Quality Improvement Strategies for Antibiotic Prescribing

1. Quality Improvement Strategies for Antibiotic Prescribing Sumant Ranji, M.D. February 16, 2005

2. “Closing the Quality Gap” • Based on subject areas identified in 2003 IOM report, “Transforming Health Care Quality” • Identifying activities that increase the rate of use of practices that are known to be effective • Synthesis of QI strategies across diseases and topic areas

3. Definitions • Quality Gap: difference between observed processes/outcomes and those achievable based on current knowledge • Due to deficiency that could be addressed by health care system • Quality improvement strategy: any intervention aimed at reducing the quality gap for representative patients • Should attempt to improve care for broad group of patients • May involve patient-, provider-, or system-level changes • Quality improvement target: outcome/process/structure the strategy is intended to influence

4. Antibiotic prescribing: background • Majority of prescriptions in US are for acute respiratory infections (ARI’s) • 41 million prescriptions in 1998 • 55% of prescriptions for ARI’s are unnecessary • Successes and failures during 1990’s • Significant decline in prescribing overall • Especially among children • Inappropriate script rate still >40% for common conditions • Marked increase in use of broad-spectrum agents • Quinolones, macrolides, 2nd/3rd gen cephalosporins, others

5. Quality of prescribing • Quality Gap: • Unnecessary prescribing of antibiotics for non-bacterial illnesses • Unnecessary use of broad-spectrum antibiotics where narrow-spectrum agents are effective • Quality improvement target: • Rate of antibiotic prescribing for non-bacterial diseases • Frequency of use of broad-spectrum agents

6. Quality Improvement Strategies • Provider Education • Audit and Feedback • Provider Reminders • Facilitated relay of clinical data to providers • Patient Education • Patient self-management • Patient reminders • Organizational change • Financial and regulatory incentives

7. Theoretical Framework for ABX prescribing Clinician Factors -sociodemographics -training/specialty -knowledge -judgment and heuristics -perceived patient expectations Patient Factors -sociodemographics -past experiences -expressed expectations -reported symptoms -illness severity System Factors -practice setting -health plan features -visit and pharmacy copay -patient enabling systems -formularies/restrictions -pharmaceutical detailing Clinician's Decision to Prescribe Antibiotics Kleinman et al, 1999

8. Quality Improvement Strategies:Prescribing specific • Patient-directed: • Education • Self-management (delayed prescriptions) • Financial and regulatory incentives • Copayments • Providers • Education by different modalities • Audit and feedback of prescribing practices • Financial and regulatory incentives • Capitation, restricted formularies • Combinations of above strategies

9. Research questions • Which QI strategies reduce antibiotic prescribing for acute non-bacterial illnesses? • Are particular QI strategies more effective for certain target conditions? • Are these strategies safe for patients? • Effects on health services utilization, clinical outcomes, satisfaction • What are the consequences of these strategies for public health and the health care system? • Effects on antimicrobial resistance, costs of prescribing • Which QI strategies are most effective in improving the selection of recommended antibiotics? • Subtopics as above

10. Inclusion/Exclusion Criteria • Topic • Acute outpatient illnesses • Major contributor to problem • Different theoretical model for inpatient prescribing • Study design: • Evaluate a QI strategy • RCT, quasi-RCT, CBA, or ITS • Outcomes • Measurement of antibiotic prescribing (overall or selection) • Antimicrobial resistance, disease outcomes, costs of prescribing, health services utilization, satisfaction with care: only abstracted if study also measured prescribing

11. A priori hypotheses • Publication bias • Smaller, non-randomized trials will have greater effects • Effect of baseline prescribing rate • Studies done in populations where over-prescribing/poor selection is common will have greater effects • Targeting of specific diseases • Studies targeting prescribing for specific diseases will be more effective than those targeting a variety of conditions or general ABX prescribing • Multifaceted strategies • As with prior research, studies using multiple QI strategies will be more effective than those using a single strategy • Intensity of intervention • Studies using interventions repeated over time will be more effective

12. Search Strategy EPOC 537 citations Hand Search 12 citations 549 citations 382 title exclusions 167 articles 93 full text exclusions 54 articles (74 comparisons) ABX selection 25 articles (33 comparisons) ABX prescription 34 articles (41 comparisons)

13. Analysis • Measured outcomes • ABX prescribing: • % visits at which patient received ABX prescription • Prescriptions per person-year • Prescriptions per provider • ABX selection: • % of total prescriptions written for recommended agent • % compliance to clinical guideline for prescribing • Prescriptions for recommended/nonrecommended ABX per person • Prescriptions for recommended/nonrecommended ABX per provider

14. Analysis • Quantitative • N=31 for ABX prescribing, N=19 for ABX selection • Meta-regression: planned but failed… • Random effects meta-analysis • However, extreme heterogeneity (I2 >90%) • Median effects semi-quantitative analysis • Limitations: no weighting by sample size/variance • Necessitates stratified analyses • Does allow preservation of natural study units • Qualitative • N=10 for ABX prescribing, N=14 for ABX selection • Systematic review format, complementary to above

15. Key Findings(a work in progress) • Overall effectiveness of QI strategies • Possible benefit of self-management • Variable methodologic quality of studies • No benefit from more intense interventions • Possible benefit of multifaceted strategies

16. Results: studies suitable for quantitative analysis • ABX prescription (N=31) • 8 US, 23 non-US • 26 target prescribing for ARI’s • 18 RCT, 13 CBA • ABX selection (N=19) • 3 US, 16 non-US • 12 target choice for ARI, 7 for UTI • 7 RCT, 12 CBA

17. Study quality • Failure to properly document intervention • Rationale for study methodology not explained • Key study components described inadequately • Duration and intensity of intervention • Short follow-up • Minimal reporting of outcomes beyond prescribing • Failure to report key data • e.g. number of patients in study • Inappropriate statistical analyses • Unit of analysis errors • Lack of accounting for temporal trends in prescribing

18. Overall results • QI strategies overall beneficial • Prescribing: Median reduction of 9.0% (IQR -16.6% to -3.4%) in prescribing of ABX when not indicated • Selection: Median increase in prescribing of recommended ABX of 13.8% (IQR 4.6% - 19.7%)

19. Comparative effects on ABX prescribing

20. Comparative effects on ABX selection

21. Median effect on Prescribing Stratified by study size and design

22. Publication Bias • Larger effects among smaller trials • Less effect of study design type

23. Baseline prescribing rate • Prescribing studies: • Would expect that studies with high baseline prescribing rate may show larger effects • Not found in our sample, but skew issues • Selection studies: • Expect baseline low compliance to correlate with higher effects • Also not demonstrated

24. Targeting of specific diseases • Hypothesize that studies targeting prescribing for specific conditions may be more likely to show effects • Not found in our analysis for either prescribing or selection studies • Confounding by sample size?

25. Multifaceted strategies • Previous work (DM) did not reveal benefit for multifaceted strategies • Possible benefit in prescribing studies • Median effect -12.0% (IQR -16.0% to -1.7%) for multifaceted studies (N=15) • Median effect -8.8% (IQR -16.9% to -5.9%) for single-faceted studies (N=16) • Selection studies: single-faceted studies all provider education only; no difference seen

26. Repeated Interventions • Complicated by poor description of study details • No difference found for either prescribing or selection studies

27. Other outcomes • Antimicrobial resistance • Only assessed in 2 studies; both showed no effect, but short duration of followup • Health services utilization • Assessed in 6 studies in prescribing group • No increase in return visits, hospitalizations seen • ? Effect on duration of illness • Patient satisfaction • Assessed only in delayed prescribing studies (N=6) • No significant effect seen • Costs of prescribing • Assessed in 7 studies; 15-30% reductions seen, but in short-term (<6 months) only • Mostly non-US

28. Conclusions and Hypotheses • No clear benefit for any single QI strategy • Possible exception of patient self-management (delayed prescribing) • Poor quality of studies limits interpretation of results • However, overall trials are effective at reducing prescribing and improving selection • Future analyses: • Stratified analyses: effects of QI strategies in relation to sample size, baseline prescribing, study design, disease targeting, country • Preliminarily no major effects • Nonparametric (rank-sum) tests for differences between groups • Further attempts at meta-regression • Common outcome measure for dichotomous and continuous studies

29. Thanks • Stanford • Vandana Sundaram • Robyn Lewis • Kathy McDonald • Doug Owens • UCSF • Ralph Gonzales • Mike Steinman • Ottawa • Kaveh Shojania