Study highlights highly successful urgent care stewardship intervention

Falling pills

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A multifaceted antibiotic stewardship intervention implemented in a network of urgent care (UC) clinics was associated with a significant reduction in antibiotic prescribing for respiratory conditions, researchers reported today in JAMA Network Open.

The study of the intervention, which was deployed at 38 UC clinics and 1 telehealth clinic operated by a nonprofit healthcare system based in Utah, found that antibiotic prescribing for respiratory conditions fell by 15 percentage points within 1 year of implementation, with reductions observed across all clinic sites and nearly all clinicians involved and no unintended consequences.

The authors of the study say the findings prove that antibiotic stewardship can be effective, even in high-volume settings in which unnecessary antibiotic prescribing is common, particularly for respiratory ailments, which are frequently caused by viruses. Previous studies have found that antibiotic prescribing for antibiotic-inappropriate respiratory diagnoses is higher in UCs than other outpatient settings.

"These results show the role we can play in reducing prescribing rates in these critical and unique care settings, which is better for patients and our community overall," lead study author Edward Stenehjem, MD, MSC, of Intermountain Health, said in a press release.

Education, EHR tools, and peer comparison

The stewardship intervention implemented at Intermountain Health involved four primary components based on the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship: Education for clinicians and patients, electronic health record (EHR) tools, a transparent clinician benchmarking dashboard, and media targeting clinicians and patients. It was developed following site assessments of the UC environment and interviews with patients and clinicians.

Within the education component, specific interventions included naming a UC antibiotic stewardship champion to provide education and serve as a resource for other clinicians, creating a clinician handbook with all treatment guidelines, developing antibiotic stewardship webpages for clinicians and patients, and placing antibiotic education brochures in lobbies and examination rooms. EHR tools included prepopulated antibiotic orders with guideline-concordant regimens.

A link to the transparent clinician benchmarking dashboard, which allows clinicians to compare their antibiotic prescribing rate to peers, was included in all emails. To promote antibiotic stewardship for respiratory conditions, staff took part in local or regional television and radio interviews, wrote newspaper articles, and posted stewardship messages on social media.

Independent of these efforts, UC leadership also introduced a financial incentive for clinicians who prescribed antibiotics in fewer than 50% of their respiratory encounters. That target was identified in a pre-intervention analysis that found that roughly 50% of respiratory encounters at Intermountain Health's UCs resulted in an antibiotic prescription.

To measure the effectiveness of these interventions, Stenehjem and his colleagues compared antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions during a baseline period (July 2018 through June 2019) and the intervention period (July 2019 through June 2020). They also analyzed the sustainability of the interventions over the following year (July 2020 through June 2021).

The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing for conditions where antibiotics are not indicated (tier 3 encounters), such as  bronchitis, and prescribing of first-line antibiotics for acute otitis media (AOM, ear infection), sinusitis, and pharyngitis.

Reductions in prescribing seen across clinics

The baseline period included 207,047 respiratory encounters (56.8% female; 92% White; mean age, 30 years) and the intervention period 183,893 (56.4% female; 91.2% White; mean age, 30.7 years). Comparison of the two periods showed the antibiotic prescribing rate declined from 47.8% during the baseline period to 33.3% during the intervention period. Across clinics, the drop in antibiotic prescribing for respiratory conditions ranged from 4.8% to 37.5%. The proportion of clinicians with a prescribing rate higher than 50% fell from 38.5% to 10.2%.

During the initial month of the intervention (July 2019), antibiotic prescribing for respiratory conditions fell by 22% (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.71 to 0.86), then continued to decrease by 5% each month over the course of the intervention (OR, 0.95; 95% CI, 0.94 to 0.96).

These results show the role we can play in reducing prescribing rates in these critical and unique care settings, which is better for patients and our community overall.

For tier 3 conditions, the antibiotic prescribing rate fell from 18.7% during the baseline to 7.5% in the intervention period, with a 47% reduction in the first month (OR, 0.53; 95% CI, 0.44 to 0.63) and a 4% decline for each following month (OR, 0.96; 95% CI, 0.94 to 0.98). First-line antibiotic prescribing for AOM, sinusitis, and pharyngitis increased from 70.7% in the observation period to 74.5% in the intervention, with a first-month increase of 18% (OR, 1.18; 95% CI, 1.09 to 1.29) but no further changes observed.

When the researchers assessed balancing measures, such as patient satisfaction and hospitalization within 14 days of a UC encounter, they found little difference between the two periods. The mean patient response rating was 4.4 during the baseline compared with 4.3 during the intervention, while hospitalizations occurred in 0.4% of baseline encounters and 0.5% of intervention encounters.

Analysis of the 1-year sustainability period found antibiotic prescribing for respiratory conditions remained stable.

"This study provides a model for UC antibiotic stewardship," Stenehjem and his colleagues wrote.

Obstacles for replicating the intervention

In an accompanying commentary, Sena Sayood, MD, and Michael Durkin, MD, MPH, of Washington University in St. Louis School of Medicine, write that the intervention demonstrates that unnecessary antibiotic use in outpatient settings, which dispense 80% to 90% of all antibiotics, can be successfully stopped without any obvious detrimental effects on patient safety or satisfaction.

But they also note that the conditions at Intermountain Health—an integrated healthcare system in which all hospitals, pharmacies, and clinics share data—that enabled the intervention to be successful may not be replicable across the fragmented US healthcare system.

"Tracking and monitoring of antibiotic use across fragmented systems and wide geographic regions covered by multiple clinics is limited by the fact that antibiotic use data are not available in real time at regional levels," they wrote.

They also argue that behavioral interventions that have shown success in reducing unnecessary prescribing in small trials are challenging to put in place in real-world settings and may not be able to overcome the factors that motivate physicians to prescribe antibiotics, such as time constraints and perceived patient satisfaction.

"At minimum, we need tracking of outpatient antibiotic use in an easy-to-access national or regional system, standardized methods of measuring the quality of antibiotic prescriptions, and restructuring of financial incentives to focus on curbing inappropriate antibiotic use," they wrote. "By 2050, resistant infections will account for 10 million deaths per year. With millions of lives on the line, as a society, we need to find a way for patients, payers, health care professionals, and leadership to care more about outpatient antibiotic stewardship."

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