Broader outpatient care points to need for stronger antibiotic education
By Megan Headley
While antibiotic stewardship has improved in recent years, the threat continues to evolve, affecting new pathogens and new places of care. The Centers for Disease Control and Prevention’s (CDC) 2019 report on Antibiotic Resistance Threats in the United States says that more than 2.8 million antibiotic-resistant infections occur in the U.S. each year, and more than 35,000 people die as a result. However, the CDC notes this is an 18% decrease compared to the number of deaths cited in its 2013 report; the decrease is attributed largely to improvements in hospitals’ antibiotic stewardship programs. Now the CDC is looking to drop that number further by targeting care in urgent care centers.
As care continues its move deeper into communities and away from traditional medical campuses, urgent care centers are exploding in growth. In 2018, there were 8,100 urgent care centers, up nearly 27% from 2014, according to Consumer Reports. Those centers see an estimated 160 million patient visits each year, according to the Urgent Care Association (UCA). While these centers may provide patients the quickest care, research suggests they may be more likely to dispense antibiotics to get those fast results.
“Urgent care providers see a significant percentage of patients with acute, infectious disease–related symptoms. Many of these patients expect an antibiotic prescription even when they don’t need one,” says Laurel Stoimenoff, PT, CHC, CEO of the UCA. “This challenge is amplified by the busy and walk-in nature of urgent care practice, and it is often difficult to help patients understand when antibiotics are appropriate.”
UCA is among the organizations seeking to highlight that health systems may need to broaden their awareness efforts around appropriate antibiotic stewardship to provide more consistent practices at outpatient settings.
A look at the data
In September 2018, CDC experts wrote in a research letter in JAMA Internal Medicine, “Sixty percent of outpatient antibiotic prescriptions dispensed in the United States are written in traditional ambulatory care settings and emergency departments. Growing markets, including urgent care centers and retail clinics, may contribute to the remaining 40 percent.”
CDC researchers found that from 2010 through 2011, at least 30% of antibiotic prescriptions written in physician offices and emergency departments were unnecessary. Turning to 2014 data, those researchers saw antibiotic prescribing for antibiotic-inappropriate respiratory diagnoses was highest in urgent care centers, suggesting that unnecessary antibiotic prescribing nationally in all outpatient settings may be higher than the estimated 30%.
More concerning, perhaps, is the large variation in prescriptions among centers. Research published by Intermountain Healthcare, the CDC, and the University of Utah School of Medicine in the October 2019 issue of Clinical Infectious Diseases set out to characterize antibiotic prescribing practices in urgent care encounters, with a focus on respiratory tract conditions. Among the 1.16 million urgent care encounters tracked, antibiotics were prescribed during 34% of them. Respiratory conditions accounted for 61% of all antibiotics prescribed, as 50% of respiratory encounters resulted in antibiotic prescriptions.
However, at the provider level, the variability in prescribing those antibiotics ranged from 3% to 94%. Similar variability between providers was observed for respiratory conditions where antibiotics were not indicated and in first-line antibiotic selection for sinusitis, otitis media, and pharyngitis. These findings, the authors conclude, support the importance of developing antibiotic stewardship interventions that target urgent care settings.
“The high volume of infectious diseases encounters and extreme provider variability in antibiotic prescribing frequency and quality highlight the importance of antibiotic stewardship interventions specifically targeting urgent care centers,” the report states.
“This is an incredible range of variation that we’re seeing in our urgent care network,” adds the study’s lead author, Edward Stenehjem, of Intermountain Healthcare’s Office of Patient Experience.
Highlighting the problem
UCA’s 2019 benchmarking report seems to agree with the CDC’s estimate that 30% of antibiotic prescriptions written at outpatient centers may be unnecessary. The report states that 98% of UCA’s surveyed urgent care centers have measures in place to monitor appropriate antibiotic prescribing. UCA is working to increase that number.
Stoimenoff says the best first step for urgent care centers is to implement evidence-based recommendations for diagnosis and management. “That way, centers can design and implement strategies to improve their prescribing practices, as well as educate patients on proper antibiotic use,” she says.
But centers don’t have to do it alone. UCA has developed tools for patient education and the training and education of both clinical and nonclinical staff. The organization also offers clinical decision support tools, data collection, evidence-based antibiotic stewardship practices, and research. Stoimenoff notes that UCA is also encouraging urgent care centers to sign on to UCA’s Commitment Statement, available on its website, www.ucaoa.org. By signing up, organizations and individuals can make a public commitment to antibiotic stewardship.
That commitment is one way UCA is bringing public attention to the need for greater antibiotic stewardship. Another strategy is its Antibiotic Stewardship Commendation program, launched in July 2019 with the College of Urgent Care Medicine®. The program requires urgent care centers to provide demonstrable evidence of their compliance with CDC’s Core Elements of Outpatient Antibiotic Stewardship.
The CDC program provides a framework for antibiotic stewardship in the outpatient setting focused around four areas:
> Commitment: Centers must demonstrate their dedication to and accountability for reductions in antibiotic prescriptions.
> Action for policy and practice: Centers must implement at least one policy or practice to improve responsible prescribing. The practice must be assessed for efficacy with an Antibiotic Stewardship Quality Plan.
> Tracking and reporting: Centers must monitor antibiotic prescribing and offer regular feedback to clinicians.
> Education and expertise: Centers must provide educational resources for both clinicians and patients on antibiotic prescribing and provide access to expertise on improving prescribing practices.
UCA began its work with six member organizations to beta-test the Antibiotic Stewardship Commendation program, with Premier Health being the first to earn the commendation.
“Premier Health is excited to have been one of the first nationwide urgent care operators to beta-test this critically important initiative,” comments Kevin DiBenedetto, MD, chief medical officer for Premier. “Urgent care clinics are the first line of defense in battling the inappropriate use of antibiotics because so many of the patients that visit our clinics with obvious viral infections believe antibiotics will make them feel better. The Antibiotic Stewardship Commendation program will give urgent care providers the clinical and educational support they need to address patients and avoid prescribing antibiotics when they are clearly not necessary.”
“To date, over 600 urgent care centers have the ABS Commendation designation,” Stoimenoff adds. The period of commendation is three years, and urgent care centers are required to provide information demonstrating ongoing compliance with the CDC’s Core Elements and an assessment of quality improvement efforts to obtain repeat commendation.
The CDC is also working with Intermountain Healthcare and the University of Utah to design a program that will educate and incentivize clinicians to improve their antibiotic stewardship at urgent care centers.
The CDC awarded a $1.8 million contract to Intermountain researchers in 2018 to implement a plan based on the CDC’s Core Elements of Outpatient Antibiotic Stewardship. Intermountain’s Stewardship in Community Outpatient Settings—Resources and Engagement—Urgent Care (SCORE-UC) program extends the system’s inpatient antibiotic stewardship efforts into the outpatient setting, where it handles nearly 700,000 urgent care visits each year. The program focuses on antibiotic prescriptions for respiratory infections across 39 rural and urban clinics, as well as one telemedicine platform, making it the first wide-scale initiative to improve antibiotic stewardship in urgent care centers.
While the Intermountain program includes an element of education for clinicians and patients and the community, much like UCA’s program, the program also has found ways to harness data that nudge providers away from overprescribing antibiotics. The system has made adjustments to electronic health records to streamline workflow and help providers make decisions about alternatives to antibiotics. Providers also have access to a dashboard that provides benchmarking data on antibiotic prescriptions across Utah, so providers can see how they compare to their peers and where they may need improvement.
Between the launch of its program in July 2019 and a January 2020 interview with HealthLeaders, Intermountain tracked a 30% reduction in antibiotic prescriptions for respiratory ailments. The system estimates that during that time, it avoided writing 10,000 antibiotic prescriptions.
Addressing future gaps
With urgent care centers working to improve antibiotic stewardship, experts are already bringing attention to the next potential gap in best practices: telemedicine.
A study published in the September 2019 issue of Pediatrics by researchers from Cleveland Clinic reported that of more than 12,000 telemedicine encounters involving children with respiratory ailments, antibiotics were prescribed for more than half (55%). While this was lower than the rate for nonpediatric patients, the researchers found that providers were more likely to receive a five-star rating from the patient’s parent in those instances when an antibiotic was prescribed (93.4% versus 80.8%).
It’s not the first study to determine that antibiotic stewardship best practices may be lacking in telemedicine encounters. A 2018 study from Cleveland Clinic found that 66.1% of more than 8,000 telemedicine visits by adults for respiratory complaints resulted in an antibiotic prescription. Much like the pediatrics study, a prescription for an antibiotic was strongly associated with a five-star rating.
As with telemedicine, stiff competition has provoked rapid growth among urgent care centers, as indicated by UCA’s report. Five-star ratings that point to an excellent patient experience tend to be the obvious metric. So as urgent care becomes a staple among communities, it becomes more important than ever to educate the public around the dangers of overprescribing medications—removing that clear-cut link between urgent care, or telemedicine, and immediate results.
On the other hand, telemedicine may also offer some solutions for improving antibiotic stewardship in urgent care and other medical centers. A VA pilot study tested the benefits of bringing infectious disease–trained specialists in to speak with interventionists at two rural VA medical centers weekly via video conference. The results, published in the October 2018 Infection Control & Hospital Epidemiology, noted that the video conference antimicrobial stewardship team reported gaining an increased awareness of antibiotic stewardship and more confidence in treating illnesses differently than in the past. After six months of video conferences, the two sites saw declines in total antibiotic use of 34% and 10%, respectively.
While this study focused on larger medical centers, the findings do hint at the need for outside-the-box thinking and additional resources to support stronger antibiotic stewardship in other settings. Lauren Stevens, PhD, one of the study’s authors, comments, “When antibiotic stewardship programs are left to those who are not trained to run them, they are more susceptible to issues and can ultimately be ineffective. As a result, our goal of reducing these multidrug-resistant organisms is more difficult to meet.”
Robin Jump, MD, PhD, senior author of the study and a physician-scientist with the Louis Stokes Cleveland VA Medical Center, adds, “Telehealth can be a low-cost and effective way to provide facilities with the expertise needed to implement these initiatives—eliminating some of the barriers that have typically thwarted these efforts.”
Urgent care centers that prioritize patient education and utilize a broad network, including evidence-based recommendations for diagnosis and management, may be best prepared to combat the dangers of antibiotic overuse.
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at firstname.lastname@example.org.