Antibiotic Awareness Week 2023

Value of collecting health equity variables and opportunities to leverage electronic health record and claims data to evaluate health disparities and inequities 

Variations in antibiotic prescribing by patient age, geography, race/ethnicity, and other sociodemographic factors have been well-reported for over a decade.^1–6 These findings have been described using a variety of data sources, most notably including electronic health record (EHR) data^1,4,7,8 and healthcare claims data.^6,9–11 A recent scoping review was performed to characterize inequities in antibiotic prescribing and use across healthcare settings in the US.¹² Of the 61 studies included, none reported underlying drivers of inequities in antibiotic prescribing. In order to promote health equity in antimicrobial stewardship, we most move from describing variations in antibiotic utilization to understanding and reducing inequities.¹³

Antibiotic stewardship is designed to improve and measure the appropriate use of antibiotic agents; however, without careful consideration of health equity variables, these efforts are likely to fall short for our most vulnerable patient populations. EHR and claims data have been widely used to describe and measure progress in antibiotic use patterns. These data sources also include variables that may be indicators of inequities such as sex, race/ethnicity, insurance, and preferred language. Further, patient address can be used to determine rurality and neighborhood indices (e.g., Rural-Urban Continuum Codes,¹⁴ Rural-Urban Commuting Area Codes,¹⁵ Social Vulnerability Index,¹⁶ Area Deprivation Index,¹⁷ Child Opportunity Index¹⁸) to further identify social vulnerabilities. Antibiotic stewardship clinicians can and should incorporate health equity variables into antibiotic use tracking and reporting efforts, including evaluation of stewardship interventions. Additionally, clinicians and researchers with access to regional or national claims data, health information exchange networks, or all-payer claims databases have the potential to evaluate inequities on an even broader level.

Upon identifying any variations in antibiotic use by health equity variables, stewardship clinicians can partner with health equity colleagues to understand drivers of inequities. A number of research frameworks are available to conceptualize factors influencing health disparities,^13,19 including a framework of factors contributing to inequities in antibiotic prescribing.¹² Further, Cichon and colleagues recently published a review on inclusion, diversity, access and equity in antimicrobial stewardship which includes the following methods to reduce antimicrobial prescribing disparities: 1) Standardize equity monitoring tools; 2) Collect equity data on prescribing and provide prescriber feedback; 3) Develop guidelines to direct equitable access to new antimicrobials; and 4) Embrace health equity as part of the quality improvement mission.²⁰ As noted in research frameworks, there are a variety of potential influences and outside variables reported within most healthcare data sources (e.g., access to care, cultural beliefs, patient-clinician interactions). However, data-driven assessment of antibiotic use with a health equity lens is an essential starting point that may lead to further exploration of inequities via quality improvement efforts, community-engagement, and/or mixed-methods research. 

Despite widespread, comprehensive hospital stewardship programs across the nation, the recent scoping review¹² identified only 1 of 61 studies with documented inequities in antibiotic prescribing reported in an acute care setting.²¹ With minimal expansions to our existing structures of reporting antibiotic use, stewardship clinicians have the potential to lead the way in advocating and advancing the concept of pharmacoequity, a goal that ensures all individuals have access to the highest-quality medications required to manage their health needs.²²