Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network

• Published in: JAMA network open 2023-05, Vol.6 (5), p.e2313011-e2313011
• Main Authors: Stenehjem, Edward, Wallin, Anthony, Willis, Park, Kumar, Naresh, Seibert, Allan M, Buckel, Whitney R, Stanfield, Valoree, Brunisholz, Kimberly D, Fino, Nora, Samore, Matthew H, Srivastava, Rajendu, Hicks, Lauri A, Hersh, Adam L
• Format: Article
• Language: English
• Subjects: Adult; Ambulatory Care; Anti-Bacterial Agents - therapeutic use; Antibiotics; Antimicrobial Stewardship; Electronic health records; Female; Humans; Infectious Diseases; Intervention; Male; Online Only; Original Investigation; Prescriptions; Quality improvement; Respiratory Tract Infections - drug therapy; Sinusitis - drug therapy
• ISSN: 2574-3805; 2574-3805
• DOI: 10.1001/jamanetworkopen.2023.13011

Urgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC. To evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network. This quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc. Stewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive. The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods. The baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), wh