National stewardship program tied to reduced antibiotics in ambulatory care

Young boy getting a throat swab
Young boy getting a throat swab

stefanamer / iStock

Antibiotic prescribing at hundreds of ambulatory care clinics across the country was nearly cut in half after implementation of an antibiotic stewardship and patient safety program, according to a study published last week in JAMA Network Open.

The program, developed by the Agency for Healthcare Research and Quality (AHRQ) and based on similar antibiotic stewardship efforts in acute care and long-term care settings, was implemented at 389 primary care, urgent care, pediatric care, and other US ambulatory clinics from December 2019 through November 2020. Over that period, total antibiotic prescribing declined by 48%, and antibiotic prescribing for respiratory infections fell by 37%.

The study also found that participating practices showed improvements in the infrastructure needed to maintain antibiotic stewardship programs.

The study authors say the encouraging results suggest that wider implementation of the program could help establish stewardship principles in an area of medical care that is rife with unnecessary antibiotic use. Most antibiotics prescribed in the United States are prescribed in doctor's offices and urgent care clinics, and up to one half of those prescriptions are for conditions that don't require antibiotics.

"This combination of pure volume of antibiotic prescriptions, a large proportion of which are inappropriate, means that this is an area where antibiotic stewardship really needs to be a priority," Sara Keller, MD, MPH, MSHP, lead study author and associate professor of medicine at Johns Hopkins University School of Medicine, told CIDRAP News.

A challenging setting for stewardship

While previous versions of the AHRQ Safety Program have been associated with reduced antibiotic prescribing after being implemented in the acute care and long-term care settings, Keller said the ambulatory care setting presents distinct challenges for antibiotic stewardship. Unlike hospital settings, where clinicians and stewardship team members review antibiotic decisions during patient rounds, primary care and urgent care clinicians and staff generally don't have the time or the opportunity to talk to each other about the decision to prescribe antibiotics to an outpatient.

In addition, she noted, test results for the type of conditions that patients present with in ambulatory settings—like respiratory or urinary tract infections—don't come back for days. That means the decision to prescribe an antibiotic is mainly between the clinician and the patient, who may or may not have an established relationship, and occurs during a short visit.

"The entire decision about what to prescribe for the patient occurs in a very time-limited clinic setting," she said. "In urgent care, that one interaction in which an antibiotic is prescribed may be the only time that that patient ever sees that clinician."

To address these challenges, Keller and colleagues at AHRQ, Northwestern University, and NORC at the University of Chicago, along with a panel of experts, developed a program that aims to encourage ambulatory care clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making.

Based on AHRQ's Four Moments of Antibiotic Decision Making framework, the AHRQ Safety Program uses webinars, audio presentations, educational tools, and office hours to establish an antibiotic stewardship infrastructure and culture. Participating clinics selected clinical and administrative leads to oversee implementation of the program, and those leads were encouraged to hold monthly staff meetings to review practice-level data on antibiotic prescribing and educational materials.

"We focused a lot of the materials on communication, because most clinicians know that prescribing antibiotics for an upper respiratory tract infection is likely inappropriate, but it's really more about how do you communicate that with a patient, and how do you make sure everyone in the practice is on the same page," Keller explained.

To evaluate the program, the investigators looked at monthly data submitted by the participating clinics during a baseline period (September through November 2019) and the intervention period (December 2019 through November 2020). The primary outcome was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits, with a secondary outcome of antibiotic prescriptions per 100 visits. Data on total visits and ARI visits were also collected.

A 'continued decline' in prescribing

Of the 467 practices that enrolled in the program, 389 remained until its completion and 292 submitted complete data for analysis. The data covered more than 6.5 million visits to 5,483 clinicians. Participants included urgent care clinics (35%), primary care practices (28%), pediatric urgent care clinics (13%), federally supported practices (12%), pediatric-only clinics (7%), and other clinics (5%).

Overall, antibiotic prescribing declined from 18.2% of visits at baseline to 9.5% of visits at the end of the program (absolute decline –8.7%; 95% confidence interval [CI], –9.9% to –7.6%). A total of 87% of practices reduced antibiotic prescribing per 100 visits, with the decrease more evident for urgent care and pediatric practices.

Antibiotic prescriptions for ARI visits declined from 39.2% at baseline to 24.7% at the end of the program (absolute reduction, –14.5%; 95% CI, –16.8% to –12.2%), with urgent care practices seeing the steepest declines. A total of 80% of practices reduced antibiotic prescribing per 100 ARI visits.

Although the study period coincided with the early months of the COVID-19 pandemic, which saw patient visits per practice per month decline substantially (from 1,624 at baseline to 906 in April 2020), by the end of the study, all practice types had returned to baseline visit rates. Keller and her colleagues also note that the decline in prescribing was per visit, so it was not as affected by patient volume.

"We saw a continued decline [in prescribing] as time went along," Keller said.

By the end of the program, practices had shown that they had the pieces in place to maintain their antibiotic stewardship efforts. "Safety Program participants appeared to have ongoing perseverance and program engagement despite significant clinical challenges during the COVID-19 pandemic," Keller and her colleagues wrote.

For Keller, one of the keys to the success of the program was creating time and space for discussions among ambulatory care clinicians and staff about antibiotic prescribing. She also noted that helping practices access their data so they could know how frequently they are prescribing antibiotics to patients—and be able to compare themselves to other clinics—was crucial.

"Data is so important in helping the practices understand how they're doing and how to improve, but accessing data was actually really difficult for the practices, so assisting practices in learning how to access their own data was important," she said.

Keller and her colleagues are developing a toolkit based on these findings that other ambulatory practices will be able use to establish antibiotic stewardship infrastructure.

"We hope this will be something that others will take advantage of to improve their antibiotic prescribing," she said.

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