A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings

Abstract

Background Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions. Methods This study was a pragmatic, cluster‐randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic‐inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed‐effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention). Results There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health‐system and provider‐level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference‐in‐differences between the two interventions was not significantly different. Conclusion Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high‐performance settings.

Interrupted time-series analysis to evaluate the impact of a behavioral change outpatient antibiotic stewardship intervention

“…12 Several studies have shown that interventions grounded in behavioral economics and decision science are effective in reducing inappropriate antibiotic prescribing for ARI in primary care and outpatient facilities. [13][14][15] These behavioral interventions generally leverage individual accountability and social norms by utilizing feedback, nudges, and peer comparisons to improve prescribing outcomes. Peer comparisons have been shown to improve prescribing outcomes and to be sustained after the intervention for at least 12 months.…”

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

“…Other differences from past peer comparison studies include geographical location and setting attributes (eg, urban academic vs rural community settings). The MITIGATE study, which included sites in urban academic settings, found a statistically significant decrease in antibiotic prescribing between 2 influenza seasons (from 2.6% to 1.4%) but was unable to show a difference in the behaviorally enhanced vs adapted interventions [ 12 ]. This was likely due to very low rates of prescribing in this study.…”

“…We utilized a number of published literature sources to develop our intervention, specifically Meeker and colleagues and the MITIGATE toolkit [ 11 , 12 ]. The Meeker and colleagues study tested 3 behavioral interventions in a randomized clinical trial—suggested alternatives, accountable justification, and peer comparison.…”

“…Preliminary work from the MITIGATE study (A M ultifaceted I ntervention T o I mprove Prescribin G for A cute Respira T ory Infection for Adults and Children in E mergency Department and Urgent Care Settings), including assessment of a CDC-funded cluster randomized comparative effectiveness trial, suggests that these interventions can be successfully tailored and adapted to academic and community ED and UCC settings with the potential to reduce inappropriate prescribing. The MITIGATE study found that stewardship interventions tailored to the local site and setting reduced inappropriate prescribing for ARTI by one-third in academic-based settings with low percentages of inappropriate prescribing [ 12 ]. However, implementation of acute care stewardship interventions in a broad array of settings, including rural community-based sites, is critical to ensure successful adoption in the real world.…”

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

“…The literature on effective antibiotic stewardship interventions for EDs and UCCs is limited, but strategies that have proven to be effective include clinical decision support tools, audit and feedback, and dedicated ED pharmacists. 8,27 Implementing stewardship processes in ambulatory care will be important in meeting The Joint Commission's new regulatory requirements.…”