Utilizing Behavioral Science to Improve Antibiotic Prescribing in Rural Urgent Care Settings

Abstract

Background: The rate of inappropriate antibiotic prescribing for acute respiratory tract infections (ARTIs) is 45% among urgent care centers across the United States. To contribute to the US National Action Plan for Combating Antibiotic-Resistant Bacteria, which aims to decrease rates of inappropriate prescribing, we implemented 2 behavioral nudges using the evidence-based MITIGATE tool kit from urgent-care settings, at 3 high-volume, rural, urgent-care centers. Methods: An interrupted time series (ITS) analysis was conducted comparing a preintervention phase during the 2017–2018 influenza season (October through March) to the intervention phase during the 2018–2019 influenza season. We compared the rate of inappropriate or non–guideline-concordant antibiotic prescribing for ARTIs across 3 urgent-care locations. The 2 intervention behavioral nudges were (1) staff and patient education and (2) peer comparison. Provider education included presentations at staff meetings and grand rounds, and patient education print materials were distributed to the 3 locations coupled with news media and social media. We utilized the CDC “Be Antibiotics Aware” campaign materials, with our hospital’s logo added, and posted them in patient rooms and waiting areas. For the peer comparison behavioral intervention, providers were sent individual feedback e-mails with their prescribing data during the intervention period and a blinded ranking e-mail in which they were ranked in comparison to their peers. In the blinded ranking email, providers were placed into categories of “low prescribers,” those with a ≤23% inappropriate antibiotic prescribing rate based on the US National Action Plan for Combating Antibiotic-Resistance Bacteria 2020 goal, or “high prescribers,” those with a rate greater than the national average (45%) of inappropriate antibiotic prescribing for ARTI. Results: Our results show that fewer inappropriate antibiotic prescriptions were written during the intervention period (58.8%) than during the preintervention period (73.0%), resulting in a 14.5% absolute decrease in rates of inappropriate prescribing among urgent-care locations over a 6-month period (Fig. 1). The largest percentage decline in rates was seen in the month of April (−35.8%) when compared to April of the previous year. The ITS analysis revealed that the rate of inappropriate prescribing was statistically significantly different during the preintervention period compared to the intervention period (95% CI, −4.59 to −0.59; P = .0142). Conclusions: Using interventions outlined in the MITIGATE tool kit, we were able to reduce inappropriate antibiotic prescribing for ARTI in 3 rural, urgent-care locations.Funding: NoneDisclosures: Larissa May repo, Speaking honoraria-Cepheid Research grants-Roche Consultant-BioRad Advisory Board-Qvella Consultant-Nabriva

Antibiotic prescribing to Kentucky Medicaid children, 2012‐2017: Prescribing is higher in rural areas

“…Current outpatient stewardship policies and initiatives are often limited to large health care organizations [24][25][26] and overlook many important sites, such as urgent cares, private practices, and rural settings. A few published interventions have decreased antibiotic prescribing for upper respiratory tract infections in targeted rural practices, 7,8 but additional work is needed to sustain and promote widespread implementation of such efforts.…”

“…In 2016, the CDC published the Core Elements of Outpatient Antibiotic Stewardship, 5 but due to organizational barriers and provider recognition, uptake of outpatient stewardship efforts remains suboptimal 6 . A few studies have described successful antibiotic stewardship interventions in rural settings, but many small, private practices lack the support or infrastructure to establish or maintain such efforts 7,8 . Kentucky is a largely rural state with 70% of counties classified as rural and 42% of the state's population living in rural areas 9 .…”

“…6 A few studies have described successful antibiotic stewardship interventions in rural settings, but many small, private practices lack the support or infrastructure to establish or maintain such efforts. 7,8 Kentucky is a largely rural state with 70% of counties classified as rural and 42% of the state's population living in rural areas. 9 The objective of this study was to analyze trends in antibiotic prescribing to Kentucky Medicaid children over time and describe variations among those who were prescribed antibiotics.…”

Experience with two antimicrobial prescribing tools in ambulatory care settings

“…Viral RTI were defined according to ICD-10 codes identified by the respective tool kits. [4][5][6] MITIGATE identified 24 diagnoses for viral RTIs, which translated to 157 ICD-10 codes, and Choosing Wisely included 45 ICD-10 diagnosis codes. In the MITIGATE data set, patients with competing diagnoses or comorbidities that might indicate appropriate antibiotic prescribing (eg, a concomitant urinary tract infection) at the time of the RTI visit were excluded.…”

“…Inappropriate antibiotic prescribing for viral respiratory tract infections (RTIs) is an important target for antimicrobial stewardship 1 ; up to 45% of outpatients with an RTI are prescribed antibiotics. [2][3][4] Multiple tools have been developed to evaluate antibiotic prescribing in ambulatory settings. The Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings (MITIGATE) and Choosing Wisely are 2 such tools promoted by the Centers for Disease Control and Prevention (CDC) and the American Board of Internal Medicine (ABIM), respectively.…”