Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: A Stepped-Wedge Cluster Randomized Trial

Abstract

Background Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown. Methods We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. Chi-squared testing was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing. Results Across 30 PC practices and 185,755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (p<0.001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (OR 0.57; 95% CI 0.52 – 0.62) and 3 (OR 0.57; 95% CI 0.53 – 0.61), but not for tier 1 (OR 0.98; 95% CI 0.83 – 1.16). Conclusion A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.

A multimodal intervention to decrease inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated healthcare system

“…Few studies have previously evaluated an intervention across a large integrated health system. [10][11][12][13] Our results demonstrated that this combination of interventions decreased prescribing for URIs by 18.5% across 4 primary-care service lines (ie, internal medicine, family medicine, pediatric medicine, urgent care). Overall, family medicine reached the 20% reduction goal (−20.4%), with the other service lines reaching close to 20% (ie, internal medicine, −19.5%; pediatric medicine, −17.2%; urgent care, −16.6%).…”

“…[5][6][7][8][9][10] Few studies to date have examined how to best integrate all of these features with ongoing measurement of prescribing rates within the context of a larger, multiple-specialty, integrated healthcare network (where most provider groups now function). [10][11][12][13] In the Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN) program, we applied a stakeholder-centered design to develop and implement a bundle of key intervention strategies in diverse ambulatory practices within a large integrated network, including (1) patient and provider education tailored to practice-specific needs and (2) easily accessible, timely data on prescribing patterns for providers and practice managers to track and compare antimicrobial prescribing rates. 14,15 The current study tests the hypothesis that implementation of CHOSEN reduces inappropriate outpatient antibiotic prescribing for upper respiratory tract infections by 20% over 2 years.…”

A Baker’s Dozen of Top Antimicrobial Stewardship Intervention Publications in Non–Hospital Care Settings in 2021

“…Inappropriate antibiotic prescribing for respiratory tract infections (RTIs) is common in primary care [ 37 ]. Dutcher and colleagues evaluated the impact of an education and feedback–based intervention to improve prescribing for respiratory tract diagnoses (RTDs) [ 24 ]. The first phase of the intervention consisted of an educational session on appropriate prescribing for common RTIs and effective patient communication strategies, particularly for when not prescribing an antibiotic.…”

“…Now that regulatory agencies require ASPs outside of acute care hospitals, data are emerging to inform ASP practice in these settings. Numerous research interventions have directed management of UTIs and RTIs [ 24 , 26–29 , 32 , 35 , 36 ]. This is not surprising considering that these are 2 of the top infectious syndromes for which excessive antimicrobial prescribing occurs, often due to colonization, lack of true infection (ASB), or viral etiology (upper RTIs).…”

Look-Back and Look-Forward Durations and the Apparent Appropriateness of Ambulatory Antibiotic Prescribing

“…Ambulatory antibiotic stewardship programs and research projects can select a duration of association that makes sense for their purposes. For example, if the intent is to identify and intervene on inappropriate diagnoses, then the use of a short interval–even same-day–is reasonable, as the proportion of prescriptions classified as inappropriate varies minimally based on the look-back and look-forward periods [ 11 , 19 , 20 , 21 , 22 ]. If the intent is to intervene on potentially appropriate antibiotic prescribing, using longer durations will capture a larger number of these diagnoses [ 23 , 24 , 25 ].…”