Clinician education, feedback led to fewer inappropriate antibiotics for respiratory tract infections

An intervention that included clinician education and monthly feedback led to decreased antibiotic use in primary care, a recent study found.

Researchers conducted a stepped-wedge cluster randomized study in 31 primary care practices within one health system in Pennsylvania to assess the impact of a clinician-targeted intervention on antibiotic prescribing for respiratory tract diagnoses. There were a variety of practice types (e.g., teaching/nonteaching, family/internal medicine) and locations (urban/nonurban). They randomly assigned each practice to one of six clusters, and each cluster implemented the intervention at monthly intervals. The first cluster implemented the intervention starting Oct. 1, 2017, and the final cluster completed crossover into the intervention by March 31, 2018, and continued through Oct. 31, 2018.

The intervention consisted of two components: 1) an initial one-time educational session on appropriate prescribing for respiratory tract infections and patient communication strategies and 2) monthly electronic feedback to clinicians on their performance regarding antibiotic prescribing for respiratory tract diagnoses. The researchers grouped respiratory tract diagnoses into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Clinicians received monthly peer comparison feedback on antibiotic prescribing for all tiers and tier 3 diagnoses specifically. The researchers compared the proportion of visits with antibiotic prescriptions before and during the intervention. Results were published July 2 by Clinical Infectious Diseases.

A total of 185,755 unique office visits were included, with 127,324 (68.5%) from the preintervention period and 58,431 (31.5%) from the intervention period. These visits represented 113,620 unique patients. From the preintervention period to the intervention period, the proportion of visits with an antibiotic prescription decreased from 35.2% to 23.0% (P<0.001). In the unadjusted analysis, the intervention was associated with a decreased odds of antibiotic prescription (odds ratio [OR], 0.47 [95% CI, 0.45 to 0.48]; P<0.001). In the multivariable analysis, the intervention was associated with significantly decreased odds of tier 2 (OR, 0.57 [95% CI, 0.52 to 0.62]; P<0.001) and tier 3 antibiotic prescribing (OR, 0.57 [95% CI, 0.53 to 0.61]; P<0.001), but not tier 1 antibiotic prescribing (OR, 0.98 [95% CI, 0.83 to 1.16]; P=0.812). While there were small increases in the use of amoxicillin-clavulanate, amoxicillin, and doxycycline in the intervention period, there was a substantial decrease in azithromycin use, from 37.0% of antibiotics prescribed preintervention to 31.8% prescribed after the intervention.

The study authors noted that they did not directly assess appropriateness of antibiotic prescribing due to the infeasibility of chart review in a large population, among other limitations. They added that they did not assess patient outcomes, including antibiotic-related adverse events.

“This study demonstrated a significant reduction in antibiotic prescribing using provider-focused education and peer comparison feedback only in diagnosis tiers where antibiotics are only sometimes or rarely indicated,” the authors concluded. “In the future, it will be important to assess the sustainability of this intervention, particularly following removal of the monthly provider feedback, given that it is well known that the impact of many behavioral interventions wane over time.”