Outpatient Antibiotic Stewardship Project Leads to Drop in Prescribing

The development of antibiotics was one of the great medical advances of the 20th century—but in the first decades of the 21st century antibiotic resistance is one of the leading threats to human health. Overuse and misuse of these miracle drugs has led to a sharp rise in antibiotic-resistant bacteria in the last two decades, causing over two million infections, and some 23,000 deaths, in the U.S. each year.

United Hospital Fund has been collaborating with New York-area health care institutions, the Greater New York Hospital Association, and both the New York State and New York City Departments of Health since 2015 to foster responsible prescribing of antibiotics, in both the inpatient and outpatient setting—and the efforts have produced notable results. In June, at the final meeting of UHF's Outpatient Antibiotic Stewardship Initiative Phase II, participants learned that, among the 34 participating practices, overall antibiotic prescribing rates for acute respiratory infections dropped 5 percentage points over the course of the program, to 26 percent.

Leading the meeting from UHF (L to R): Deborah Halper, Pooja Kothari, Joan Guzik

Acute respiratory infections, such as common colds or acute bronchitis, are usually caused by viruses, so do not respond to bacteria-targeting antibiotics, yet national data suggest significant over-prescription and misuse of antibiotics for those conditions. The Centers for Disease Control and Prevention estimates that, nationwide, up to 50 percent of outpatient prescriptions for acute respiratory infections are unnecessary.

The declines recorded in the UHF initiative were driven by a range of actions designed to educate both patients and practitioners, such as handouts on managing cold symptoms, waiting room videos on antibiotic use, and provider feedback reports. Some sites sent automated messages to patients, and others adapted material from the Centers for Disease Control and Prevention about appropriate antibiotic use.

“Leadership support and actively engaged clinical champions played a key role in antibiotic stewardship,” Joan Guzik, UHF's director of quality improvement and head of its antibiotic stewardship initiatives, told meeting attendees. What worked for some practices didn't work for others, she noted, highlighting the need for each health care system to customize the solutions most effective for its patient populations and providers.

That was borne out by variations that were found, from the beginning of the initiative to its conclusion, in prescribing for subgroups of patients:

By age group, the greatest drop in prescribing rates was for 40-to-59-year-olds (from 32% to 23%)
By gender, prescribing decreased more for female patients than males (from 29% to 23%)
By language, prescribing dropped most for Spanish speakers (from 26% to 12%)
“We now must focus on how to sustain and expand on these efforts,” said Ms. Guzik. “Keeping these programs going will be challenging, but I think we've proven how important, and effective, they are.” To help other practices better manage their antibiotic prescribing, UHF has distilled the lessons learned from its stewardship projects into a set of tools and guidelines for prescribers and health care institutions, to be released later this year.

The meeting was led by three of the initiative's faculty members: Belinda Ostrowsky, MD, MPH, field medical officer NY, Centers for Disease Control and Prevention; Gopi Patel, MD, MS, associate professor and director of antibiotic stewardship, The Mount Sinai Hospital; and Anne-Marie Audet, MD, MSc, SM, senior medical officer, UHF.

Participants in Stage II of the initiative were Medisys Health Network, Memorial Sloan Kettering Cancer Center, Montefiore Medical Center, Mount Sinai Health System, NewYork-Presbyterian Queens, NYU Langone Health, and Wyckoff Heights Medical Center.

July 13, 2018
Focus Area
Clinical-Community PartnershipsQuality and Efficiency
Quality Institute