Discontinuation of Audit and Feedback Reverses Benefits of an Outpatient Antimicrobial Stewardship Intervention
Background: We completed a successful outpatient antimicrobial stewardship intervention combining education with prescribing audit and feedback across a large, pediatric primary care network. The intervention significantly reduced broad-spectrum antibiotic prescribing in intervention sites relative to controls. To assess durability of this intervention, we followed antibiotic prescribing across intervention and control sites for 18 months after termination of clinician audit and feedback.
Methods: We conducted a cluster-randomized trial of outpatient antimicrobial stewardship within 18 community-based pediatric primary care practices using a common EHR. The intervention included clinician education with audit and feedback of antibiotic prescribing to children with sinusitis, streptococcal pharyngitis, and pneumonia. The primary outcome was broad-spectrum (off-guideline) antibiotic prescribing. Twelve months after initiating the intervention, we stopped providing antibiotic prescribing audit and feedback to providers in the intervention arm and extended our observation period for 18 months. Using a piecewise generalized linear model with knots at month 0 (intervention start) and 12 (end of audit and feedback), we modeled the trajectory of the log odds of prescribing between treatment and control practices standardized for patient-level covariates.
Results: There were 1,259,938 office visits by 185,868 unique patients to 180 clinicians at 18 practices during the 50-month study period. During the 12-month intervention, the overall proportion of antibiotic prescriptions that were broad-spectrum decreased from 26.8% to 14.3% in the intervention group and from 28.4% to 22.6% in control practices, which was a statistically significant difference in trajectories between groups (p=0.01). Following termination of audit and feedback, however, broad-spectrum antibiotic prescribing reverted to near baseline levels for both the intervention group (28%) and control group (30%) (Figure).
Conclusion: The initial benefits of an outpatient antimicrobial stewardship intervention were reversed after discontinuation of audit and feedback of clinician prescribing.
J. S. Gerber,
R. Localio, None
L. Bell, None
T. Zaoutis, Merck: Investigator, Research grant
Merck: Consultant, Consulting fee
Pfizer: Consultant, Consulting fee
Astellas: Consultant, Consulting fee