Electronic intervention in GP practices reduces antibiotic prescribing for respiratory infections

2019 ◽  
Keyword(s):  
Respiratory Infections ◽  
Antibiotic Prescribing ◽  
Electronic Intervention

scholarly journals 145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S83-S83
Author(s):  
Shelby J Kolo ◽  
David J Taber ◽  
Ronald G Washburn ◽  
Katherine A Pleasants
Keyword(s):  
Primary Care ◽  
Respiratory Infections ◽  
Primary Care Providers ◽  
The United States ◽  
Delivery Mode ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Care Providers ◽  
Intervention Period ◽  
Provider Education

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

scholarly journals 143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S82-S82
Author(s):  
Zahra Kassamali Escobar ◽  
Todd Bouchard ◽  
Jose Mari Lansang ◽  
Scott Thomassen ◽  
Joanne Huang ◽  
...  
Keyword(s):  
Primary Care ◽  
Viral Infections ◽  
Respiratory Infections ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Specific Rate ◽  
Inclusion Criteria ◽  
Diagnosis Codes ◽  
Control And Prevention ◽  
Viral Respiratory Infections

Abstract Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing. Methods This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing. Results Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month. Conclusion Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic. Disclosures All Authors: No reported disclosures

scholarly journals 141. Implementation of Veterans Affairs Outpatient Antimicrobial Stewardship Interventions for Asymptomatic Bacteriuria and Acute Respiratory Infections, a Stepped Wedge Randomized Study

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S81-S82
Author(s):  
Grace Mortrude ◽  
Mary Rehs ◽  
Katherine Sherman ◽  
Nathan Gundacker ◽  
Claire Dysart
Keyword(s):  
Patient Satisfaction ◽  
Primary Outcome ◽  
Respiratory Infections ◽  
Asymptomatic Bacteriuria ◽  
Educational Interventions ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Stepped Wedge ◽  
Post Intervention ◽  
The Impact

Abstract Background Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance in the United States. The objective of this study was to design, implement and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the outpatient setting. Methods This randomized, stepped-wedge trial evaluated the impact of educational interventions to providers on adult patients presenting to primary care (PC) clinics for ARIs and ASB from 10/1/19 to 1/31/20. Data was collected by retrospective chart review. An antibiotic prescribing report card was provided to PC providers, then an educational session was delivered at each PC clinic. Patient education materials were distributed to PC clinics. Interventions were made in a step-wise (figure 1) fashion. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper-respiratory infection otherwise unspecified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes included individual components of the primary outcome, a composite safety endpoint of related hospital, emergency department or primary care visit within 4 weeks, antibiotic appropriateness, and patient satisfaction surveys. Figure 1 Results There were 887 patients included for analysis (405 pre-intervention, 482 post-intervention). Baseline characteristics are summarized in table 1. After controlling for type 1 error using a Bonferroni correction the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for bronchitis (20.99% vs 12.66%; p=0.0003). Appropriateness of prescriptions for sinusitis (OR 4.96; CI 1.79–13.75; p=0.0021) and pharyngitis (OR 5.36; CI 1.93 – 14.90; p=0.0013) was improved in the post-intervention group. The composite safety outcome and patient satisfaction survey ratings did not differ between groups. Table 1 Conclusion Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visit or patient satisfaction surveys. Disclosures All Authors: No reported disclosures

scholarly journals Tackling antimicrobial resistance in the community

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
S Tonkie-Crine ◽  
L Abel ◽  
O Van Hecke ◽  
K Wang ◽  
C Butler
Keyword(s):  
Antibiotic Resistance ◽  
Community Care ◽  
Respiratory Infections ◽  
Antibiotic Prescription ◽  
Future Research ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Community Settings ◽  
The Public ◽  
Need Support

Abstract Antibiotic prescription is a major driver of antibiotic resistance. The majority of antibiotic prescribing occurs in community care settings, often for respiratory infections. A substantial proportion of prescriptions are issued not according to guidelines, particularly for acute respiratory infections which can be self-limiting. Prescribers in these settings need support to prescribe antibiotics more prudently. Patients and the public also need support to manage infections which are self-limiting. This presentation presents a summary of how antimicrobial stewardship (AMS) activities are being used in community settings. Firstly, types of community-level interventions are discussed, including those aimed at clinicians, patients and the public. Next, we assess interventions based on their effectiveness at reducing antibiotic prescriptions or use and their cost-effectiveness. Finally, we discuss directions for future research and consider how the research to date could influence policy.

scholarly journals Novel Method to Evaluate Diagnostic Shifting After a Pediatric Antibiotic Stewardship Intervention

2020 ◽  
Vol 41 (S1) ◽  
pp. s332-s333
Author(s):  
Nora Fino ◽  
Benjamin Haaland ◽  
Karl Madaras-Kelly ◽  
Katherine Fleming-Dutra ◽  
Adam Hersh ◽  
...  
Keyword(s):  
Respiratory Infections ◽  
Population Attributable Fraction ◽  
Acute Otitis Media ◽  
Population Level ◽  
Estimating Equation ◽  
Audit And Feedback ◽  
Antibiotic Prescribing ◽  
Post Intervention ◽  
Intervention Effect ◽  
Diagnostic Coding

Background: Audit-and-feedback interventions track clinician practice patterns for a targeted practice behavior. Audit and feedback of antibiotic prescribing data for acute respiratory infections (ARI) is an effective stewardship strategy that relies on administrative coding to identify eligible visits for audit. Diagnostic shifting is the misclassification of a patient’s diagnosis in response to audit and feedback and is a potential unintended consequence of audit and feedback. Objective: To develop a method to identify patterns consistent with diagnostic shifting including both positive shifting (improved diagnosis and documentation) and negative shifting (intentionally altering documentation of diagnosis to justify antibiotic prescribing), after implementation of an audit-and-feedback intervention to improve ARI management. Methods: We evaluated the intervention effect on diagnostic shifting within 12 University of Utah pediatric clinics (293 providers). Data included 66,827 ARI diagnoses: pneumonia, sinusitis, bronchitis, pharyngitis, upper respiratory infection (URI), acute otitis media (AOM), or serous otitis with effusion (OME). To determine whether rates of ARI diagnoses changed after the intervention, we developed logistic generalized estimating equation (GEE) models with robust sandwich standard error estimates to account for clinic-wise clustering. Outcomes included the change in each ARI diagnosis relative to the competing 6 diagnoses included in audit-and-feedback reports before and after intervention implementation. Models tested for a change in outcomes after the intervention (ie, diagnostic shift) after adjustment for month of diagnosis. For each diagnosis, we estimated the population attributable fraction (PAF) for antibiotic prescriptions due to combined shifts in diagnostic frequencies and prescription rates for each diagnosis. The PAF is the estimated fraction of antibiotic prescriptions that would have changed under a population-level intervention. Results: In month-adjusted analyses, diagnoses of pneumonia and OME decreased after the intervention: odds ratio (OR), 0.46 (95% CI, 0.31–0.68) and OR, 0.81 (95% CI, 0.67–0.99), respectively. In addition, URI diagnoses increased: OR, 1.05 (95% CI 1.00, 1.11). We did not detect changes in the diagnosis rates of sinusitis, AOM, bronchitis, and pharyngitis post intervention. The intervention effect on the PAF for antibiotics prescriptions was consistently positive but relatively small in magnitude. PAF was highest for URIs (PAF, 8.87%), followed by AOM (PAF, 3.56%) and sinusitis (PAF, 2.76%), and was lowest for pneumonia and bronchitis (PAF, 0.41% for both). Conclusions: Our analysis found minimal evidence overall of diagnostic shifting after a stewardship intervention using audit and feedback in these pediatric clinics. Small changes in diagnostic coding may reflect more appropriate diagnosis and coding, a positive effect of audit and feedback, rather than intentional negative diagnostic shift.Funding: NoneDisclosures: None

scholarly journals Dissecting the mechanisms of a 5-year decline in antibiotic prescribing

2020 ◽  
Author(s):  
Stephen M. Kissler ◽  
R. Monina Klevens ◽  
Michael L. Barnett ◽  
Yonatan H. Grad
Keyword(s):  
Infectious Disease ◽  
Antibiotic Stewardship ◽  
Respiratory Infections ◽  
Medical Condition ◽  
Outpatient Visit ◽  
Antibiotic Prescribing ◽  
Medical Conditions ◽  
Outpatient Visits ◽  
Prescribing Trends ◽  
Tract Infections

AbstractImportanceThe mechanisms driving the recent decline in outpatient antibiotic prescribing are unknown.ObjectiveTo estimate the extent to which reductions in the number of antibiotic prescriptions filled per outpatient visit (stewardship) and reductions in the monthly rate of outpatient visits (observed disease) for infectious disease conditions each contributed to the decline in annual outpatient antibiotic prescribing rate in Massachusetts between 2011 and 2015.DesignOutpatient medical and pharmacy claims from the Massachusetts All-Payer Claims Database were used to estimate rates of antibiotic prescribing and outpatient visits for 20 medical conditions and their contributions to the overall decline in antibiotic prescribing. Trends were compared to those in the National Ambulatory Medical Care Survey (NAMCS).SettingOutpatient visits in Massachusetts between January 2011 and September 2015.Participants5,075,908 individuals with commercial health insurance or Medicaid in Massachusetts under the age of 65 and 495,515 patients included in NAMCS.Main outcomes and measuresThe number of antibiotic prescriptions avoided through reductions in observed disease and reductions in per-visit prescribing rate per medical condition.ResultsBetween 2011 and 2015, the January antibiotic prescribing rate per 1,000 individuals in Massachusetts declined by 18.9% and the July antibiotic prescribing rate declined by 13.6%. The mean prescribing rate for children under 5 declined by 42.8% (95% CI 21.7%, 59.4%), principally reflecting reduced wintertime prescribing. The monthly rate of outpatient visits per 1,000 individuals in Massachusetts declined (p < 0.05) for respiratory infections and urinary tract infections. Nationally, visits for medical conditions that merit an antibiotic prescription also declined between 2010 and 2015. Of the estimated 358 antibiotic prescriptions per 1,000 individuals avoided over the study period in Massachusetts, 59% (95% CI 54%, 63%) were attributable to reductions in observed disease and 41% (95% CI 37%, 46%) to reductions in prescribing per outpatient visit.Conclusions and relevanceThe decline in antibiotic prescribing in Massachusetts was driven by a decline in observed disease and improved antibiotic stewardship, with a contemporaneous reduction in visits for conditions prompting antibiotics observed nationally. A focus on infectious disease prevention should be considered alongside antibiotic stewardship as a means to reduce antibiotic prescribing.Key pointsQuestionHow did the separate mechanisms of improved stewardship and reductions in observed disease contribute to a 5-year decline in outpatient antibiotic prescribing in Massachusetts from 2011-2015?FindingsIn an observational analysis of insurance claims, reduced monthly rates of outpatient visits for infectious conditions and reduced probability of prescribing an antibiotic per outpatient visit both contributed to the decline in antibiotic prescribing. An estimated 358 antibiotic prescriptions per 1,000 individuals were avoided over the study period through the two mechanisms, 211 of which were attributable to reductions in outpatient visits and 147 to reduced antibiotic prescribing per visit.MeaningPreventing the need for outpatient visits should be considered alongside antibiotic stewardship as a means of reducing antibiotic prescribing.

scholarly journals An antibiotic stewardship programme to reduce inappropriate antibiotic prescribing for acute respiratory infections in rural Chinese primary care facilities: study protocol for a clustered randomised controlled trial

2020 ◽  
Author(s):  
Chao Zhuo ◽  
Xiaolin Wei ◽  
Zhitong Zhang ◽  
Joseph Paul Hicks ◽  
Jinkun Zheng ◽  
...  
Keyword(s):  
Primary Care ◽  
Antibiotic Stewardship ◽  
Respiratory Infections ◽  
Inappropriate Prescribing ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Care Facilities ◽  
Randomised Controlled ◽  
Antibiotic Stewardship Programme

Abstract Background: Inappropriate prescribing of antibiotics for acute respiratory infections at primary care level represents the major source of antibiotic misuse in healthcare, and is a major driver for antimicrobial resistance worldwide. In this study we will develop, pilot and evaluate the effectiveness of a comprehensive antibiotic stewardship programme in China’s primary care hospitals to reduce inappropriate prescribing of antibiotics for acute respiratory infections among all ages.Methods: We will use a parallel-group, cluster-randomised, controlled, superiority trial with blinded outcome evaluation but unblinded treatment (providers and patients). We will randomise 34 primary care hospitals from two counties within Guangdong province into the intervention and control arm (1:1 overall ratio) stratified by county (8:9 within-county ratio). In the control arm, antibiotic prescribing and management will continue through usual care. In the intervention arm, we will implement an antibiotic stewardship programme targeting family physicians and patients/caregivers. The family physician components include: 1) training using new operational guidelines, 2) improved management and peer-review of antibiotic prescribing, 3) improved electronic medical records and smart phone app facilitation. The patient/caregiver component involves patient education via family physicians, leaflets and videos. The primary outcome is the proportion of prescriptions for acute respiratory infections (excluding pneumonia) that contain any antibiotic(s). Secondary outcomes will address how frequently specific classes of antibiotics are prescribed, how frequently key non-antibiotic alternatives are prescribed and the costs of consultations. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and a long-term benefit evaluation. The duration of the intervention will be 12 months, with another 24 months post-trial long-term follow-up.Discussion: Our study is one of the first trials to evaluate the effect of an antibiotic stewardship programme in primary care settings in a low- or middle-income country (LMIC). All intervention activities will be designed to be embedded into routine primary care with strong local ownership. Through the trial we intend to impact on clinical practice and national policy in antibiotic prescription for primary care facilities in rural China and other LMICs.Trial registration: ISRCTN, ISRCTN96892547. Registered 18 August 2019, http://www.isrctn.com/ISRCTN96892547

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