Bang for the Buck: Lessons Learned from An Ambulatory Stewardship Pilot to Reduce Excess Antibiotic Prescribing for Adult Upper Respiratory Infections

Background: Upper respiratory infections (URIs) are a source of unnecessary antibiotic use in the US¹. To address antibiotic overuse in our clinics, we participated in a multi-phase stewardship collaborative established by the United Hospital Fund. We aimed to pilot stewardship policies for adult URIs at the Montefiore Medical Group (MMG) practices in Bronx, NY.

Methods: Phase 1: evaluation of provider use of ICD-10 codes for URIs generally not requiring antibiotics at target sites (TS) with random chart abstraction validation. Phase 2: implementation of stewardship interventions (Table 1). Prescribing patterns were evaluated using electronic health record data at the end of Phase 2 comparing TS (n=6; 2 resident clinics, 4 non-resident clinics) to the prior year and to non-target sites (NTS) (n=13).

Results: There were 6819 visits of interest from October 2017 to February 2018 within MMG. Top three codes utilized are shown in Figure 1. TS prescribing declined post-intervention and compared to NTS (Table 2). Non-resident TS participated in 4 interventions, and resident TS were involved in 2-3. Macrolides were the most utilized antibiotic class (Figure 2).

Conclusion: We attribute the decline in prescribing at TS to the collective impact of our stewardship activities. Stewardship team driven interventions had better uptake than provider-driven initiatives. We plan to continue activities with the highest uptake and feasibility. Long-term goals include development and integration of stewardship metrics into our outpatient quality structure.

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¹ Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother. 2014;69(1):234-40

Table 1: Phase 2 interventions and uptake

Interventions	Intended Clinic Uptake
Provider Lectures	5/5
Provider Report Card	6/6
Viral Prescription pad	0/5
Commitment Poster	5/6
Follow-up Phone Calls to Patients	0/2
Educational Email to Patients	4/4
In-office Video Session with Patients	1/1
Waiting Room Video	3/6

Table 2: Prescribing rates for top 3 URI ICD-10 codes

	Antibiotics prescribed (%)	p-value*
TS – Oct17-Feb18	435 (17%)	--
TS– Oct 16-Feb17	633 (25%)	<0.001
NTS– Oct17-Feb18	736 (25%)	<0.001

*comparing to Oct17-Feb18 TS; χ-square used