Improving antimicrobial prescribing for upper respiratory infections in the emergency department: Implementation of peer comparison with behavioral feedback

Abstract

Objective: To reduce inappropriate antibiotic prescribing for acute respiratory infections (ARIs) by employing peer comparison with behavioral feedback in the emergency department (ED).

Design: A controlled before-and-after study.

Setting: The study was conducted in 5 adult EDs at teaching and community hospitals in a health system.

Patients: Adults presenting to the ED with a respiratory condition diagnosis code. Hospitalized patients and those with a diagnosis code for a non-respiratory condition for which antibiotics are or may be warranted were excluded.

Interventions: After a baseline period from January 2016 to March 2018, 3 EDs implemented a feedback intervention with peer comparison between April 2018 and December 2019 for attending physicians. Also, 2 EDs in the health system served as controls. Using interrupted time series analysis, the inappropriate ARI prescribing rate was calculated as the proportion of antibiotic-inappropriate ARI encounters with a prescription. Prescribing rates were also evaluated for all ARIs. Attending physicians at intervention sites received biannual e-mails with their inappropriate prescribing rate and had access to a dashboard that was updated daily showing their performance relative to their peers.

Results: Among 28,544 ARI encounters, the inappropriate prescribing rate remained stable at the control EDs between the 2 periods (23.0% and 23.8%). At the intervention sites, the inappropriate prescribing rate decreased significantly from 22.0% to 15.2%. Between periods, the overall ARI prescribing rate was 38.1% and 40.6% in the control group and 35.9% and 30.6% in the intervention group.

Conclusions: Behavioral feedback with peer comparison can be implemented effectively in the ED to reduce inappropriate prescribing for ARIs.

Fig. 1

Upper respiratory infection visits and prescribing rates for intervention and control emergency departments. The intervention was implemented in the intervention emergency departments in April 2018 (vertical dashed line). The number of upper respiratory infection (ARI) visits (A) is seasonal, reflecting the increased likelihood of respiratory infections in the winter. The overall ARI prescribing rate (B) generally tends to follow an inverse seasonal pattern, reflecting an increased likelihood to prescribe when the number of ARI visits are lower, whereas the inappropriate prescribing rate (C) has only minor fluctuations and does not seem particularly related to season.

Fig. 2

Interrupted time series regression analysis. The intervention was implemented in the intervention emergency departments in April 2018 (vertical dashed line).