10/9/2017. Evidence-Based Interventions to Reduce Inappropriate Prescription of Antibiotics. Prescribing for Respiratory Tract Infections

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1 Evidence-Based Interventions to Reduce Inappropriate Prescription of Antibiotics Ann Thomas, MD, MPH Oregon Public Health Division Prescribing for Respiratory Tract Infections Antibiotic use is primary driver of resistance 2/3 of antibiotic prescriptions dispensed in outpatient settings 72% of all antibiotics prescribed for kids given for respiratory tract infections, and 41% of antibiotics for adults are for respiratory infections Antibiotics unnecessary in 50% of patients receiving prescriptions for respiratory infections Suda J Antimicrob Chemotherapy 2013;68:715-18; Hersh Pediatrics 2011;128: ; Shapiro J Antimicrob Chemotherapy 2014;69:234-40; Fleming-Dutra JAMA 2016:315: Proportion of patients filling antibiotic prescriptions vs proportion needing antibiotics, Oregon, 2014 Percent Acute Otitis Media Sinusitis Pharyngitis Bronchitis Common Cold Received Antibiotic Likely Needed Antibiotic 11 5 Gonzales CID 2001;33:757-62; Oregon APAC data,

2 Proportion of patients receiving broad and narrow * spectrum antibiotics, by syndrome, Oregon, AOM Sinusitis Pharyngitis Bronchitis URI Broad Narrow * Includes penicillin, ampicillin, amoxicillin, and first generation cephalosporins Class of antibiotics used for respiratory infections, Oregon, 2014 Antibiotic Class AOM SINUSITIS (n=66,788) (n=54,930) PHARYNGITIS (n=57,729) BRONCHITIS (n=45,761) URI (n=20,696) Narrow spectrum beta lactams # 66.4% 29.4% 65.2% 8.5% 28.0% Amoxicillinclavulanate 11.7% 29.7% 7.5% 5.8% 9.3% Azithromycin 11.4% 22.8% 19.2% 70.2% 47.7% Fluoroquinolones 0.6 % 3.2% 1.0% 4.4% 3.1% 2nd generation and above cephalosporins All other broad spectrum 7.9% 5.7% 2.3% 1.7% 3.3% 2.1% 9.3% 4.9% 9.4% 8.6% Oregon APAC data, 2014 Antibiotic Pneumococcus GAS (2016) Vancomycin 0% 0% Cefotaxime 3% 0% Penicillin* 1% 0% Clindamycin 5% 14% Amoxicillin 1% - Erythromycin 16% 14% Tetracycline 7% 20% *Based on 2012 CLSI (Clinical and Laboratory Standards Institute) breakpoints (S<=2; I=4; R>=8) for non-meningeal infections Oregon Emerging Infections Program ABCs data 2

3 Summary of Priorities to Reduce Unnecessary Prescribing in Oregon 1) Improve adherence to clinical criteria for treating AOM, sinusitis 2) Do not prescribe antibiotics for bronchitis in patient w/o CLD 3) Treat pharyngitis only if rapid strep or culture is positive 4) For upper respiratory tract infections, use beta-lactams unless serious allergy present, avoid macrolides 7 Overview of Outpatient Stewardship Strategies Patient Education Influence Clinician Prescribing Habits Communication Strategies Patient education on when antibiotics are needed, AEs Audit and Feedback Wait and See Prescription Triage systems to reduce unnecessary visits Clinical Decision Support Communication skills training for clinicians Waiting Room Posters 8 CDC. MMWR 2016: Recommendations and Reports/ Vol 65/No.6 Patient Education: reducing antibiotic use in children in outpatient settings Strategies that combined parent education with clinician behavior change decreased antibiotic prescribing by 6%-21% Biggest effect in a study using a parent-clinician interactive book Passive written materials less useful Clinical decision supports (CDS) effective Best to involve clinicians in planning the intervention Vodicka Brit J Gen Pract 2013;612:

4 Francis BMJ 2009;339:b2885 Patient Education: Can improving knowledge of antibiotic associated adverse events (AEs) reduce demand? 6 telephone focus groups conducted with adult patients and mothers of young children discussed their knowledge and attitudes about antibiotic resistance and AEs associated with antibiotic use Roberts RM, et al. Health Serv Res Manag Epidemiol doi / Parents Most mothers didn t consult clinician about URI symptoms unless they felt a serious infection needed to be ruled out Familiar with AEs such as diarrhea and rash, but few knew about C. difficile and anaphylaxis Nearly all parents felt clinicians should discuss AEs with parents at the time antibiotics are recommended, would likely question whether antibiotics needed in future Adults Adults rarely sought care for URIs but did expect an antibiotic if they sought care Did not feel risk of AEs was a significant issue and that information about AEs would not dissuade them from wanting antibiotic I rely on the doctor s judgement. 12 4

5 Triage Systems: Optimizing the use of telephone nursing advice of upper respiratory infection symptoms Tracked calls for advice about URI symptoms for Kaiser Permanente s Northern CA Appt and Advice Call Center Included all Kaiser members over 18 years of age calling about cough, cold, influenza, or sinus symptoms in 2009 Callers with symptoms requiring clinical assessment are transferred to RNs who use computer-based, symptom-specific decision support protocols to manage callers Judged advice to be sufficient if patient did not call back within 7 days and receive a higher level call outcome such as clinic appt 13 Harper et al. Am J Managed Care 2015:21: Results Outcome of Incoming Calls (n=450,484) 0.5% 0.2% % % 10.1% ED referral Appointments Message to PCP Advice for home care Other Of the 279,625 URI calls where advice given, 88% either required no follow-up or phone advice only only 0.1% had ED referral, rest either given appts or had message left with PCP 14 Waiting Room Posters: nudging guidelineconcordant antibiotic prescribing RCT in 5 outpatient primary care clinics in LA Intervention: displaying poster-sized commitment letters in exam room for 12 weeks, contained clinician photographs and signatures stating their commitment to avoid inappropriate antibiotic prescribing for ARIs Tracked antibiotic prescribing for inappropriate diagnoses: URI, larygnitis, bronchitis, flu Meeker JAMA Intern Med doi: /jamainternmed

6 Results No evidence of diagnostic shift away from antibiotic-inappropriate codes There was no change in rate of antibiotic-appropriate prescribing over time after intervention ended Audit and Feedback: System of quality improvement that promotes individualized adherence to evidence-based practices Most effective methods compare individual clinician prescribing rates to co-workers or expected prescribing rates based on clinical practice guidelines ACUTE AND COMMUNICABLE DISEASE PREVENTION Public Health Division Effect of an outpatient antibiotic stewardship intervention on prescribing by primary care pediatricians Cluster randomized trial comparing prescribing between intervention and control practices (18 practices in pediatric network in PA and NJ) using a common electronic health record Excluded children with chronic conditions, antibiotic allergies and prior antibiotic used Defined broad spectrum agents as amoxicillin-clavulanate, 2 nd or3rd generation cephalosporin Single hour of clinician education followed by 1 year of personalized quarterly audit and feedback by secure Tracked use of broad spectrum drugs for sinusitis, pneumonia and GAS pharyngitis 18 Gerber JAMA 2013;309:

7 Pneumonia Sinusitis GAS pharyngitis 19 Cluster randomized trial to improve antibiotic use for adults with URI/bronchitis in EDs 16 hospitals participated, with 1 VA and 1 non-va hospital each in 8 urban areas Intervention included performance feedback (aggregate data for each ED), clinician education and patient educational materials Tracked % of visits for URI and bronchitis that received antibiotics, return visits, and visit satisfaction (rated on 5-point scale ranging from 1=very un-satisfied to 5=very satisfied 20 Metlay Ann Emerg Med 2007;50: Results Control sites Intervention sites Pre Post Pre Post % prescribing 47% 47% 52% 42% Return visits 5.5% 10.1% 8.1% 9.5% Patient satisfaction For URI, drop at intervention sites was 9.5% for URI and 5.0% for bronchitis Despite improvement, still high levels of prescribing for conditions that typically do not warrant antibiotic use 21 7

8 Clinical Decision Support (CDS) Provides clinicians with information at specific times during the patient encounter to facilitate accurate diagnoses and treatment Clinical information, such as signs and symptoms, can be entered electronically or on paper to determine if an antibiotic is needed A few examples of clinical decision support (CDS) Setting Condition CDS 2 Large VA healthcare systems CAP, sinusitis, bronchitis, COPD and URI in adults Providers click on symptoms, get advice on whether to use Abx. Could override computer advice at end 33 primary care practices belonging to integrated health system Acute bronchitis Clinics divided into 3 groups: 1) control; 2) printed materials; 3) clinical decision support tool Rattinger PlosOne 2012;7(12): e51147; Gonzales JAMA Int Med 2013;173:267-73; Results Setting Results 2 Large VA healthcare systems % of unwarranted prescriptions of azithromycin /FQs decreased from 22% to 3% 33 primary care practices belonging to integrated health system 1) Control sites increased from 73% to 74% 2) Printed materials dropped from 80% to 68% 3) Computerized group 74% to 61% 4) No changes in 30-day return visits 24 8

9 National trends in use of CDS for antibiotic prescribing for bronchitis and URI, Use of CDS 16% of visits 55% of visits Overall Abx prescribing for URI and bronchitis 35% 45% Percent decrease in use of Abx when CDS used 17% 19% Decreased risk of receiving antibiotics when clinician uses CDS was fairly constant between 2006 to 2010 McCullogh J Am Med Inform Assoc 2014;21: Adjusted probability of receiving antibiotics, by use of CDS, *controlling for patient, provider, and practice characteristics Delayed Antibiotic Prescribing Patient is asked to wait (usually hours) after a clinical visit to determine if an antibiotic is needed for an illness that may not appear to immediately warrant an antibiotic Several ways to give a delayed antibiotic prescription: 1) writing a post-dated prescription; 2) re-contacting a patient after a clinical visit; or 3) providing a prescription and giving a verbal order to fill the prescription after a predetermined length of time if symptoms do not improve Little BMJ 2014:348:e1606; Chao Pediatrics 2008;121:e

10 Evaluation of wait-and-see prescription (WASP) for AOM Design: Randomized, controlled trial in an ED setting of kids diagnosed with AOM, received either standard prescription (SP) or wait-and-see prescription (WASP) Findings: 62% of WASP vs 13% of SP did not fill prescription No difference between 2 groups in number of kids with fever, ear pain, or unscheduled visits Spiro JAMA 2006;296: Review of delayed antibiotics for respiratory infections (10 studies, 3,157 patients) Measure Findings Outcomes No differences for cough and common cold minor differences in pain and fever for sore throat and AOM in some of the studies Use of Abx Delayed antibiotic prescription resulted in significant reduction in antibiotic use (32% vs 93% in immediate group) Complications Parent Satisfaction Little difference between immediate and delayed antibiotics, no difference in re-consulting rates Delay slightly reduces satisfaction compared to immediate antibiotics (87% vs 92%) Spurling. Cochrane database of systematic reviews 2013;Vol 4 Communication Skills Training: Communication practices and antibiotic use for acute respiratory tract infections in children Previous research by these investigators had explored use of: Positive recommendations: You can give her a teaspoon of honey before bedtime until the cough clears up Negative recommendations: What we have here is just a virus, so antibiotics won t help Findings: use of negative recommendations increase the odds that parents will question non-antibiotic treatment plans 30 Mangione-Smith, et al. Ann Fam Med 2015;13:

11 Methods Enrolled parents of children 6 months -10 years of age seen for cough, congestion, sore throat, ear pain or ear tugging Parents completed a post-visit survey to: rate the care they received report whether they received positive or negative treatment recommendations Charts reviewed to obtain visit diagnosis and whether antibiotics prescribed Results apply to viral infections only Mangione-Smith, et al. Ann Fam Med 2015;13: Results Strategy Antibiotic use Parent rating high Positive recs only 52% reduction - Negative recs only No change - Combination of positive and negative Antibiotics prescribed (5% of viral URI visits) 85% reduction + n/a - 32 Summary of interventions to reduce antibiotic prescribing CDS, audit and feedback can be effective Wait and see prescriptions can reduce abx use without diminishing parent satisfaction Other low-cost, low-tech strategies can also be effective, such as poster interventions Most effective interventions combine strategies Helpful to engage clinicians in developing the intervention 11

12 Resources Resources: HealthInsight Implementing the Core Elements qualifies as an Improvement Activity in the Quality Payment Program 36 12

13 Oregon Health Authority Guidelines for clinicians Waiting room poster template Patient education materials TIBIOTICRESISTANCE/Pages/provider.aspx Available here: NTIBIOTICRESISTANCE/Pages/Difficult-conversations.aspx 38 Motivational Interviewing Seminar Developed to target difficult and or pressured conversations around antibiotic use. Useful for all clinical professionals: MD, DO, Pharmacist, PA, RN, NP, MA Focuses on developing tools and skills for quick motivational interviewing. Estimated time: one hour Dates available: expires June 1,

14 Purpose of Motivational Interviewing Get a conversation going - express empathy through reflective listening Develop discrepancy between a patients' goals or values and their current behavior Avoid argument and direct confrontation and adjust to resistance rather than opposing it directly Support self-efficacy and optimism THANK YOU! 41 14

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