Trends and patterns in antibiotic prescribing among out-of-hours primary care providers in England, 2010–14

Abstract Background Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold). Methods This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period. The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes. Results Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. Conclusion Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates. Disclosures All Authors: No reported disclosures

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22. Patient Satisfaction Remains Unchanged Following Implementation of an Antibiotic Stewardship Intervention in Primary Care

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa417.021 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S11-S12

Author(s):

Zachary Hostetler ◽

Keith W Hamilton ◽

Leigh Cressman ◽

McWelling H Todman ◽

Ebbing Lautenbach ◽

...

Keyword(s):

Primary Care ◽

Patient Satisfaction ◽

Odds Ratio ◽

Logistic Regression Model ◽

Adjusted Odds Ratio ◽

Primary Care Providers ◽

Mixed Effects ◽

Antibiotic Prescribing ◽

Care Providers ◽

Targeted Intervention

Abstract Background Inappropriate prescription of antibiotics for respiratory tract infections (RTIs) in ambulatory care settings is common, increasing the risk of adverse health outcomes. Behavioral and educational interventions targeting primary care providers (PCPs) have shown promise in reducing inappropriate antibiotic prescribing for RTIs. While one perceived barrier to such interventions is the concern that these adversely impact patient satisfaction, few data exist in this area. Here, we examine whether a recent PCP-targeted intervention that significantly reduced antibiotic prescribing for RTIs was associated with a change in patient satisfaction. Methods The PCP-targeted intervention involved monthly education sessions and peer benchmarking reports delivered to 31 clinics within an academic health system, and was previously shown to reduce antibiotic prescribing. Here, we performed a retrospective, secondary analysis of Press Ganey (PG) surveys associated with the outpatient encounters in the pre- and post-intervention periods. We evaluated the impact on patient perceptions of PCPs based on provider exposure to the intervention using a mixed effects logistic regression model. Results There were 17,416 out of 197,744 encounters (8.8%) with associated PG surveys for the study time period (July 2016 to September 2018). In the multivariate model, patient satisfaction with PCPs was most strongly associated with patient-level characteristics (age, race, health status, education status) and survey-level characteristics (survey response time, patient’s usual provider) (Figure 1). Satisfaction with PCPs did not change following delivery of the provider-based intervention even after adjusting for patient- and survey-level characteristics [adjusted odds ratio (95% CI): 1.005 (0.928, 1.087)]. However, a small increase in satisfaction associated with receiving antibiotics during the entire study period was seen [adjusted odds ratio (95% CI): 1.146 (1.06, 1.244)]. Figure 1: Association of a provider-targeted intervention as well as patient, provider, and practice characteristics with patient satisfaction in a multivariable mixed effects logistic regression model Conclusion Patient perceptions of PCPs remain unchanged following the delivery of a behavioral and educational intervention to primary care providers that resulted in observable decreases in antibiotic prescribing practices for RTIs. Disclosures All Authors: No reported disclosures

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Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00337-18 ◽

2018 ◽

Vol 62 (8) ◽

Cited By ~ 25

Author(s):

Nathan R. Shively ◽

Deanna J. Buehrle ◽

Cornelius J. Clancy ◽

Brooke K. Decker

Keyword(s):

Primary Care ◽

Health Care ◽

Tract Infection ◽

Health Care System ◽

Primary Care Providers ◽

Acute Respiratory Tract Infection ◽

Chronic Obstructive ◽

Antibiotic Prescribing ◽

Care Providers ◽

Care System

ABSTRACT Data are needed from outpatient settings to better inform antimicrobial stewardship. In this study, a random sample of outpatient antibiotic prescriptions by primary care providers (PCPs) at our health care system was reviewed and compared to consensus guidelines. Over 12 months, 3,880 acute antibiotic prescriptions were written by 76 PCPs caring for 40,734 patients (median panel, 600 patients; range, 33 to 1,547). PCPs ordered a median of 84 antibiotic prescriptions per 1,000 patients per year. Azithromycin (25.8%), amoxicillin-clavulanate (13.3%), doxycycline (12.4%), amoxicillin (11%), fluoroquinolones (11%), and trimethoprim-sulfamethoxazole (10.6%) were prescribed most commonly. Medical records corresponding to 300 prescriptions from 59 PCPs were analyzed in depth. The most common indications for these prescriptions were acute respiratory tract infection (28.3%), urinary tract infection (23%), skin and soft tissue infection (15.7%), and chronic obstructive pulmonary disease (COPD) exacerbation (6.3%). In 5.7% of cases, no reason for the prescription was listed. No antibiotic was indicated in 49.7% of cases. In 12.3% of cases, an antibiotic was indicated, but the prescribed agent was guideline discordant. In another 14% of cases, a guideline-concordant antibiotic was given for a guideline-discordant duration. Therefore, 76% of reviewed prescriptions were inappropriate. Ciprofloxacin and azithromycin were most likely to be prescribed inappropriately. A non-face-to-face encounter prompted 34% of prescriptions. The condition for which an antibiotic was prescribed was not listed in primary or secondary diagnosis codes in 54.5% of clinic visits. In conclusion, there is an enormous opportunity to reduce inappropriate outpatient antibiotic prescriptions.

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A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada

BMC Family Practice ◽

10.1186/s12875-021-01536-3 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Warren McIsaac ◽

Sahana Kukan ◽

Ella Huszti ◽

Leah Szadkowski ◽

Braden O’Neill ◽

...

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Care Provider ◽

Primary Care Provider ◽

Antibiotic Use ◽

Primary Care Providers ◽

Audit And Feedback ◽

Antibiotic Prescribing ◽

Care Providers ◽

Tract Infections

Abstract Background More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. Methods Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. Results There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). Conclusions A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. Trial registration clinicaltrials.gov (NCT03517215).

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Qualitative Analysis of Primary Care Provider Prescribing Decisions for Urinary Tract Infections

Antibiotics ◽

10.3390/antibiotics8020084 ◽

2019 ◽

Vol 8 (2) ◽

pp. 84 ◽

Cited By ~ 4

Author(s):

Larissa Grigoryan ◽

Susan Nash ◽

Roger Zoorob ◽

George J. Germanos ◽

Matthew S. Horsfield ◽

...

Keyword(s):

Primary Care ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Primary Care Providers ◽

Effective Control ◽

Antibiotic Prescribing ◽

Care Providers ◽

Sources Of Information ◽

Acute Cystitis ◽

Tract Infections

Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs’ knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.

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Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports

BMJ Open Quality ◽

10.1136/bmjoq-2018-000351 ◽

2019 ◽

Vol 8 (1) ◽

pp. e000351 ◽

Cited By ~ 10

Author(s):

Richard V Milani ◽

Jonathan K Wilt ◽

Jonathan Entwisle ◽

Jonathan Hand ◽

Pedro Cazabon ◽

...

Keyword(s):

Primary Care ◽

Patient Education ◽

Test Group ◽

Primary Care Providers ◽

Antibiotic Prescribing ◽

Care Providers ◽

Normative Comparison ◽

Second Year ◽

Tract Infections ◽

The Impact

ImportanceAntibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI).ObjectiveTo evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI.DesignNon-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year.SettingPrimary care providers in a large regional healthcare system.ParticipantsThe test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions.InterventionThe intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year.Main outcomes and measuresRate of inappropriate antibiotic prescription for ARTI.ResultsBaseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention.Conclusions and relevanceProvider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.

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Antimicrobial Resistance Education in the Primary Care Setting

Journal of Doctoral Nursing Practice ◽

10.1891/2380-9418.9.2.217 ◽

2016 ◽

Vol 9 (2) ◽

pp. 217-225

Author(s):

Jenna Oesterle ◽

Meghan Sternemann ◽

Tiffany Sande ◽

Christina Aplin-Kalisz ◽

Diane Towers

Keyword(s):

Primary Care ◽

Antimicrobial Resistance ◽

Educational Intervention ◽

Treatment Guidelines ◽

Primary Care Providers ◽

National Committee ◽

Antibiotic Prescribing ◽

Care Providers ◽

Prescribing Practices ◽

Convenience Sample

Background:Antimicrobial resistance has become a problem of epidemic proportions; however, patients believe antibiotics can treat any infection (National Committee for Quality Assurance [NCQA], 2011). Judicious prescribing practices are known to decrease antimicrobial resistance in the community (Centers for Disease Control [CDC], 2012).Purpose:Primary care providers (PCPs) are in a position to change current prescribing practices and patient beliefs regarding antimicrobials. This project focused on a PCP-facilitated educational intervention.Design/Methods:A quasi-experimental chart review performed over 3 months. PCPs were educated on CDC treatment guidelines for acute bronchitis, sinusitis, pharyngitis, and the educational pamphlet. The PCPs provided a brief educational session with the pamphlet to patients presenting with upper respiratory infections (URIs).Sample:A convenience sample of patients 18–64 years old presenting with URI symptoms; data were collected on antibiotic prescriptions, patient demographics, comorbid diagnoses, and discharge diagnosis.Results:Antibiotic prescribing rates for patient’s pre- to postintervention decreased significantly from 77.9% to 61.6% (1,N= 163) = 0.02,p< .05. Improved adherence to guidelines from pre- to postintervention for bronchitis was demonstrated yet no statistically significant improvement for pharyngitis and sinusitis.Conclusion:A PCP-facilitated educational intervention demonstrated an effective method to reduce antibiotic prescriptions for URIs in primary care.

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Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review

Journal of the American Medical Informatics Association ◽

10.1136/amiajnl-2014-002886 ◽

2014 ◽

Vol 22 (1) ◽

pp. 236-242 ◽

Cited By ~ 42

Author(s):

Jakob Holstiege ◽

Tim Mathes ◽

Dawid Pieper

Keyword(s):

Primary Care ◽

Decision Support ◽

Clinical Decision Support Systems ◽

Clinical Decision ◽

Primary Care Providers ◽

Antibiotic Prescribing ◽

Care Providers ◽

Prescribing Behavior ◽

Computer Aided ◽

Prescribing Practice

Abstract Objective To assess the effectiveness of computer-aided clinical decision support systems (CDSS) in improving antibiotic prescribing in primary care. Methods A literature search utilizing Medline (via PubMed) and Embase (via Embase) was conducted up to November 2013. Randomized controlled trials (RCTs) and cluster randomized trials (CRTs) that evaluated the effects of CDSS aiming at improving antibiotic prescribing practice in an ambulatory primary care setting were included for review. Two investigators independently extracted data about study design and quality, participant characteristics, interventions, and outcomes. Results Seven studies (4 CRTs, 3 RCTs) met our inclusion criteria. All studies were performed in the USA. Proportions of eligible patient visits that triggered CDSS use varied substantially between intervention arms of studies (range 2.8–62.8%). Five out of seven trials showed marginal to moderate statistically significant effects of CDSS in improving antibiotic prescribing behavior. CDSS that automatically provided decision support were more likely to improve prescribing practice in contrast to systems that had to be actively initiated by healthcare providers. Conclusions CDSS show promising effectiveness in improving antibiotic prescribing behavior in primary care. Magnitude of effects compared to no intervention, appeared to be similar to other moderately effective single interventions directed at primary care providers. Additional research is warranted to determine CDSS characteristics crucial to triggering high adoption by providers as a perquisite of clinically relevant improvement of antibiotic prescribing.

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2065. Reducing Inappropriate Antibiotic Prescriptions in the Primary Care Setting

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1745 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S696-S696

Author(s):

Marlena Klein ◽

Diana Zackey ◽

Niharika Sathe ◽

Ayobamidele S Balogun ◽

Mona Domadia ◽

...

Keyword(s):

Primary Care ◽

Antibiotic Prescription ◽

Average Rate ◽

Primary Care Providers ◽

Prescribing Patterns ◽

Resistant Bacteria ◽

Antibiotic Prescribing ◽

Care Providers ◽

Office Visits ◽

Post Intervention

Abstract Background In 2015, the CDC established the National Action Plan for Combating Antibiotic-Resistant Bacteria, with the goal of reducing inappropriate outpatient antibiotic use by 50% by 2020. Upper respiratory infections, (URIs) account for one of the top three diagnoses prompting outpatient visits, and despite viral pathogens being the etiology of most URIs, many patients are treated with antibiotics. This study aimed to reduce inappropriate antibiotics prescribing for URIs at Cooper Primary Care offices. Methods Using the electronic medical record, we analyzed office visits (OVs) of 63 primary care providers during the influenza season (November 1, 2017–February 28, 2018) that were associated with a URI diagnosis code and resulted in an antibiotic prescription. The intervention was a personalized digital URI score card (Figure 1) emailed to each primary care physician. It included (1) Cooper Hospitals’ Primary Care Department Average Rate of Antibiotic Prescribing for URI OVs and (2) each physician’s average rate of antibiotic prescribing for URI office visits. Data were collected post-intervention (November 1, 2018–February 28, 2019) to evaluate for changes in antibiotic prescribing patterns. Results Using Fischer’s Exact test we analyzed the pre vs. post-intervention rate of antibiotic prescribing for URI OVs. There were 7,295 total pre-intervention office visits. Of these, 41.03% resulted in an antibiotic prescription. There were 6,642 total post-intervention office visits. Of these, 35.85% resulted in an antibiotic prescription. There was a 5.18% overall decrease in antibiotics prescribed for all URI office visits (P < 0.001) (see Figure 2). Conclusion Increasing providers’ awareness of their own prescribing patterns compared with their department’s prescribing patterns utilizing a single report card decreased the rate of antibiotics prescribed for URIs by 5.18% for all URI-related office visits. Specifically, there was 10.19% decrease in antibiotics prescribed for bronchitis, which is by definition, of viral etiology. This is significant given the potential side-effects of unnecessary antibiotics, and the emergence of antibiotic resistance. Limitations include a lack of certainty in “true” inappropriate prescriptions and diagnosis coding. Disclosures All authors: No reported disclosures.

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The Perspective of Older Men With Depression on Suicide and Its Prevention in Primary Care

Crisis ◽

10.1027/0227-5910/a000511 ◽

2018 ◽

Vol 39 (5) ◽

pp. 397-405 ◽

Cited By ~ 3

Author(s):

Steven Vannoy ◽

Mijung Park ◽

Meredith R. Maroney ◽

Jürgen Unützer ◽

Ester Carolina Apesoa-Varano ◽

...

Keyword(s):

Primary Care ◽

Low Socioeconomic Status ◽

Thematic Analysis ◽

Older Men ◽

Primary Care Providers ◽

Depression Treatment ◽

Care Providers ◽

Low Socioeconomic ◽

Self Image ◽

The Impact

Abstract. Background: Suicide rates in older men are higher than in the general population, yet their utilization of mental health services is lower. Aims: This study aimed to describe: (a) what primary care providers (PCPs) can do to prevent late-life suicide, and (b) older men's attitudes toward discussing suicide with a PCP. Method: Thematic analysis of interviews focused on depression and suicide with 77 depressed, low-socioeconomic status, older men of Mexican origin, or US-born non-Hispanic whites recruited from primary care. Results: Several themes inhibiting suicide emerged: it is a problematic solution, due to religious prohibition, conflicts with self-image, the impact on others; and, lack of means/capacity. Three approaches to preventing suicide emerged: talking with them about depression, talking about the impact of their suicide on others, and encouraging them to be active. The vast majority, 98%, were open to such conversations. An unexpected theme spontaneously arose: "What prevents men from acting on suicidal thoughts?" Conclusion: Suicide is rarely discussed in primary care encounters in the context of depression treatment. Our study suggests that older men are likely to be open to discussing suicide with their PCP. We have identified several pragmatic approaches to assist clinicians in reducing older men's distress and preventing suicide.

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