According to estimates from the Centers for Disease Control and Prevention (CDC), more than half of the antibiotics used in the U.S. are prescribed unnecessarily or used improperly. The more we use antibiotics, the more likely it is that bacteria will adapt to them. The result: antibiotic resistant infections, or “superbugs,” which cause millions of illnesses and tens of thousands of deaths each year.
To combat this growing health crisis, many hospitals have created programs aimed at reducing the use of broad-spectrum antibiotics (such as the Z-Pak). These drugs target a wide range of disease-causing bacteria, which means they have the potential to create many types of bacteria that are antibiotic resistant.
Narrow-spectrum antibiotics, like penicillin and amoxicillin, target only the bacteria known to cause a specific bacterial infection. Using these narrow-spectrum antibiotics whenever possible helps prevent the development of antibiotic resistance.
The Children’s Hospital of Philadelphia (CHOP) wanted to help battle superbugs in outpatient settings, too. To do so, CHOP implemented an outpatient antimicrobial stewardship program in its primary care network. It is the first hospital to initiate a program like this.
The goal of the initiative is to encourage pediatricians to use antimicrobials appropriately and rely more on narrow-spectrum options — which are recommended by national guidelines — than broad-spectrum antibiotics.
This extensive quality improvement project has resulted in nearly all practices in CHOP’s Care Network meeting or exceeding the quality standards set by CHOP leadership for antibiotic prescription rates.
Adapting research findings for sustainable quality improvement
The idea for the program was the result of research conducted in the CHOP Care Network in 2010 by pediatric infectious diseases specialist Jeffrey Gerber, MD, PhD. Through ongoing education and feedback about prescribing habits, his intervention changed prescribing behavior. Pediatricians were much more likely to follow the guidelines by prescribing a narrow-spectrum antibiotic.
After the education and feedback ended, however, many doctors reverted back to their old behaviors. Gerber’s method of intervention worked initially, but would need to be altered in order to achieve long-term change.
“When you look at data for how doctors treat patients, specifically infectious diseases, they’re all over the map, even for the most common stuff,” says Gerber. “When there are guidelines like we have for antibiotic use, which are based on the best available evidence, it’s important that we help doctors treat patients in this way that applies this standard.”
Gerber brought his research and a plan to improve prescription habits in CHOP’s Care Network to the Office of Clinical Quality Improvement (OCQI). The project was officially named the Outpatient Antimicrobial Stewardship Project, and a team was formed to run the initiative alongside Gerber. It includes Lisa Biggs, MD, associate chief medical officer of the Care Network; all of the primary care network’s regional medical directors, including Khoi Dang, MD; Kathy Filograna, MD; Vicky Scheid, MD; Scott Tomaine, DO; and Elizabeth Brooks as the project manager and improvement advisor. Together, with the expertise and support of OCQI, they kicked off their work in October 2014.
“Our review of prescription habits at all sites showed that there was huge variation,” says Brooks. “Because each pediatrician in the CHOP Care Network falls under the same leadership and there are recognized ‘best practice standards,’ we should generally make the same recommendations to patients. The goal was to minimize that variation, and get to a place where each provider was making the correct choices.”
The group decided to focus their efforts on four methods of intervention.
The first step was to ensure that all pediatricians were aware of the most recent guidelines for antibiotic prescription. “Guidelines are updated regularly, and there are multiple groups involved, from the AAP to the CDC,” says Gerber. “It’s challenging to stay on top of them, and really not surprising that awareness wasn’t penetrating.” The regional medical directors, led by Biggs, presented the CHOP-accepted guidelines to each practice in the network, and updated them on Gerber’s research and their goals for the project.
Performance tracking and feedback
It’s critical to support the education provided to pediatricians with data about their own prescribing habits. This is done monthly, using an application developed specifically for this quality improvement project by an informatics support group. The app pulls information from Epic, CHOP’s electronic medical record system, in real-time. It displays each provider’s data, showing him how he compares to his peers. The data includes all patients given an antibiotic dating back to 2012, and analyzes rates of guideline concordance by the provider.
Supporting the decision-making process
A third element of the intervention are tools being built into Epic to support the decision-making process while doctors are prescribing antibiotics. As a provider records a specific bacterial diagnosis and a prescription for an antibiotic in a patient’s electronic medical record, an alert fires automatically if the doctor attempts to prescribe an antibiotic that is inappropriate for the diagnosis. Providers will also be offered additional prescribing guidance in the antibiotic order sets they use routinely. This element of the project is expected to begin in May 2015.
Educational handouts and posters were developed for primary care waiting rooms to inform parents about the role of broad-spectrum antibiotics in the rise in antibiotic resistant bacteria. CHOP believes it’s important that families understand why their pediatrician is changing the way she prescribes antibiotics.
Implementing change network wide
The results of the project so far have been impressive. As of April 2015, nearly all CHOP practices and practitioners are meeting the percentage standards set for correct antibiotic prescribing. Comparing calendar year 2013 to the second quarter of 2015, the percentage of correct prescriptions increased significantly:
- Ear infections: 83% to 93%
- Sinusitis: 83% to 95%
- Strep throat: 92% to 96%
- Bacterial pneumonia: 66% to 90%
The project team plans to raise the bar on these standards, which will drive pediatricians in the network to perform even better in the years to come.
An added benefit of prescribing the correct antibiotic every time is cost savings for the payers and families. Broad-spectrum antibiotics are much more expensive and may cause more side effects than narrow-spectrum alternatives.
Filograna adds, “The Outpatient Antimicrobial Stewardship Project has shown that we can mobilize 30 practices to make significant improvements in prescribing narrow-spectrum antibiotics in a short period of time. For our team, the emphasis is that we're improving care for thousands of patients. As the biggest pediatric care network in the country, changes that we make can have an influence outside our organization.”
Next steps to influence change
The project team will soon be reaching out to urgent care locations in Philadelphia and the suburban regions to share the educational materials developed as part of the quality improvement project. “Patients are seen at these urgent care locations and prescribed broad-spectrum antibiotics inappropriately,” says Filograna. “Getting all providers to follow the latest guidelines is an important step in addressing the antibiotic resistance problem, and a great way for CHOP to expand the impact of this work.”