140. Impact of Pharmacist-led Audit & Feedback on Outpatient Antibiotic Prescribing for UTIs and SSTIs

Abstract Background An estimated 30% of all outpatient antibiotic prescriptions in the U.S. are unnecessary. Effective January 2020, The Joint Commission has implemented new core elements of performance requiring antimicrobial stewardship programs (ASP) to expand to outpatient practice settings. The purpose of this study was to determine whether pharmacist-led audit-and-feedback would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infection (SSTI) at two primary care practices. Methods This retrospective, quasi-experimental study was conducted evaluating patients treated for UTI and SSTI at two outpatient primary care offices, one Family Medicine and the other Internal Medicine. The primary objective was to compare rates of total appropriateness of antibiotic prescribing before (Pre-ASP) versus after (Post-ASP) implementing a pharmacist-led audit-and-feedback process reviewing antibiotics prescribed for UTIs and SSTIs. Total appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy antimicrobial guidelines. Secondary objectives included comparing patient outcomes, including infection-related re-visits and Clostridioides difficile infections between groups. Results A total of 400 patients were included in this study (Pre-ASP n=200, Post-ASP n=200) Total antibiotic appropriateness improved significantly from 27.5% to 50.5% after implementation of the audit-and-feedback process (p< 0.0001). Significant improvement was also seen for individual prescribing components including appropriate drug selection (94% vs. 98%, p=0.041), duration (57.5% vs.83.5%, p< 0.0001), and therapy indication (94% vs. 98%, p=0.041). There were no differences in patient outcomes between groups including adverse drug events, treatment failure, C.difficile infections, and infection-related re-visits or hospitalizations within 30 days. Conclusion A pharmacist-led audit-and-feedback outpatient stewardship strategy demonstrated significant improvement in outpatient antibiotic prescribing for UTI and SSTI. Disclosures All Authors: No reported disclosures

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Impact of pharmacist-led selective audit and feedback on outpatient antibiotic prescribing for UTIs and SSTIs

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab110 ◽

2021 ◽

Author(s):

Patricia W Choi ◽

Jessica A Benzer ◽

Joel Coon ◽

Nnaemeka E Egwuatu ◽

Lisa E Dumkow

Keyword(s):

Primary Care ◽

The United States ◽

Empiric Therapy ◽

Primary Objective ◽

Audit And Feedback ◽

Antibiotic Prescribing ◽

Feedback Process ◽

Clostridioides Difficile ◽

The Individual ◽

Tract Infections

Abstract Purpose An estimated 30% of all outpatient antibiotic prescriptions in the United States are unnecessary. The Joint Commission in 2016 implemented core elements of performance requiring antimicrobial stewardship programs (ASPs) to expand to outpatient practice settings. A study was conducted to determine whether pharmacist-led audit and feedback would improve antibiotic prescribing for urinary tract infections (UTIs) and skin and soft tissue infection (SSTIs) at 2 primary care practices. Methods A retrospective, quasi-experimental study was conducted to evaluate antibiotic prescribing for patients treated for a UTI or SSTI at 2 primary care offices (a family medicine office and an internal medicine office). The primary objective was to compare the rate of appropriate antibiotic prescribing to patients treated before implementation of a pharmacist-led audit-and-feedback process for reviewing antibiotics prescribed for UTIs and SSTIs (the pre-ASP group) and patients treated after process implementation (the post-ASP group). Total regimen appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy guidelines. Secondary objectives included comparing rates of infection-related revisits and Clostridioides difficile infection between groups. Results A total of 400 patients were included in the study (pre-ASP gropu, n = 200; post-ASP group, n = 200). The rate of total antibiotic prescribing appropriateness improved significantly, from 27.5% to 50.5% (P < 0.0001), after implementation of the audit-and-feedback process. There were also significant improvements in the post-ASP group vs the pre-ASP period in the individual components of regimen appropriateness: appropriate drug (70% vs 53%, P < 0.001), appropriate duration (83.5% vs 57.5% , P < 0.001), and appropriate therapy indication (98% vs 94% , P = 0.041). There were no significant between-group differences in other outcomes such as rates of adverse events, treatment failure, C. difficile infection, and infection-related revisits or hospitalizations within 30 days. Conclusion A pharmacist-led audit-and-feedback outpatient stewardship strategy was demonstrated to achieve significant improvement in outpatient antibiotic prescribing for UTI and SSTI.

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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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Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention

Infection Control and Hospital Epidemiology ◽

10.1086/677826 ◽

2014 ◽

Vol 35 (S3) ◽

pp. S69-S78 ◽

Cited By ~ 43

Author(s):

Julia E. Szymczak ◽

Kristen A. Feemster ◽

Theoklis E. Zaoutis ◽

Jeffrey S. Gerber

Keyword(s):

Primary Care ◽

Respiratory Tract ◽

Antimicrobial Stewardship ◽

Respiratory Tract Infections ◽

Audit And Feedback ◽

Antibiotic Prescribing ◽

Theory Approach ◽

Antibiotic Overuse ◽

Acute Respiratory Tract Infections ◽

Tract Infections

Objective.Inappropriate antibiotic prescribing commonly occurs in pediatric outpatients with acute respiratory tract infections. Antimicrobial stewardship programs are recommended for use in the hospital, but less is known about whether and how they will work in the ambulatory setting. Following a successful cluster-randomized trial to improve prescribing for common acute respiratory tract infections using education plus audit and feedback in a large, pediatric primary care network, we sought to explore the perceptions of the intervention and antibiotic overuse among participating clinicians.Methods.We conducted a qualitative study using semistructured interviews with 24 pediatricians from 6 primary care practices who participated in an outpatient antimicrobial stewardship intervention. All interviews were transcribed and analyzed using a modified grounded theory approach.Results.Deep skepticism of the audit and feedback reports emerged. Respondents ignored reports or expressed distrust about them. One respondent admitted to gaming behavior. When asked about antibiotic overuse, respondents recognized it as a problem, but they believed it was driven by the behaviors of nonpediatric physicians. Parent pressure for antibiotics was identified by all respondents as a major barrier to the more judicious use of antibiotics. Respondents reported that they sometimes “caved” to parent pressure for social reasons.Conclusions.To improve the effectiveness and sustainability of outpatient antimicrobial stewardship, it is critical to boost the credibility of audit data, engage primary care pediatricians in recognizing that their behavior contributes to antibiotic overuse, and address parent pressure to prescribe antibiotics.

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Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19

Antibiotics ◽

10.3390/antibiotics10010032 ◽

2021 ◽

Vol 10 (1) ◽

pp. 32

Author(s):

Nina J. Zhu ◽

Monsey McLeod ◽

Cliodna A. M. McNulty ◽

Donna M. Lecky ◽

Alison H. Holmes ◽

...

Keyword(s):

Primary Care ◽

Time Series ◽

Patient Outcomes ◽

Broad Spectrum ◽

Antibiotic Prescribing ◽

Broad Spectrum Antibiotic ◽

Out Of Hours ◽

Broad Spectrum Antibiotics ◽

National Quality ◽

General Practices

We describe the trend of antibiotic prescribing in out-of-hours (OOH) general practices (GP) before and during England’s first wave of the COVID-19 pandemic. We analysed practice-level prescribing records between January 2016 to June 2020 to report the trends for the total prescribing volume, prescribing of broad-spectrum antibiotics and key agents included in the national Quality Premium. We performed a time-series analysis to detect measurable changes in the prescribing volume associated with COVID-19. Before COVID-19, the total prescribing volume and the percentage of broad-spectrum antibiotics continued to decrease in-hours (IH). The prescribing of broad-spectrum antibiotics was higher in OOH (OOH: 10.1%, IH: 8.7%), but a consistent decrease in the trimethoprim-to-nitrofurantoin ratio was observed OOH. The OOH antibiotic prescribing volume diverged from the historical trend in March 2020 and started to decrease by 5088 items per month. Broad-spectrum antibiotic prescribing started to increase in OOH and IH. In OOH, co-amoxiclav and doxycycline peaked in March to May in 2020, which was out of sync with seasonality peaks (Winter) in previous years. While this increase might be explained by the implementation of the national guideline to use co-amoxiclav and doxycycline to manage pneumonia in the community during COVID-19, further investigation is required to see whether the observed reduction in OOH antibiotic prescribing persists and how this reduction might influence antimicrobial resistance and patient outcomes.

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Inappropriate Azithromycin Use in Nine Primary-Care Clinics Before and After Implementation of Provider Guidance in the EMR

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.869 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s292-s293

Author(s):

Alexandria May ◽

Allison Hester ◽

Kristi Quairoli ◽

Sheetal Kandiah

Keyword(s):

Primary Care ◽

Retrospective Chart Review ◽

Antibiotic Prescribing ◽

Upper Respiratory Tract ◽

National Guidelines ◽

Targeted Interventions ◽

Primary Care Clinics ◽

Before And After ◽

Upper Respiratory ◽

Tract Infections

Background: According to the CDC Core Elements of Outpatient Stewardship, the first step in optimizing outpatient antibiotic use the identification of high-priority conditions in which antibiotics are commonly used inappropriately. Azithromycin is a broad-spectrum antimicrobial commonly used inappropriately in clinical practice for nonspecific upper respiratory infections (URIs). In 2017, a medication use evaluation at Grady Health System (GHS) revealed that 81.4% of outpatient azithromycin prescriptions were inappropriate. In an attempt to optimize outpatient azithromycin prescribing at GHS, a tool was designed to direct the prescriber toward evidence-based therapy; it was implemented in the electronic medical record (EMR) in January 2019. Objective: We evaluated the effect of this tool on the rate of inappropriate azithromycin prescribing, with the goal of identifying where interventions to improve prescribing are most needed and to measure progress. Methods: This retrospective chart review of adult patients prescribed oral azithromycin was conducted in 9 primary care clinics at GHS between February 1, 2019, and April 30, 2019, to compare data with that already collected over a 6-month period in 2017 before implementation of the antibiotic prescribing guidance tool. The primary outcome of this study was the change in the rate of inappropriate azithromycin prescribing before and after guidance tool implementation. Appropriateness was based on GHS internal guidelines and national guidelines. Inappropriate prescriptions were classified as inappropriate indication, unnecessary prescription, excessive or insufficient treatment duration, and/or incorrect drug. Results: Of the 560 azithromycin prescriptions identified during the study period, 263 prescriptions were included in the analysis. Overall, 181 (68.8%) of azithromycin prescriptions were considered inappropriate, representing a 12.4% reduction in the primary composite outcome of inappropriate azithromycin prescriptions. Bronchitis and unspecified upper respiratory tract infections (URI) were the most common indications where azithromycin was considered inappropriate. Attending physicians prescribed more inappropriate azithromycin prescriptions (78.1%) than resident physicians (37.0%) or midlevel providers (37.0%). Also, 76% of azithromycin prescriptions from nonacademic clinics were considered inappropriate, compared with 46% from academic clinics. Conclusions: Implementation of a provider guidance tool in the EMR lead to a reduction in the percentage of inappropriate outpatient azithromycin prescriptions. Future targeted interventions and stewardship initiatives are needed to achieve the stewardship program’s goal of reducing inappropriate outpatient azithromycin prescriptions by 20% by 1 year after implementation.Funding: NoneDisclosures: None

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Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.728 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s188-s189

Author(s):

Jeffrey Gerber ◽

Robert Grundmeier ◽

Keith Hamilton ◽

Lauri Hicks ◽

Melinda Neuhauser ◽

...

Keyword(s):

Predictive Value ◽

Gold Standard ◽

Antibiotic Stewardship ◽

Chart Review ◽

Antibiotic Use ◽

Audit And Feedback ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Tract Infections ◽

The Impact

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

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Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

Antibiotics ◽

10.3390/antibiotics9090610 ◽

2020 ◽

Vol 9 (9) ◽

pp. 610

Author(s):

Nahara Anani Martínez-González ◽

Ellen Keizer ◽

Andreas Plate ◽

Samuel Coenen ◽

Fabio Valeri ◽

...

Keyword(s):

Primary Care ◽

Respiratory Tract ◽

Usual Care ◽

Respiratory Tract Infections ◽

Point Of Care ◽

Antibiotic Prescribing ◽

C Reactive Protein ◽

Reactive Protein ◽

Meta Analyses ◽

Tract Infections

C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

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Effectiveness and cost-effectiveness of Improving clinicians’ diagnostic and communication Skills on Antibiotic prescribing Appropriateness in patients with acute Cough in primary care in CATalonia (the ISAAC-CAT study): study protocol for a cluster randomised controlled trial

Trials ◽

10.1186/s13063-019-3727-3 ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Rafa Ruiz ◽

Ana Moragas ◽

Marta Trapero-Bertran ◽

Antoni Sisó ◽

Anna Berenguera ◽

...

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Communication Skills ◽

Controlled Trial ◽

Sensitivity Analyses ◽

Antibiotic Prescribing ◽

Cluster Randomised ◽

Life Years ◽

Effectiveness And Efficiency ◽

Tract Infections

Abstract Background Despite their marginal benefit, about 60% of acute lower respiratory tract infections (ALRTIs) are currently treated with antibiotics in Catalonia. This study aims to evaluate the effectiveness and efficiency of a continuous disease-focused intervention (C-reactive protein [CRP]) and an illness-focused intervention (enhancement of communication skills to optimise doctor-patient consultations) on antibiotic prescribing in patients with ALRTIs in Catalan primary care centres. Methods/design A cluster randomised, factorial, controlled trial aimed at including 20 primary care centres (N = 2940 patients) with patients older than 18 years of age presenting for a first consultation with an ALRTI will be included in the study. Primary care centres will be identified on the basis of socioeconomic data and antibiotic consumption. Centres will be randomly assigned according to hierarchical clustering to any of four trial arms: usual care, CRP testing, enhanced communication skills backed up with patient leaflets, or combined interventions. A cost-effectiveness and cost-utility analysis will be performed from the societal and national healthcare system perspectives, and the time horizon of the analysis will be 1 year. Two qualitative studies (pre- and post-clinical trial) aimed to identify the expectations and concerns of patients with ALRTIs and the barriers and facilitators of each intervention arm will be run. Family doctors and nurses assigned to the interventions will participate in a 2-h training workshop before the inception of the trial and will receive a monthly intervention-tailored training module during the year of the trial period. Primary outcomes will be antibiotic use within the first 6 weeks, duration of moderate to severe cough, and the quality-adjusted life-years. Secondary outcomes will be duration of illness and severity of cough measured using a symptom diary, healthcare re-consultations, hospital admissions, and complications. Healthcare costs will be considered and expressed in 2021 euros (year foreseen to finalise the study) of the current year of the analysis. Univariate and multivariate sensitivity analyses will be carried out. Discussion The ISAAC-CAT project will contribute to evaluate the effectiveness and efficiency of different strategies for more appropriate antibiotic prescribing that are currently out of the scope of the actual clinical guidelines. Trial registration ClinicalTrials.gov, NCT03931577.

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Evaluation of clinicians’ knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.42 ◽

2020 ◽

Vol 41 (6) ◽

pp. 672-679 ◽

Cited By ~ 1

Author(s):

Hayli R. Hruza ◽

Tania Velasquez ◽

Karl J. Madaras-Kelly ◽

Katherine E. Fleming-Dutra ◽

Matthew H. Samore ◽

...

Keyword(s):

Communication Strategies ◽

Implementation Strategies ◽

Patient Communication ◽

Audit And Feedback ◽

Antibiotic Prescribing ◽

Health Administration ◽

Prescribing Practices ◽

Diagnostic Uncertainty ◽

Appropriate Prescribing ◽

Tract Infections

AbstractBackground:Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans’ Health Administration clinics.Methods:We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.Results:Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.Conclusion:Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians’ perceptions of antibiotic prescribing practices and should enhance their patient communication skills.

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2076. Comparison of Diagnosis and Prescribing Practices between Virtual Visits and Office Visits for Sinusitis within a Primary Care Network

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1756 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S700-S700

Author(s):

Kristen Johnson ◽

Kayla Burns ◽

Lisa Dumkow ◽

Megan Yee ◽

Nnaemeka Egwuatu

Keyword(s):

Primary Objective ◽

Antibiotic Prescribing ◽

Upper Respiratory Tract ◽

Office Visits ◽

Prescribing Practices ◽

National Guidelines ◽

Duration Of Treatment ◽

Online Questionnaire ◽

Virtual Visits ◽

Tract Infections

Abstract Background The majority of antibiotics prescribed in the outpatient setting result from upper respiratory tract infections; however, these infections are often viral. Virtual visits (VV) have emerged as a popular alternative to office visits (OV) for sinusitis complaints and are an important area for stewardship programs to target for intervention. Methods A retrospective cohort study was conducted utilizing the outpatient electronic medical record for Mercy Health Physician Partners (MHPP) and Zipnosis database for VV to compare diagnosis and prescribing between OV and VV for sinusitis. VV consisted of an online questionnaire for patients to complete, which was then sent to a provider to evaluate electronically without face-to-face interaction. Adult patients were included with a diagnosis code for sinusitis during the 6-month study period from January to June 2018. The primary objective was to compare rates of appropriate diagnosis of viral vs. bacterial sinusitis between OV and VV, based on national guideline recommendations. Secondary objectives were to compare the appropriateness of antibiotic prescribing and supportive therapy prescribing between OV and VV, as well as 24-hour, 7-day and 30-day re-visits. Results A total of 350 patients were included in the study (OV n = 175, VV n = 175). Appropriate diagnosis per national guidelines was 45.7% in OV compared with 69.1% in the VV group (P < 0.001). Additionally, patients that completed VV were less likely to receive antibiotic prescriptions (OV 94.3%, VV 68.6%, P < 0.001). Guideline-concordant antibiotic prescribing was similar between groups (OV 60.6%, VV 58.3%, P = 0.70) and both visit types had a median duration of treatment of 10 days (P = 0.88). Patients that completed VV were more likely to re-visit for sinusitis within 24 hours (OV 1.7%, VV 8%, P = 0.006) and within 30-days (OV 7.4%, VV 14.9%, P = 0.027). In multivariate logistic regression the only factor independently associated with 24-hour re-visit was patient self-request for antibiotics (OR 0.20, 95% CI 0.06–0.68). Conclusion Appropriate diagnosis of sinusitis was more likely in the VV group, which shows that VV provides a good platform to target outpatient antimicrobial prescribing. These findings support opportunities for antimicrobial stewardship intervention in both OV and VV. Disclosures All authors: No reported disclosures.

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