Effects of utilization management on health outcomes: evidence from urinary tract infections and community-acquired pneumonia

ABSTRACT

Background

Utilization management policies are pervasive in the Medicare Part D program. We assess the effect of utilization management restrictions in the Medicare Part D program on the quality of care in two clinical areas – community-acquired pneumonia (CAP) and urinary tract infections (UTI).

Methods

In this study, we identified new cases of CAP and UTI from Medicare claims data from 2010 to 2016. We assessed the relationship between exposure to utilization management for antibiotic medications suitable for treating these conditions and adverse health outcomes, based on the Agency for Healthcare Research and Quality prevention quality indicators.

Results

We identified 147,526 cases of CAP and 632,407 UTI cases in our data. In these samples, the adverse event rate varied from 3.6 to 5.7%. The probability of an adverse event increased by 0.75 (p = 0.061) percentage points for each ten percentage point increase in exposure to quantity limits (one form of utilization management) among people with CAP. There was no relationship between utilization management and adverse events in the UTI cohort.

Conclusions

In some circumstances, exposure to utilization management policies–particularly quantity limits–may adversely affect health.

KEYWORDS:

• Antibiotic prescribing
• pneumonia
• urinary tract infections
• utilization management

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

M Andersen secured funding, acquired the data, supervised the statistical analysis, and edited the manuscript for intellectual content. A Pant was responsible for statistical analysis and drafting the manuscript. The authors agree for the final version of the manuscript to be published.

Additional information

Funding

This work was funded by the National Institute on Aging (AG058132).