By Christopher Cheney
A multifaceted antibiotic stewardship initiative for respiratory conditions at Intermountain Health urgent care clinics resulted in a significant reduction in antibiotic prescribing, a new research article found.
Most antibiotic prescriptions in the United States are made in outpatient settings and as many as 30% of those prescriptions may be unnecessary. Antibiotic overuse has been linked to antibiotic resistance and antibiotic-associated adverse effects.
The research article, which was published by JAMA Network Open, is based on data collected from nearly 500,000 urgent care encounters at 38 urgent care clinics and one telemedicine clinic operated by Intermountain Health. The data was collected during a 12-month baseline period from July 1, 2018, to June 30, 2019, a 12-month intervention period from July 1, 2019, to June 30, 2020, and a 12-month sustainability period from July 1, 2020, through June 30, 2021.
The intervention was based on the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship. The intervention incorporated all four of the CDC core elements, including the following:
1. Education for clinicians and patients: Education for clinicians included an urgent care antibiotic stewardship champion who served as a peer-to-peer resource for clinicians, a handbook that included guidelines, and monthly update lectures at regional urgent care meetings. Education for patients included a symptomatic therapies checklist and a patient-facing antibiotic stewardship webpage.
2. Electronic health record tools: Clinicians had EHR tools such as receiving azithromycin prescribing justification alerts in the EHR and the addition of delayed antibiotic prescriptions in the EHR.
3. Clinician antibiotic prescribing dashboard: This dashboard included all clinicians and clinics, which allowed for peer comparison.
4. Media campaign: Intermountain Health launched a media campaign that included television and radio interviews, print media such as newspaper articles, and Facebook and Twitter posts.
In addition to the four CDC core elements, Intermountain Health designed a quality measure financial incentive for urgent care clinicians. The financial incentive gave clinicians increased compensation if they prescribed antibiotics in less than 50% of respiratory illness encounters.
The study generated several key data points:
- Clinicians prescribed antibiotics for respiratory conditions for 47.8% of encounters in the baseline period and 33.3% of encounters in the intervention period.
- In the first month of the intervention, antibiotic prescribing decreased 22% and antibiotic prescriptions fell 5% monthly during the intervention.
- Among clinicians who were working in both the baseline and intervention periods, 95% decreased their prescribing of antibiotics for respiratory conditions.
- During the baseline period, 38.5% of clinicians prescribed antibiotics for more than 50% of respiratory condition encounters. During the intervention period, 10.2% of clinicians prescribed antibiotics for more than 50% of respiratory condition encounters.
- There was no statistically significant decrease in patient satisfaction when comparing the baseline and intervention periods.
- The was no statistically significant increase in hospitalizations within 14 days of an urgent care encounter when comparing the baseline and intervention periods.
“The findings of this quality improvement study indicated that an [urgent care] antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for [urgent care] antibiotic stewardship,” the study’s co-authors wrote.
Interpreting the Data
The research shows that outpatient antibiotic stewardship programs can be successful, the study’s co-authors wrote. “This study adds to growing evidence about effective outpatient stewardship programs, including those focused on [urgent care] settings. Features of successful programs include the use of audit and feedback, clinician and patient education, EHR tools, and peer comparison or benchmarking.”
The urgent care antibiotic stewardship initiative made gains beyond the reduction in prescribing for respiratory conditions, the study’s co-authors wrote. “In addition to reductions in the overall rate of antibiotic prescribing for respiratory conditions, several other areas of antibiotic prescribing improved, including the use of azithromycin and delayed prescriptions. Because these areas were explicitly targeted by components of our intervention, they likely represent changes in clinical practice and were sustained beyond the intervention period.”
The finding that there were no statistically significant changes in patient satisfaction and patient safety is noteworthy, the study’s co-authors wrote. “This is important because of the relatively large reduction in antibiotic use for respiratory conditions that occurred with the intervention. Our observation that patient satisfaction scores were stable may provide reassurance to clinicians that practicing antibiotic stewardship is not associated with unintended consequences in patient satisfaction and other important dimensions of clinical care, including visit duration, both of which have been cited as barriers to mitigating antibiotic overuse.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.