Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network

Abstract

ImportanceUrgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC.ObjectiveTo evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network.Design, Setting, and ParticipantsThis quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc.InterventionsStewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive.Main Outcomes and MeasuresThe primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods.ResultsThe baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period.Conclusions and relevanceThe findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship.

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

“…While some of these factors, if found to be contributing, may require solutions specific to telemedicine (eg, developing protocols to smoothly transition to local in-person care), other factors may benefit from outpatient antibiotic stewardship methods. Effective interventions to improve existing ARTI quality metrics exist for in-person outpatient settings, and important work is adapting these interventions for telemedicine settings . Our results also highlight the need to use antibiotic quality metrics that are diagnosis-specific (which may mask increased antibiotic use due to overdiagnosis) alongside broader measures to monitor and guide improvement in antibiotic management.…”

The Challenge of Outpatient Antibiotic Stewardship

“…While conceptually simple, actually stopping unnecessary antibiotic use has proven to be exceedingly difficult. Stenehjem et al, however, have been able to describe a system-level outpatient stewardship intervention across dozens of outpatient urgent care clinics that demonstrated a significant and durable reduction in antibiotic use without any obvious detrimental effects on patient safety or satisfaction.…”

“…But given that 80%-90% of antibiotics are dispensed in outpatient facilities, the impact on overall antibiotic consumption in humans has been negligible . Despite being the higher yield target, stewardship interventions in outpatient settings are less commonly described in the literature …”

“…The article by Stenehjem et al describes a successful bundle of interventions in an urgent care setting, which employed a multipronged approach that included patient education, prescriber education, community messaging, order sets, guideline development, tracking metrics, and direct prescriber feedback. Additionally, though it wasn’t part of the formal intervention, there was a financial incentive offered to prescribers who could reduce their prescribing to levels that would be anticipated to be in line with guideline-concordant care.…”

“…To replicate the study by Stenehjem et al on a larger scale, we must consider the impediments to implementing antibiotic stewardship interventions in outpatient settings. 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.…”