Maria Y. Tian, MBS Department of Medical Education Geisinger Commonwealth School of Medicine Scranton PA

Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid Interview with:

Maria Y. Tian, MBSDepartment of Medical Education
Geisinger Commonwealth School of Medicine
Scranton PA

Maria Tian

Maria Y. Tian, MBS
Department of Medical Education
Geisinger Commonwealth School of Medicine
Scranton PA What is the background for this study?

Response: The antibiotic crisis continues to worsen in the United States (U.S.), which has seen an increasing number of deaths associated with antibiotic resistance, becoming one of the most pressing threats to public health. Concurrently, the availability of effective antibiotics are decreasing, which increases the rates and severity of infections, particularly in patients with respiratory tract infections.

Unfortunately, a persistent and pernicious contributing factor to the crisis is the unnecessary prescription of antibiotics. In a previous study, 25% of antibiotics prescribed in the outpatient setting to Medicaid beneficiaries were not associated with a provider visit [2]. Furthermore, among 298 million prescriptions filled by 53 million Medicaid patients between 2004 and 2013, 45% of the prescriptions for antibiotics were made without any clear rationale [2].

In our study, we aimed to provide an up-to-date analysis of antibiotic prescribing in the U.S. through examining the temporal profile of outpatient antibiotic use reported by Medical Expenditure Panel System (MEPS) and geographical patterns of antibiotic prescribing rates among US Medicaid program beneficiaries. This will help identify potentially unnecessary prescriptions and inform stewardship efforts.  What are the main findings?

Response: We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020.

We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. A 38.7% decrease in antibiotic prescriptions in MEPS was identified from 2013 to 2020 with a larger decline for the broad (−53.7%) than narrow (−23.5%) spectrum antibiotics. Similarly, the total number of patients that were dispensed antibiotics decreased from 71.3 million in 2013 to 42.7 million (−40.0%) in 2020.

The reduction in recipients of broad-spectrum agents (−55.6%) was over twice as large as narrow-spectrum (−23.3%). In Medicaid, antibiotic prescriptions decreased by 6.7% with broad-spectrum antibiotic prescriptions decreasing by 14.11% compared to 7.95% for narrow-spectrum agents.

There was also substantial geographic variation in antibiotic prescribing, with a 2.8-fold difference between the highest (Kentucky = 855 prescriptions per 1,000 enrollees) and lowest (Oregon = 299) states. A significant finding was that the South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). Thus, sizable disparities by geography were identified in the prescribing rates of eight antibiotics with over three-fold state-level differences.  What should readers take away from your report?

Response: The antibiotic crisis is a present threat not only to the individual, but can affect communities at large. It is important to decrease unnecessary prescription of antibiotics and to increase investigation in antibiotic distribution and use to aid stewardship efforts. Interestingly, there were reductions in the overall dispensing of antibiotics nationally from 2013 to 2020 but the exact mechanism responsible for this observed decrease may be multifactorial. Furthermore, there was significant geographic variations in the prescribing rates of antibiotics. State-level disparities may be explained by differences in patient and provider health beliefs and behaviors, legislative polices, disease prevalence, and should be investigated further.  What recommendations do you have for future research as a result of this study?

Response: Additional investigative efforts should be dedicated to further analyzing the observed geographic variation in antibiotic prescription disparities to identify the contributory factors. For example, the databases in this study do not contain information about specific conditions (e.g., upper respiratory infections or urinary tract infections), which would be valuable to characterize in future investigations of the pronounced state-level disparities among Medicaid patients. These insights may assist with developing strategies to reduce the rate of antibiotic misuse and abuse and increase pharmacoequity in the U.S.  Is there anything else you would like to add?

Response: The MEPS is a large national set of surveys of patients, families, and their medical providers that is reliable, nationally representative of the U.S. civilian non-institutionalized population, and involves verifying patient-reported information about prescription drugs. Medicaid is one of the largest payers for healthcare in the U.S. and is a joint federal and state program that provides coverage for 75 million people or 21% of the US population. More public health researchers and data journalists should use these findings to inform antibiotic stewardship efforts.


  1. Aguilar AG, Canals PC, Tian M, et al. Decreases and pronounced geographic variability in antibiotic prescribing in Medicaid. Pharmacy 2024, 12, 46.
  2. Fischer MA, Mahesri M, Lii J, et al. Non-infection-related and non-visit-based antibiotic prescribing is common among Medicaid patients. Health Affairs 2020, 39, 280–288.

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Last Updated on April 1, 2024 by Marie Benz MD FAAD