Audit and Feedback: A Quality Improvement Study to Improve Antimicrobial Stewardship
Purpose: Many antibiotics prescribed in an outpatient setting may be inappropriate, and by some estimates, half of the antibiotic prescriptions for acute bronchitis may be inappropriate. This quality improvement study aimed to decrease the rate of potentially inappropriate (not guideline concordant) antibiotic prescribing in acute bronchitis.
Methods: This program used an audit and feedback approach. Clinicians received education coupled with audit and feedback, which are components of the Centers of Disease Control and Prevention framework for an effective antimicrobial stewardship program. Antibiotic prescribing rates in patients with acute bronchitis without underlying chronic lung disease or evidence of bacterial infection were compared over two 9-month periods. The baseline period was October 1, 2017 to June 30, 2018 and the posteducation period was October 1, 2018 to June 30, 2019.
Results: Potentially inappropriate antibiotic prescribing dropped from 75% (160/213) at baseline to 60% (107/177) posteducation (95% CI 0.05, 0.24; P < .01, 2-sample binomial test). Rates were lower for 7 health care providers (HCPs), unchanged for 1 HCP, and slightly increased for 1 HCP between study periods ( P = .02, Wilcoxon signed rank test for paired data).
Conclusions: Study findings show a decline in potentially inappropriate antibiotic prescribing and a resulting improvement in clinic antimicrobial stewardship efforts.
Discussion
Acute bronchitis remains a common diagnosis where antibiotics are prescribed despite being a predominately viral illness. Guidelines and evidence-based practices advise against antibiotics for this diagnosis. According to the American Academy of Family Physicians, antibiotics are reserved for cases where chronic lung disease is present as these patients are at a high risk of developing pneumonia.3 The decision to prescribe antibiotics is complex and driven by several interdependent factors, such as patient expectations, health system limitations, clinician training, and specialty.15 HCPs may more aggressively treat acute bronchitis among American Indian/Alaskan Native (AI/AN) people due to a high risk of developing serious complications from respiratory illnesses.16 A clinician’s background, usual patient cohort (ie, mostly pediatric or geriatric), and time spent in urgent care or in activities outside of patient care (administration) may account for the difference in patient encounters by HCP for acute bronchitis.
Following the CDC framework, this antimicrobial stewardship program helped empower people involved in patient care (eg, pharmacists, HCPs), educate staff on proper use of antibiotics for acute bronchitis, and track and report antibiotic prescribing through the A&F process. Educational interventions coupled with ongoing A&F are reproducible by other health care facilities and are not usually time consuming. This study showcases a successful example of implementing A&F in an antimicrobial stewardship quality improvement project that could be translated toward other conditions (eg, sinusitis, urinary tract infection, community-acquired pneumonia).
In a similar study, Meeker and colleagues used a variation of an A&F intervention using a monthly email showing peer comparisons to notify clinicians who were prescribing too many unnecessary antibiotics for common respiratory illnesses that did not require antibiotics, such as the common cold.17 The peer comparison intervention arm emailed a rank order that listed prescribers by the number of prescriptions for common respiratory illnesses. This intervention demonstrated a reduction of 5.2% in inappropriate antibiotic prescribing.
Limitations
This quality improvement study had several limitations. The study did not account for the duration of symptoms as a factor to judge appropriateness. Although this was identified early in the study, it was unavoidable since there was no report that could extract the duration of symptoms in the electronic health record. Future studies should consider a manual review of each encounter to overcome this limitation. Another limitation was that only three-quarters of the year and not the entire year were reviewed. Future studies should include longer time frames to measure the durability of changes to antibiotic prescriptions. Lastly, the study did not assess diagnosis shifting (the practice of changing the proportion of antibiotic-appropriate acute respiratory tract infection diagnosis over time), effects of patient demographics (patient age and sex were not recorded), or any sustained effect on prescribing rates after the study ended.
Conclusions
Clinician education coupled with A&F are components of the CDC’s framework for an effective antimicrobial stewardship program. The intervention seem to be an effective means toward reducing inappropriate antibiotic prescribing for acute bronchitis and has the potential for application to other antimicrobial stewardship initiatives. The present study adds to the growing body of evidence on the importance and impact an antimicrobial stewardship program has on a clinic or health system.
Acknowledgment
The results of this study have been reported at the 2019 IHS Southwest Regional Pharmacy Continuing Education Seminar, April 12-14, 2019.
