Assessing insurance claims as a measure for outpatient antimicrobial stewardship.

Objective: This study evaluated Medicaid claims (MC) data as a valid source for outpatient antimicrobial stewardship programs (ASPs) by comparing it to electronic medical record (EMR) data from a single academic center.

Methods: This retrospective study compared pediatric patients' MC data with EMR data from the Marshall Health Network (MHN). Claims were matched to EMR records based on patient Medicaid ID, service date, and provider NPI number. Demographics, antibiotic choice, diagnosis appropriateness, and guideline concordance were assessed across both data sources.

Setting: The study was conducted within the MHN, involving multiple pediatric and family medicine outpatient practices in West Virginia, USA.

Patients: Pediatric patients receiving care within MHN with Medicaid coverage.

Results: MC and EMR data showed >90% agreement in antibiotic choice, gender, and date of service. Discrepancies were observed in diagnoses, especially for visits with multiple infectious diagnoses. MC data demonstrated similar accuracy to EMR data in identifying inappropriate prescriptions and assessing guideline concordance. Additionally, MC data provided timely information, enhancing the feasibility of impactful outpatient ASP interventions.

Conclusion: MC data is a valid and timely resource for outpatient ASP interventions. Insurance providers should be leveraged as key partners to support large-scale outpatient stewardship efforts.