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

Abstract

Objective: To evaluate the effectiveness of Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), a multicomponent outpatient stewardship program to reduce inappropriate antibiotic prescribing for upper respiratory infections by 20% over 2 years. Design: Before-and-after interrupted time series of antibiotics prescribed between 2 periods: April 2016–October 2017 and May 2018–March 2020. Setting: The study included 162 primary-care practices within a large healthcare system in the greater Charlotte, North Carolina region. Participants: Adult and pediatric patients with encounters for upper respiratory infections for which an antibiotic is inappropriate. Methods: Patient and provider educational materials, along with a web-based provider prescribing dashboard aimed at reducing inappropriate antibiotic prescribing were developed and distributed. Monthly antibiotic prescribing rates were calculated as the number of eligible encounters with an antibiotic prescribed divided by the total number of eligible encounters. A segmented regression analysis compared monthly antibiotic prescribing rates before versus after CHOSEN implementation, while also accounting for practice type and seasonal trends in prescribing. Results: Overall, 286,580 antibiotics were prescribed during 704,248 preintervention encounters and 277,177 during 832,200 intervention encounters. Significant reductions in inappropriate prescribing rates were observed in all outpatient specialties: family medicine (relative difference before and after the intervention, −20.4%), internal medicine (−19.5%), pediatric medicine (−17.2%), and urgent care (−16.6%). Conclusions: A robust multimodal intervention that combined a provider prescribing dashboard with a targeted education campaign demonstrated significant decreases in inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated ambulatory network.

Differences and similarities in outpatient antibiotic prescribing among advanced practice clinicians and physicians—Where do we go from here?

“…Approaches should also encourage practices to employ techniques that have been shown to be effective in reducing the frequency of antibiotic prescribing, included provider-facing dashboards with peer comparisons, as well as more intensive education at practice meetings. 9 More research is needed to elucidate why and in which specific ways prescribing practices differ between physicians and APCs, such that effective interventions can be crafted appropriately. Future research should focus on expanding the breadth of settings evaluated, including urgent-care centers, retail clinics, dental practices, etc, exploring the reasons for these differences, and evaluating the effectiveness of proposed interventions.…”

“…Approaches should also encourage practices to employ techniques that have been shown to be effective in reducing the frequency of antibiotic prescribing, included provider-facing dashboards with peer comparisons, as well as more intensive education at practice meetings. 9 …”