variations of up to 41&#46;98&#37; &#40;12&#46;75 <span class="elsevierStyleHsp" style=""></span>DID in winter and 8&#46;98<span class="elsevierStyleHsp" style=""></span>DID in summer&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41; in the 75 to 79 age range&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">A higher number of prescriptions were written &#40;mainly amoxicillin with and without inhibitors&#44; azithromycin&#44; and cefuroxime&#41; in the winter months as compared to the summer months&#46; Fosfomycin was the only ingredient for which prescribing increased in the summer months compared to winter months&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">By economic variables &#40;income levels and treatment cost&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows the quality indicators for prescribing by contribution groups&#46; In the pensioners group&#44; the total prescriptions &#40;28&#46;89 DID&#41; of cephalosporins &#40;4&#46;80 DID&#41; and quinolones &#40;5&#46;26 DID&#41; received a &#8220;very low&#8221; prescribing quality&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">In the group of low-income active workers&#44; the quality of total prescribing &#40;17&#46;60<span class="elsevierStyleHsp" style=""></span>DID&#41; and of quinolones &#40;0&#46;98<span class="elsevierStyleHsp" style=""></span>DID&#41; was &#8220;high&#8221; according to the ESAC criteria&#44; while prescribing of penicillins &#40;11&#46;37<span class="elsevierStyleHsp" style=""></span>DID&#41; and cephalosporins &#40;1&#46;85 DID&#41; was &#8220;low&#8221; quality&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In middle-income active workers&#44; total prescribing &#40;17&#46;44<span class="elsevierStyleHsp" style=""></span>DID&#41; and that of quinolones &#40;0&#46;94<span class="elsevierStyleHsp" style=""></span>DID&#41; was &#8220;high&#8221; quality and prescribing of penicillins &#40;10&#46;92<span class="elsevierStyleHsp" style=""></span>DID&#41; and cephalosporins &#40;1&#46;93<span class="elsevierStyleHsp" style=""></span>DID&#41; was &#8220;low&#8221; quality&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In high-income active workers&#44; total prescribing &#40;10&#46;43<span class="elsevierStyleHsp" style=""></span>DID&#41; and that of penicillins &#40;4&#46;68<span class="elsevierStyleHsp" style=""></span>DID&#41; was &#8220;high&#8221; quality&#44; while prescribing of cephalosporins &#40;1&#46;74<span class="elsevierStyleHsp" style=""></span>DID&#41; and quinolones &#40;1&#46;50<span class="elsevierStyleHsp" style=""></span>DID&#41; was &#8220;low&#8221; quality&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> lists the various active ingredients&#44; grouped according to therapeutic-pharmacological subgroup &#40;fourth level of the ATC classification&#41;&#44; according to their cost &#40;expressed in euros per DDD&#41;&#46; The penicillins subgroup &#40;J01CA&#41;&#44; which includes the active ingredients amoxicillin &#40;J01CA04&#41; and ampicillin &#40;J01CA01&#41;&#44; presented a lower cost per DDD &#40;0&#46;14<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD&#41;&#46; The subgroup of other antibacterials &#40;J01XX&#41;&#44; which includes fosfomycin &#40;J01XX01&#41;&#44; presented the highest cost per DDD &#40;7&#46;07<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD&#41;&#46; The amount prescribed &#40;expressed in DID&#41; is also included in each contribution group&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">As the cost of the active ingredients increased&#44; the amount of antibiotics prescribed fell &#40;&#8220;price effect&#8221;&#41;&#46; With the exception of penicillins&#44; the pensioner group &#40;TSI 002&#41; presented higher consumption than the other groups &#40;attributable to epidemiological reasons&#41; with statistically significant differences in fluoroquinolones &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41; and macrolides &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;053&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The amount of penicillins prescribed &#40;J01CA and J01CR&#41; to high-income active workers was significantly lower &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;020 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;051&#44; respectively&#41; than the amount prescribed to the other contribution groups &#40;&#8220;income effect&#8221;&#41;&#46; While no statistically significant differences were detected&#44; a larger number of fluoroquinolones&#44; macrolides&#44; third generation cephalosporins&#44; and fosfomycins were prescribed to high-income active workers than to the other actively working groups&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> also includes prescribing quality according to the relative consumption indicators &#40;J01CR&#44; J01MA and J01DD&#41;&#46; All the contribution groups received a &#8220;very low&#8221; prescribing quality in third generation cephalosporins&#44; and the pensioner and high-income active worker groups did in fluoroquinolones&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">The analysis of prescribing quality has been a fundamental topic of public health for years&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19&#44;20</span></a> It has currently gained relevance in the field of antibiotics<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> due to the relationship between their elevated use and the appearance of resistances to these drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">22&#44;23</span></a> Understanding how not only epidemiological&#44; but also economic variables impact antibiotic prescribing habits enables actions to be carried out to control resistance in clinical practice<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a> and&#44; by extension&#44; allows healthcare costs to be managed more effectively&#46; This study addresses the need<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> to have performance indicators and to evaluate the results of action plans against antibiotic resistance&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">To improve antibiotic resistance rates&#44; prescribing quality must also be measured outside the European context&#46; Local and regional data provide information about the setting where management decisions are made and facilitate the acquisition&#44; use&#44; and return of information&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> In addition&#44; the comparative evaluation methodology<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a> used gives validity to regional studies like this one&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In this analysis&#44; antibiotic prescribing in adults &#40;from the age of 15&#41; during 2017 via official prescription was estimated to be 18&#46;55<span class="elsevierStyleHsp" style=""></span>DID&#46; The number of TSIs was used as the population value for calculations&#46; The Ministry of Health&#44; Consumer Affairs and Social Welfare estimated said prescribing volume to be 18&#46;45<span class="elsevierStyleHsp" style=""></span>DID&#44; a difference attributable to the fact that said Ministry used the number of inhabitants&#46; Both values indicated a &#8220;high&#8221; quality of antibiotic prescribing with official prescription according to the standards defined by ESAC&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Antibiotic prescribing in patients belonging to medical insurance companies was 21&#46;79<span class="elsevierStyleHsp" style=""></span>DID&#46; This figure indicated a prescribing quality for medical insurance companies that is also &#8220;low&#8221;&#44; as per the ESAC standards&#46; The number of policy holders was used as the population value for calculations &#40;from MUFACE and ISFAS&#41;&#46; Nevertheless&#44; the Ministry of Health&#44; Consumer Affairs and Social Welfare estimated this figure using the number of total inhabitants&#44; thereby obtaining a prescription rate in medical insurance of 0&#46;99<span class="elsevierStyleHsp" style=""></span>DID&#46; In this study&#44; it was seen that the prescribing habits of medical insurance companies with a higher number of affiliates &#40;MUFACE and ISFAS&#44; which represent 93&#37; of this population&#41; was 0&#46;95 DID&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In addition&#44; antibiotics consumption via private prescription was 6&#46;58<span class="elsevierStyleHsp" style=""></span>DID&#44; according to estimates from the Ministry of Health&#44; Consumer Affairs and Social Welfare&#46; In this study&#44; no results have been presented for this value due to the absence of these records in the database&#46; Therefore&#44; total antibiotic consumption&#44; or the sum or DID dispensed as official prescriptions &#40;18&#46;45<span class="elsevierStyleHsp" style=""></span>DID taking the number of inhabitants as the population value and 18&#46;55<span class="elsevierStyleHsp" style=""></span>DID the number of health cards&#41;&#44; as prescriptions from various medical insurance companies &#40;0&#46;99<span class="elsevierStyleHsp" style=""></span>DID&#41;&#44; and from private prescriptions &#40;6&#46;58 <span class="elsevierStyleHsp" style=""></span>DID&#41;&#44; for adults in La Rioja in 2017 would be estimated to be between 26&#46;02 and 26&#46;12<span class="elsevierStyleHsp" style=""></span>DID&#46; This result would correspond to a &#8220;very low&#8221; prescribing quality&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Some authors<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> have pointed out that antibiotic prescribing in the private sector is less normalised than it is in the public sector&#44; with there being a deviation in antibiotic prescribing from official prescriptions to private prescriptions&#46; By way of estimation&#44; if we put into context the value that the Ministry of Health&#44; Consumer Affairs and Social Welfare provides for La Rioja&#44; 6&#46;58<span class="elsevierStyleHsp" style=""></span>DID<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> for private prescriptions compared to 26<span class="elsevierStyleHsp" style=""></span>DID &#40;result obtained in this study for the sum of official&#44; medical insurance&#44; and private prescriptions&#41;&#44; we would see that approximately 25&#37; of the DID would be attributable to private prescriptions&#46; In any event&#44; this estimate is a subject for future analysis&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The patient groups and antibiotic families that rational antibiotic use policies could impact were identified&#46; The highest consumption rates were found in the groups over the age of 60&#46; One possible explanation is that age is an influential factor in the immune status of the patient &#40;infections are more easily contracted and additionally are harder to resolve without the aid of drugs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a> Therefore&#44; antibiotics consumption is higher starting with this age group&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">As with previous studies<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">9&#44;28</span></a> significant differences were detected in the number of prescriptions written to women and to men&#46; As per the quality indicators&#44; quinolones prescribing for groups over the age of 60 and penicillins prescribing for women aged 25 to 39 exceeded the standards that the ESAC classified as &#8220;high&#8221; quality &#40;&#62;2&#46;42<span class="elsevierStyleHsp" style=""></span>DID and &#62;9&#46;95<span class="elsevierStyleHsp" style=""></span>DID&#44; respectively&#41;&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Differences were found regarding prescribing quality by type of contribution according to the TSI group assigned to the patients&#44; this being &#8220;high&#8221; in the active workers group and &#8220;low&#8221; in pensioners&#46; The contribution groups showed a wide margin for improvement in the indicators for relative consumption of third generation cephalosporins and&#44; with the exception of low- and middle-income active workers&#44; in the consumption of fluoroquinolones&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Regarding seasonality&#44; it was detected that fosfomycin did not meet the characteristic seasonality<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">29</span></a> of antibiotics &#40;higher consumption in winter months&#41;&#44; as it increased by 12&#46;15&#37; in the summer months compared to the winter&#46; This active ingredient is mainly prescribed for urinary tract infections which are more common in the summer and in women&#46; Despite this characteristic of the antibiotics&#44; the quality indicators showed overuse of antibiotics in women over the age of 60 in the winter months as compared to the summer&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">As for economic variables&#44; a &#8220;price effect&#8221; was detected that could potentially signal the choice of lower-priced active ingredients&#46; Antibiotic prescribing seems to follow a pattern similar to that of the consumption of other goods&#58; higher demand for lower-priced items&#44; and vice versa&#44; as can be deduced from the observation in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#44; which mirrors the typical demand curve&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Significant differences were found in prescribing for pensioners &#40;TSI 002&#41; compared to the other groups &#40;TSI 003&#44; TSI 004 and TSI 005&#41; of fluoroquinolones and macrolides&#44; whose costs were 1&#46;32<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD and 1&#46;87<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD&#44; respectively&#46; These differences may be attributable to epidemiological issues&#46; What&#39;s more&#44; statistically significant differences were found in prescriptions for antibiotic subgroups with the lowest prices&#44; penicillins &#40;J01CA with 0&#46;14<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD and J01CR with 1&#46;22<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD&#41; in high-income active workers compared to other groups&#44; with a lower amount prescribed to high-income active workers&#44; thereby detecting an &#8220;income effect&#8221; that seemed to indicate&#44; in economic terms&#44; that penicillins would be an inferior good with respect to income&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">While the prescribed amount of the active ingredient with the highest cost &#40;other antibacterials&#44; such as fosfomycin&#44; 7&#46;07<span class="elsevierStyleHsp" style=""></span>&#8364;&#47;DDD&#41; was higher in high-income active workers&#44; no significant differences were found in the amounts prescribed between contribution groups&#46; Therefore&#44; no lack of equity was detected in access to high-cost antibiotics due to the purchasing power of the patients&#44; which is desirable from a healthcare policy perspective&#46; Nevertheless&#44; it is the patient who makes the decision to withdraw the prescription from the pharmacy&#44; which may be influenced by his or her purchasing power&#44; something which was not investigated in this study&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">It must be kept in mind that the data source did not include a series of aspects that affect the obtained results&#44; such as real consumption &#40;different from dispensing of multiple packages of antibiotics in one prescription&#41; and the paediatric population&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">It is necessary to consider the differences between the volume of antibiotics prescribed&#44; dispensed&#44; and consumed&#46; While it would have been ideal to study the effective consumption of the population of La Rioja in 2017&#44; it is worth pointing out that the available data does not allow us to accurately know said consumption&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">As some studies<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> indicated&#44; bias can appear in the results for the same period and population depending on whether prescribing or dispensing is observed&#46; Some authors<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">30</span></a> have quantified the percent of antibiotic prescriptions that are written but not dispensed to be 30&#37; &#40;based on a comparison of prescribing data with reimbursement data for the 2002 to 2005 period in Spain&#41;&#46; In addition&#44; once a patient obtains the antibiotic&#44; it is his or her choice to consume it or not&#44; either partially or fully&#44; perhaps contemplating future self-medication&#46; In this sense&#44; the newspaper <span class="elsevierStyleItalic">El Global</span>&#44; on 24 May 2018&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> highlighted that 63&#37; of Spanish adults admitted to having used the same medication that in the past had cured the same or similar symptoms and without prior prescription from their doctor&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">This study has used data from official prescriptions that were prescribed and dispensed&#44; whose content may or may not have ultimately been consumed by the patient&#44; as this information is difficult to know from the available data&#46; Therefore&#44; the previously mentioned bias of 30&#37; difference between volume prescribed and dispensed would not affect this study&#44; though the bias regarding final consumption of the antibiotic would&#44; which is hard to estimate&#46; In this vein&#44; the results of the 2016 Eurobarometer on citizen awareness of antibiotics&#44; published by the European Commission<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a> and analysed by the Ministry of Health&#44; Consumer Affairs and Social Welfare&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> indicated that 5&#37; of the Spaniards surveyed admitted to self-medicating with antibiotics&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">One study<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a> analysed irregular private prescriptions for J01 oral antibacterials in 247 pharmacies across all of Spain &#40;except Ceuta and Melilla&#41; between 2016 and 2017&#46; It concluded that 29&#37; of private prescriptions did not follow regulations&#44; mainly for being issued through emergency reports&#44; verbal or telephone prescriptions&#44; prescriptions for insufficient dosages&#44; medical discharge reports&#44; and deferred prescriptions&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Another cross-sectional study<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> using a sample of 977 pharmacies from northwest Spain and carried out between 2016 and 2017 estimated that a fifth of said pharmacies had dispensed antibiotics without a prescription to the &#8220;actors&#8221; who attempted to obtain them&#44; supplying antibiotics at 18&#46;83&#37; of visits&#46; The rural setting was a deciding factor in the study results&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">In addition&#44; in a literature review<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">36</span></a> from 2018 on determinants in antibiotics dispensing without prescription&#44; it was pointed out that Internet purchases constituted a risk factor for access to these drugs&#46; Nevertheless&#44; it concluded that pharmacies were the main means for obtaining antibiotics without a prescription&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">The WHO assures that&#44; for practical reasons&#44; the DDD indicator has been constructed according to adult consumption&#44; with the exception of certain drugs used exclusively in children&#46; To prevent bias in the results due to this fact&#44; all records prescribed to the paediatric population &#40;up to and including age 14&#41; have been excluded from the study&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">In conclusion&#44; the overall rate of antibiotic prescribing &#40;official&#44; medical insurance&#44; and private prescriptions&#41; in La Rioja during 2017 &#40;26&#46;02<span class="elsevierStyleHsp" style=""></span>DID as per population data and 26&#46;12 DID as per the number of health cards&#41; presented &#8220;very low&#8221; quality&#44; according to the intervals defined by the ESAC&#46; According to data from the European Centre for Disease Prevention and Control&#44; the community sits in the higher consumption bracket of the European ranking<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">37</span></a> and has a large margin for improvement for reducing prescribing volume&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">This study has identified which population groups and antibiotic families should be the focus of prescribing improvement measures&#44; including quinolones for patients over the age of 45&#44; fluoroquinolones for those over 30&#44; penicillins for women aged 25 to 39 and for men and women over the age of 70&#44; and third generation cephalosporins for pensioners and active workers&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Therefore&#44; the various healthcare proposals and policies designed to reduce antibiotic consumption&#44; such as antimicrobial administration programmes in hospital settings<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> and in primary care&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a> campaigns for restrained use and personalised diagnosis programmes&#44; can use these results and more effectively fight the threat that the appearance of antibiotic resistance poses to public health&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0325" class="elsevierStylePara elsevierViewall">This paper was funded by a predoctoral contract FPI-CAR 2018&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0330" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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            0 => "Antibi&#243;ticos"
            1 => "Prescripci&#243;n"
            2 => "Atenci&#243;n Primaria"
            3 => "Farmacoepidemiolog&#237;a"
            4 => "Tarjeta sanitaria individual"
          ]
        ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The inappropriate and indiscriminate use of antibiotics is one of the main factors contributing to the onset of antimicrobial resistance&#46; In 2007&#44; the European Surveillance of Antimicrobial Consumption &#40;ESAC&#41; project established certain indicators to assess the quality of antibiotic use&#46; We analysed the quality of antibiotic prescription in La Rioja &#40;Spain&#41; in 2017&#44; using epidemiological &#40;age&#44; sex&#44; seasonal nature&#41; and financial variables &#40;price of the antibiotic and income level&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Using data on monthly distributions of antibiotics &#40;J01&#41; through official prescriptions and prescriptions from medical insurance companies&#44; we calculated the population rates for the number of prescriptions per 1000 inhabitants&#44; as well as the values of 9 quality indicators &#40;by antibiotic family&#44; age group&#44; sex and income&#41;&#44; defined by ESAC&#44; classifying the prescription quality as &#8220;very high&#8221;&#44; &#8220;high&#8221;&#44; &#8220;low&#8221; and &#8220;very low&#8221;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The quality of antibiotic prescriptions in La Rioja in 2017 was &#8220;high&#8221; for antibiotics dispensed through official prescriptions &#40;18&#46;55 daily defined doses per 1000 inhabitants &#91;DID&#93;&#41; and &#8220;low&#8221; for those dispensed through medical insurance companies &#40;21&#46;79 DID&#41;&#46; When we included private prescriptions &#40;26&#46;02 DID&#41;&#44; the quality was &#8220;very low&#8221;&#44; taking into account the margins indicated by ESAC&#46; We detected high rates of prescription for broad-spectrum antibiotics for men older than 45 years&#44; penicillins for women aged 25 to 39 years&#44; quinolones for pensioners and cephalosporins for high-income patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The quality of antibiotic prescription is determined not only by epidemiological variables&#44; such as age and sex&#44; but also by financial variables&#44; such as patient income and antibiotic price&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El uso inadecuado e indiscriminado de los antibi&#243;ticos es uno de los principales factores que contribuye a la aparici&#243;n de resistencias bacterianas&#46; En 2007 el Proyecto europeo de vigilancia del consumo de antimicrobianos &#40;ESAC&#41; estableci&#243; unos indicadores para evaluar la calidad de uso de los antibi&#243;ticos&#46; Se analiza la calidad de la prescripci&#243;n de antibi&#243;ticos en La Rioja en 2017&#44; por variables epidemiol&#243;gicas &#40;edad&#44; sexo y estacionalidad&#41; y econ&#243;micas &#40;precio del antibi&#243;tico y nivel de renta&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Dispensaciones mensuales de antibi&#243;ticos &#40;J01&#41; mediante receta oficial y mutuas&#44; con los que se calcularon tasas poblacionales de n&#250;mero de recetas prescritas por cada 1&#46;000 habitantes y los valores de 9 indicadores de calidad &#40;por familias de antibi&#243;ticos&#44; grupos de edad&#44; sexo y renta&#41;&#44; definidos por el ESAC&#44; calificando como &#171;muy alta&#187;&#44; &#171;alta&#187;&#44; &#171;baja&#187; y &#171;muy baja&#187; la calidad de prescripci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La calidad de la prescripci&#243;n de antibi&#243;ticos en La Rioja en 2017 result&#243; &#171;alta&#187; en antibi&#243;ticos dispensados mediante receta oficial &#40;18&#44;55 dosis diarias definidas por 1&#46;000 habitantes &#8211;DHD&#8211;&#41; y &#171;baja&#187; mediante mutuas &#40;21&#44;79 DHD&#41;&#46; Al incluir la receta privada &#40;26&#44;02 DHD&#41; la calidad fue &#171;muy baja&#187; atendiendo a los m&#225;rgenes indicados por el ESAC&#46; Se detectaron altas tasas de prescripci&#243;n de&#44; entre otros&#58; antibi&#243;ticos de amplio espectro para hombres de m&#225;s de 45 a&#241;os&#44; penicilinas para mujeres entre 25 y 39 a&#241;os&#44; quinolonas para pensionistas y cefalosporinas en renta alta&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La calidad de la prescripci&#243;n de antibi&#243;ticos est&#225; determinada no solo por variables epidemiol&#243;gicas&#44; como la edad o el sexo&#44; sino tambi&#233;n por variables econ&#243;micas&#44; como la renta del paciente y el precio del antibi&#243;tico&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rojas Garc&#237;a P&#44; Anto&#241;anzas Villar F&#46; Evaluaci&#243;n de la calidad de la prescripci&#243;n de antibi&#243;ticos en un sistema regional de salud&#46; Rev Cl&#237;n Esp&#46; 2021&#59;221&#58;497&#8211;508&#46;</p>"
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            "apendice" => "<p id="par0345" class="elsevierStylePara elsevierViewall">The following are supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0060"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Formulas used&#46; ESAC methodology&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The population data are expressed in the number of health cards and&#47;or number of policy holders&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Indicators for antibiotic prescription quality by age groups and sex&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Own draft based on Coenen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Seasonal variation of total prescribing &#40;J01SV&#41;&#46;</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Own draft based on Coenen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Indicators for antibiotic prescription quality by contribution groups&#46;</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">J01&#58; prescription quality evaluation parameters &#40;&#60;14&#46;52<span class="elsevierStyleHsp" style=""></span>DID&#41; dark green &#8220;very high&#8221;&#59; &#40;14&#46;52<span class="elsevierStyleHsp" style=""></span>DID-20&#46;31<span class="elsevierStyleHsp" style=""></span>DID&#41; light green &#8220;high&#8221;&#59; &#40;20&#46;32<span class="elsevierStyleHsp" style=""></span>DID-23&#46;77<span class="elsevierStyleHsp" style=""></span>DID&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;23&#46;77<span class="elsevierStyleHsp" style=""></span>DID&#41; red &#8220;very low&#8221;&#46; J01C&#58; prescription quality evaluation parameters &#40;&#60;6&#46;80<span class="elsevierStyleHsp" style=""></span>DID&#41; dark green &#8220;very high&#8221;&#59; &#40;6&#46;80<span class="elsevierStyleHsp" style=""></span>DID-9&#46;94<span class="elsevierStyleHsp" style=""></span>DID&#41; light green &#8220;high&#8221;&#59; &#40;9&#46;95<span class="elsevierStyleHsp" style=""></span>DID-12&#46;83<span class="elsevierStyleHsp" style=""></span>DID&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;12&#46;83<span class="elsevierStyleHsp" style=""></span>DID&#41; red &#8220;very low&#8221;&#46; J01D&#58; prescription quality evaluation parameters &#40;&#60;0&#46;64<span class="elsevierStyleHsp" style=""></span>DID&#41; dark green &#8220;very high&#8221;&#59; &#40;0&#46;64<span class="elsevierStyleHsp" style=""></span>DID-1&#46;60<span class="elsevierStyleHsp" style=""></span>DID&#41; light green &#8220;high&#8221;&#59; &#40;1&#46;61<span class="elsevierStyleHsp" style=""></span>DID-2&#46;42<span class="elsevierStyleHsp" style=""></span>DID&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;2&#46;42<span class="elsevierStyleHsp" style=""></span>DID&#41; red &#8220;very low&#8221;&#46; J01M&#58; prescription quality evaluation parameters &#40;&#60;0&#46;80<span class="elsevierStyleHsp" style=""></span>DID&#41; dark green &#8220;very high&#8221;&#59; &#40;0&#46;80<span class="elsevierStyleHsp" style=""></span>DID-1&#46;23<span class="elsevierStyleHsp" style=""></span>DID&#41; light green &#8220;high&#8221;&#59; &#40;1&#46;24<span class="elsevierStyleHsp" style=""></span>DID-2&#46;29<span class="elsevierStyleHsp" style=""></span>DID&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;2&#46;30<span class="elsevierStyleHsp" style=""></span>DID&#41; red &#8220;very low&#8221;&#46;</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Own draft based on Coenen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p>"
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Cost &#40;&#8364;&#47;DDD&#41; per active ingredient and use &#40;DID&#41; by contribution groups&#46;</p> <p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">J01CA &#40;penicillins&#41;&#58; includes amoxicillin &#40;J01CA04&#41; and ampicillin &#40;J01CA01&#41;&#46; J01CR &#40;combinations of penicillins&#41;&#58; includes amoxicillin and beta-lactamase inhibitors &#40;J01CR02&#41;&#46; Prescription quality evaluation parameters&#58; &#40;&#60;14&#46;42&#37;&#41; dark green &#8220;very high&#8221;&#59; &#40;14&#46;42&#8211;22&#46;70&#37;&#41; light green &#8220;high&#8221;&#59; &#40;22&#46;71&#8211;33&#46;98&#37;&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;33&#46;98&#37;&#41; red &#8220;very low&#8221;&#46;</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">J01MA &#40;fluoroquinolones&#41;&#58; includes ciprofloxacin &#40;J01MA02&#41;&#44; levofloxacin &#40;J01MA12&#41;&#44; moxifloxacin &#40;J01MA14&#41; and norfloxacin &#40;J01MA06&#41;&#46; Prescription quality evaluation parameters &#40;&#60;4&#46;82&#37;&#41; dark green &#8220;very high&#8221;&#59; &#40;4&#46;82&#8211;7&#46;28&#37;&#41; light green &#8220;high&#8221;&#59; &#40;7&#46;29&#8211;9&#46;06&#37;&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;9&#46;06&#37;&#41; red &#8220;very low&#8221;&#46; J01FA &#40;macrolides&#41;&#58; includes azithromycin &#40;J01FA10&#41;&#44; clarithromycin &#40;J01FA09&#41;&#44; erythromycin &#40;J01FA01&#41; and spiramycin &#40;J01FA02&#41;&#46;</p> <p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">J01DD &#40;third generation cephalosporins&#41;&#58; includes cefditoren &#40;J01DD16&#41; and cefixime &#40;J01DD08&#41;&#46; Prescription quality evaluation parameters &#40;&#60;0&#46;04&#37;&#41; dark green &#8220;very high&#8221;&#59; &#40;0&#46;04&#8211;0&#46;51&#37;&#41; light green &#8220;high&#8221;&#59; &#40;0&#46;52&#8211;1&#46;88&#37;&#41; yellow &#8220;low&#8221;&#59; &#40;&#62;1&#46;88&#37;&#41; red &#8220;very low&#8221;&#46;</p> <p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">J01XX &#40;others antibacterials&#41;&#58; includes fosfomycin &#40;J01XX01&#41;&#46;</p> <p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;020&#46;</p> <p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;051&#46;</p> <p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42;&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#46;</p> <p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">&#42;&#42;&#42;&#42;Significant differences compared to the other TSI groups with a significance level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;053&#46;</p> <p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Own draft based on Coenen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">What do we know&#63;</span><p id="par0315" class="elsevierStylePara elsevierViewall">In 2018&#44; the World Health Organisation pointed to the development of antibiotic resistance as one of the 10 major threats to public health&#46; The action plans against antibiotic resistance focus their strategies on prevention and consumption control&#44; while evaluation of the results is a fundamental yet barely addressed issue&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">What does this study offer&#63;</span><p id="par0320" class="elsevierStylePara elsevierViewall">This study addresses the need to evaluate antibiotics prescribing patterns in primary care&#44; including epidemiological variables &#40;age&#44; sex&#44; and seasonality&#41; and economic variables &#40;income level and price of the antibiotic&#41;&#46; The patient groups and active ingredients that rational antibiotic use policies could impact were identified&#46;</p></span></span>"
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      "titulo" => "References"
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        0 => array:2 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "D&#237;a europeo para el uso prudente de los antibi&#243;ticos&#44; 2017&#46; Declaraci&#243;n de Vytenis Andriukaitis&#44; comisario de salud y seguridad alimentaria&#44; y Carlos Moedas&#44; comisario de investigaci&#243;n&#44; ciencia e innovaci&#243;n"
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                          "autores" => array:1 [
                            0 => "Comisi&#243;n Europea"
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                      "Libro" => array:1 [
                        "fecha" => "2017"
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              "identificador" => "bib0205"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Strategic action plan to reduce the risk of selection and dissemination of antibiotic resistance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Agencia espa&#241;ola de medicamentos y productos sanitarios"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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              ]
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            2 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Campa&#241;as en Europa"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "European Centre for Disease Prevention and Control &#40;ECDC&#41;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
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                    ]
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                ]
              ]
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            3 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Plan nacional frente a la resistencia a los antibi&#243;ticos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "Ministerio de sanidad&#44; consumo y bienestar social"
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                  ]
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                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2017"
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              ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evoluci&#243;n del consumo de antibi&#243;ticos en Espa&#241;a&#44; 1985&#8211;2000"
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                          "etal" => false
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                            0 => "E&#46; L&#225;zaro"
                            1 => "M&#46; Madurga"
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0025-7753(02)72453-6"
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2002"
                        "volumen" => "118"
                        "paginaInicial" => "561"
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                      ]
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2020.04.013

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