Tackling Antibiotic Prescribers' Behaviors for Respiratory Infections at the VA

An audit feedback intervention is an approach used to help providers translate evidence into behavior change, and at ID Week, 1 abstract showed that it helped to reduce antibiotic prescribing for acute respiratory infections (ARIs). Another report showed that antibiotic prescribing rates for ARIs at medical centers operated by the Department of Veterans Affairs (VA) have steadily declined since 2010.

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ID Week is an annual conference focused on many different infectious disease topics.

In the first abstract, the authors noted that the generalizability and sustainability of using an audit-feedback intervention are unknown. They looked at an audit-feedback intervention and outcomes across multiple seasons in different clinic settings.

Researchers examined reports from 2 VA medical centers, which distributed audit-feedback reports targeting providers with frequent ARI visits in emergency department (ED) and primary care (PC) during 2015 to 2016 and 2016 to 2017. A visit from academic peers accompanied the initial audit-feedback report.

The intervention was expanded to ED and PC clinics (n = 10) in 3 other VA facilities in 2017 to 2018. Outcomes included rates of antibiotics prescribed, recurrent visits for ARIs within 30 days, and adverse events. The researchers assessed intervention sustainability in initiating VAs, and intervention generalizability in expansion VAs. Mixed-effect logistic regression models were used to assess intervention effect on antibiotic prescribing and outcomes.

The researchers found that antibiotic prescribing for uncomplicated ARI visits (n = 7814) declined from 53.8% to 27.9% postintervention. The intervention was associated with a reduction in odds of prescribing antibiotics in initiating facilities (odds ratio [OR] 0.6 (95% CI 0.3, 0.9), which declined further with an annual OR 0.8 [95% CI 0.7, 1.1] per year.

Preliminary 6-month postintervention results were available from pilot clinics (n = 3) within 2 of the expansion VAs, which indicated similar effectiveness (OR 0.5 [0.4, 0.7]).

Recurrent visits for ARIs (8.2% vs. 8.6%, P = 0.14) and adverse events (2.3% vs. 2.1%, P = 0.90) were not different pre/post intervention. Receipt of an antibiotic was not associated with recurrent visits for ARI (8.6% vs. 8%, P = 0.45) or adverse events (1.9% vs. 1.7%, P = 0.11).

The audit-feedback intervention sustained a reduction in antibiotic prescribing for ARIs over 3 years, and resulted in similar reductions in antibiotic use in varied ED and PC settings without affecting ARI-related return visit rates.

In the other report, also involving the VA, antibiotic prescribing rates for ARIs were found to have fallen since 2010, and aditional decline in antibiotic prescribing was associated with the launch of a national campaign to improve ARI management.

Researchers created a retrospective cohort of ARI visits between 2009 and April 2018 and calculated antibiotic prescribing rates, excluding patients with complicating conditions.

A provider-directed VA-wide ARI campaign began in October 2017. It was implemented locally by antibiotic stewards or regional personnel trained in academic detailing (AD). Campaign components included dashboards for tracking provider and facility prescribing metrics, printable feedback reports, and AD educational materials. Metrics included ARI antibiotic prescribing rates, bronchitis/URI-NOS antibiotic prescribing rates, guideline-concordant antibiotic selection for sinusitis or pharyngitis, and proportion of ARI visits with a sinusitis diagnosis. A logistic generalized estimating equation model assessed metrics over time pre/post intervention and chi-squared tests compared guideline concordant antibiotic proportions pre/post intervention.

Researchers found there were 1,580,612 and 137,421 ARI visits pre/post intervention, respectively. Antibiotic prescribing decreased from 2009, annual odds ratio (OR) 0.94 [95% CI 0.93, 0.96; P <0.001]. An additional effect was observed post-intervention [OR 0.88, (0.84, 0.88), P <0.001].

Bronchitis/URI-NOS prescribing rates decreased from 2009 [annual OR 0.94 (CI 0.93, 0.95), P <0.001]. Additional effect was observed post-intervention [OR 0.86, (0.81, 0.91), P <0.001]. Overall, the proportion of ARI visits diagnosed with sinusitis increased [annual OR 1.09 (1.08, 1.10), P <0.01], but the proportion of sinusitis diagnoses decreased [OR 0.72 (0.69, 0.75), P <0.001] post- intervention. Guideline-concordant antibiotic selection was 61.5% vs. 71.2% for sinusitis and 63.3% vs. 67.8% for pharyngitis pre/post intervention, respectively (both P <0.001).

References

Madaras-Kelly K, Hruza H, Pontefract B, et al. Multi-centered evaluation of an acute respiratory tract infection audit-feedback intervention: impact on antibiotic prescribing rates and patient outcomes. Presented at ID Week 2018; October 4, 2018; San Francisco, California. Abstract 213.

Madaras-Kelly K, Hruza H, Pontefract B, et al. Trends in antibiotic prescribing for acute respiratory tract infections and implementation of a provider-directed intervention within the veterans affairs healthcare system (VA). Presented at ID Week 2018; October 4, 2018; San Francisco, California. Abstract 208.