Implementation and outcomes of a clinician-directed intervention to improve antibiotic prescribing for acute respiratory tract infections within the Veterans' Affairs Healthcare System

Abstract

Objective: To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.

Design: Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.

Participants: Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded.

Intervention(s): Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary.

Measure(s): We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity.

Results: We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78-0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59-0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73-1.09). Return visits (OR, 1.00; 95% CI, 0.94-1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92-1.59) were not different before and after implementation within facilities that performed intensive implementation.

Conclusions: Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity-dependent manner. No impact on ARI-related clinical outcomes was observed.

Fig. 1.

Study flow diagram for the VHA ARI Campaign. Note. VHA, Veterans’ Healthcare Administration; ARI, acute respiratory tract infection; COPD, chronic obstructive pulmonary disease; SSTI, skin and soft-tissue infection. ^AVisits may have met >1 exclusion criteria.

Fig. 2.

Observed (2a) and predicted (2b) antibiotic prescription (%) for uncomplicated acute respiratory tract infection (ARI) diagnoses. (a) Observed monthly percentage of antibiotic prescribing was calculated for the whole cohort (overall) for the whole study period and by facility dashboard access quartiles (no access, Q1–Q4) for the 18-month postimplementation period. The probability of antibiotics prescribed for each individual was predicted using the generalized estimating equation (GEE) model as described in the Methods. (b) Predicted monthly percentage of antibiotics prescribing was estimated as the mean of the predicted probabilities for the whole cohort (overall) for the whole study period and by the facility dashboard access quartiles (no access, Q1–Q4) for the 18-month postimplementation period.