Objective: To evaluate the comparative effectiveness of patient and provider education adapted for the acute care setting (adapted intervention) to an intervention with behavioral nudges and individual peer comparisons (enhanced intervention), on reducing inappropriate antibiotic use for ARI in EDs and UCCs.
Methods: Pragmatic, cluster randomized clinical trial conducted in three academic health systems (1 pediatric-only, 2 serving adults and children) that included five adult and pediatric EDs and 4 UCCs. Sites were block randomized by health system, and providers at each site assigned to receive the adapted or enhanced intervention. Implementation science strategies were employed to tailor interventions at each site. The main outcome was the proportion of antibiotic inappropriate ARI diagnosis visits that received an antibiotic. We estimated a hierarchical mixed effects logistic regression model for visits that occurred between November and February for 2016-2017 (baseline) and 2017-2018 (intervention), controlling for organization and provider fixed effects.
Results: Across all sites, there were 45,160 ARI visits among 534 providers, with overall antibiotic prescribing at 2.6%; the pediatric-only system had a lower baseline rate (1.6%) compared to the other 2 systems (5.0% and 7.1%), p<0.001). Despite the unusually low rate, we found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.6% to 1.4 % (odds ratio 0.52; 0.38-0.72). Reductions in prescribing between the two interventions were in the expected direction, but not significantly different (p<0.062).
Conclusion: Implementation of antimicrobial stewardship for ARI is feasible and effective in the ED and UCC settings. The enhanced behavioral nudging methods were not more effective in high-performance settings.
R. Mistry, None
J. Doctor, None
K. Fleming-Dutra, None
R. Fleischman, None
S. Gaona, None
A. Stahmer, None
L. May, None
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