Multi-centered Evaluation of an Acute Respiratory Tract Infection Audit-Feedback Intervention: Impact on Antibiotic Prescribing Rates and Patient Outcomes

Background: Audit-feedback of antibiotic prescribing rates for acute respiratory infections (ARIs) is a promising approach to reduce antibiotic use; however, the generalizability and sustainability are unknown. We describe an audit-feedback intervention and outcomes across multiple seasons in different clinic settings.

Methods: Two VA Medical Centers distributed audit-feedback reports targeting providers with frequent ARI visits in emergency department (ED) and primary care (PC) during 2015-16 and 2016-17. An academic detailing visit delivered by local peers accompanied the initial audit-feedback report. The intervention was expanded to ED and PC clinics (n=10) in three other VA facilities in 2017-18. Outcomes included rates of antibiotics prescribed, recurrent visits for ARIs within 30 days, and adverse events. We assessed intervention sustainability in initiating VAs, and intervention generalizability in expansion VAs. Mixed-effect logistic regression models were used to assess intervention effect on antibiotic prescribing and outcomes.

Results: Antibiotic prescribing for uncomplicated ARI visits (n=7814) declined from 53.8% to 27.9% post intervention. The intervention was associated with a reduction in odds of prescribing antibiotics in initiating facilities (Odds Ratio [OR] 0.6 (95% CI 0.3, 0.9), which declined further with an annual OR 0.8 [95% CI 0.7, 1.1] per year. Preliminary 6-month post-intervention results were available from pilot clinics (n=3) within two of the expansion VAs, which indicated similar effectiveness (OR 0.5 [0.4, 0.7]). Recurrent visits for ARIs (8.2% vs. 8.6%, p=0.14) and adverse events (2.3% vs. 2.1%, p=0.90) were not different pre/post intervention. Receipt of an antibiotic was not associated with recurrent visits for ARI (8.6% vs. 8.0%, p=0.45) or adverse events (1.9% vs. 1.7%, p=0.11).

Conclusion: An audit-feedback intervention sustained a reduction in antibiotic prescribing for ARIs over three years, and resulted in similar reductions in antibiotic use in varied ED and PC settings without affecting ARI-related return visit rates.