Community-acquired pneumonia (CAP) is a common infection in children. Guidelines recommend amoxicillin as first line therapy for CAP, while macrolides are recommended for school-aged children with atypical pneumonia. Despite guidelines, antibiotic choice for CAP varies widely among providers. We aimed to determine the impact of outpatient audit and feedback to individual providers on adherence with published guidelines.
We conducted a randomized controlled trial of primary care clinicians in a multi-state primary care network from 8/2016-2/2017. Providers received baseline education. The intervention included personalized feedback from investigators at 1-month intervals on the providers management of a case of CAP identified by ICD-10-CM codes. Prescription counts of guideline-recommended antibiotic therapy were compared between groups by Pearsons chi-squared. Performance scores incorporating diagnostic and treatment decisions such as physical examination elements, antibiotics and medication dosing appropriate for a CAP encounter as defined by clinical practice guidelines were calculated for each encounter during study intervals.
Among the 43 providers, the majority were physicians (76% control, 86% intervention). There were no significant differences in work hours, years since board certification, sex or race between groups. 316 distinct cases of CAP were diagnosed (214 control; 102 intervention). In patients <5 years, there was no significant difference in prescription of amoxicillin between groups (61/103 (59.2%) control; 23/48 (47.9%) intervention, p=0.19). In patients ≥5 years, there was a significant difference in prescription of guideline recommended antibiotics of amoxicillin or azithromycin (81/103 (78.6%) control; 48/51 (94.1%) intervention, p<0.05). There was a small, but apparent upward trend in mean performance scores in the intervention group (Figure 1).
Personalized, scheduled audit and feedback in the outpatient setting had a small but measurable impact on improving physician adherence with guidelines. Audit and feedback alone is insufficient to substantially improve guideline adherence in the management of CAP and should be combined with other antimicrobial stewardship interventions.
L. Werk, None
M. C. Diaz, None
J. Franciosi, None
J. Dent, None
J. Hossain, None
J. Crutchfield Jr., None
T. Wysocki, None