Provision of pneumococcal prophylaxis for publicly insured children with sickle cell disease

Abstract

Context: It is recommended that children younger than 5 years with sickle cell disease (SCD) take daily prophylactic antibiotics to prevent pneumococcal infections; however, how much prophylactic medication they actually are dispensed is unclear.

Objectives: To measure the amount of prophylactic antibiotics dispensed to young children with SCD and to investigate factors associated with increased delivery of medication.

Design, setting, and patients: Retrospective longitudinal study conducted January 1995 through December 1999 using Tennessee and Washington State Medicaid administrative claims and encounter data. Children (N = 261) who had 1 inpatient or 2 outpatient claims or encounters listing an International Classification of Diseases, Ninth Revision, Clinical Modification code for SCD, were younger than 4 years at study entry (mean age, 1.4 years), and were continuously enrolled in Medicaid for a 1-year period.

Main outcome measure: Number of days during a 365-day period covered by prescription fills for a penicillin or macrolide antibiotic, or for trimethoprim-sulfamethoxazole.

Results: In a 365-day period, patients were dispensed a mean of 148.4 (SD, 121.3; median, 114; interquartile range [IQR], 39-247) days of prophylactic medication. The total amount of medication dispensed varied widely: 10.3% of patients received none and 21.5% received more than 270 days of medication. In a 365-day period, a mean of 12.7 (SD, 10.5; range, 0-40) prophylactic prescriptions were filled per patient. The median prescription duration was 10 days. In a multivariate linear regression model adjusting for state, sex, age at study entry, inclusion year, residence in urban community, outpatient inclusion encounter, required prescription co-payment, and number of outpatient visits for nonpreventive care, each preventive visit was associated with 12.0 (95% confidence interval [CI], 2.3-21.7) additional days of prophylactic antibiotics, and each emergency department visit was associated with 10.0 (95% CI, 1.2-18.8) additional days.

Conclusions: Publicly insured children with SCD may receive inadequate antibiotic prophylaxis against pneumococcal infections, placing them at increased risk of morbidity and mortality; however, increased numbers of outpatient visits for preventive care are associated with improved provision of prophylactic antibiotics.