Antibiotic Prescribing at CHOP: Primary Care
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Antibiotic Prescribing at CHOP: Primary Care
Jeffrey S. Gerber MD, PhD, MSCEDivision of Infectious Diseases
The Children’s Hospital of Philadelphia
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• Primary Care PediatricsBob Grundmeier, Alex Fiks, Mort Wasserman
• General PediatricsLou Bell, Ron Keren
• Pediatric Infectious DiseasesTheo Zaoutis, Priya Prasad, Jeff Gerber
• Biostatistics/data managementRussell Localio, Lihai Song
• PeRC AdministratorJim Massey
Study Team
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Agenda
1. Rationale for assessing antibiotic use2. Antibiotic prescribing data
• across-practice analyses• within-clinician analyses
3. Intervention
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Agenda
1. Rationale for assessing antibiotic use2. Antibiotic prescribing data
• across-practice analyses• within-clinician analyses
3. Intervention
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AHRQ Goal
To implement and evaluate evidence-based methods or strategies for reducing the inappropriate use of antibiotics in primary care office practices
• must address:1. conditions for which abx are not effective2. broad-spectrum antibiotic use when
narrow-spectrum antibiotics are indicated
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Background
• about half of antibiotic use is unnecessary• overuse well-documented in primary care• antibiotic overuse leads to:
bacterial resistance drug-related adverse events increases in health care costs
$20 billion estimated by IOM
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Antibiotic Resistance
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Resistance Aside. . .
• 5%–25% diarrhea• 1 in 1000 visit emergency department for
adverse effect of antibiotic– comparable to insulin, warfarin, and digoxin
• 1 in 4000 chance that an antibiotic will prevent serious complication from URI
Shehab N. CID 2008:47; Linder JA. CID 2008:47
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Antimicrobial Stewardship
• Antimicrobial Stewardship Programs recommended for hospitals
• most antibiotic use (and misuse) occurs in the outpatient setting
• is outpatient “stewardship” achievable?
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Agenda
1. Rationale for assessing antibiotic use2. Antibiotic prescribing data
• across-practice analyses• within-clinician analyses
3. Intervention
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Study Setting: CHOP Care Network
• 5 urban, academic
• 24 “private” practices
urban, suburban, rural
• common EHR
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Case Definitions
• ICD9 codes for common infections (+/- GAS testing, antibiotic use)verified by chart review and provider feedback
• Excluding:– antibiotic allergy– visit within prior 3 months with antibiotic– concurrent bacterial infection
• AOM, SSTI, UTI, lyme, acne, chronic sinusitis, mycoplasma, scarlet fever, animal bite, proph, oral infections, pertussis, STD, bone/joint
– complex chronic conditions (Feudtner, Pediatrics 2000)
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Broad-Spectrum Antibiotics
• amoxicillin-clavulanate• cephalosporins• azithromycin*
*not considered broad-spectrum therapy for pneumonia
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Table 1. Demographic characteristics of the study cohort, by site
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1,296,517 Encounters
51,421 narrow ABX
29,635 broad ABX
102,102 antibiotic Rx
8,204prior ABX
14,298 ABX allergy
399,793 sick visits
630,502 office visits
363,049 sick visits
230,709 preventive
666,015phone, refills
36,744 visits w/ CCC
260,947no antibiotics
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Antibiotic Prescribing for Sick Visits
Excluding: preventive visits, CCCStandardized by: age, sex, age-sex, race, Medicaid
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Antibiotic Prescribing: Std for ARTI Dx
Excluding: preventive visits, CCCStandardized by: age, sex, age-sex, race, Medicaid, ARTI Dx
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Broad Antibiotic Prescribing
Excluding: preventive visits, CCC, antibiotic allergy, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid
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Broad Antibiotics: Std ARTI Dx
Excluding: preventive visits, CCC, antibiotic allergy, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid, ARTI Dx
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Diagnosis rate of AOM
Excluding: preventive visits, CCC, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid
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Broad Antibiotics for AOM
Excluding: preventive visits, CCC, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid
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Broad Antibiotics for Sinusitis
Excluding: preventive visits, CCC, antibiotic allergy, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid
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Broad Antibiotics for GAS pharyngitis
Excluding: preventive visits, CCC, antibiotic allergy, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid
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Broad Antibiotics for Pneumonia
Excluding: preventive visits, CCC, antibiotic allergy, prior antibioticsStandardized by: age, sex, age-sex, race, Medicaid
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Summary of variability data
• antibiotic prescribing at sick visits varies significantly across practice sites
• broad-spectrum antibiotic prescribing at sick visits varies significantly across practice sites
• the rate of diagnosis of ARTIs varies significantly across practice sites
• adherence to prescribing guidelines for AOM, sinusitis, GAS pharyngitis, and pneumonia varies significantly across practice sites
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Agenda
1. Rationale for assessing antibiotic use2. Antibiotic prescribing data
• across-practice analyses• within-clinician analyses
3. Intervention
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Antibiotic Prescribing by Patient Race
• within clinician analyses of antibiotic prescribing and diagnoses in same cohort
• Excluding:– complex chronic conditions– preventive visits, asthma, (allergy, prior antibiotics)
• Adjusted for:– sex, age category (0-1; 1-5; 6-10; 11-18)– Medicaid, site
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Antibiotic Prescribing by Patient Race
OR (black) 95% CI Margins P-value0.764 0.738, 0.790 0.29, 0.24 <0.0001
Receipt of antibiotic prescription per SICK VISIT:
• Excluding: CCC, asthma
• Adjusted for: age category, sex, Medicaid
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Visit Rate by Patient Race
Sick visits per year by race:
Primary care Black Non-black
sick visits 1.2 2.0preventive visits 1.1 1.1
CHOP ED (5 practices) Black Non-black
all ED visits 0.57 0.63ED visits for ARTI 0.02 0.02
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Antibiotic Prescribing by Patient Race
IRR (black) 95% CI P-value0.64 0.63, 0.65 <0.0001
Receipt of antibiotic prescription per CHILD:
• Excluding: CCC
• Adjusted for: age category, sex, Medicaid
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Diagnosis by Patient Race
Diagnosis of various ARTIs:
condition OR 95% CI Margins P-valueAOM 0.767 0.735, 0.801 0.15, 0.12 <0.0001acute sinusitis 0.817 0.761, 0.877 0.06, 0.05 <0.0001GAS pharyngitis 0.623 0.576, 0.674 0.05, 0.03 <0.0001pneumonia 1.058 0.963, 1.163 0.02, 0.02 0.235UTI 0.985 0.903, 1.074 0.02, 0.02 0.733
• Excluding: CCC, asthma
• Adjusted for: age category, sex, Medicaid
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Antibiotic Prescribing by Patient Race
OR 95% CI Margins P-value0.834 0.781, 0.891 0.36, 0.32 <0.0001
Receipt of broad-spectrum antibiotic (if any antibiotic prescribed)
• Excluding: CCC, asthma, allergy
• Adjusted for: age category, sex, Medicaid
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Antibiotic Prescribing by Patient Race
Receipt of broad antibiotics for ARTI:condition OR 95% CI Margins P-valueAOM 0.737 0.662,
0.8210.38, 0.31 <0.0001
GAS pharyngitis 0.849 0.569, 1.266
0.08, 0.07 0.421
sinusitis 0.947 0.814, 1.102
0.44, 0.43 0.483
pneumonia 1.003 0.712, 1.412
0.17, 0.17 0.988
• Excluding: CCC, asthma, allergy
• Adjusted for: age category, sex, Medicaid
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Summary of race data
• black children receive fewer antibiotic prescriptions per sick visit and per child than non-black children
• black children are diagnosed with less ARTI than non-black children
• when diagnosed with AOM, black children receive more appropriate (i.e. less broad-spectrum) antibiotics
• black children have less sick visits than non-black children (but equal number of well visits)
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Why?
• confounding?• difference in epidemiology of disease,
including BOTH prevalence and severity of illness linked with race?
• parental expectations/pressure linked with race?
• perception of parental expectations/pressure linked with race?
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Agenda
1. Rationale for assessing antibiotic use2. Antibiotic prescribing data
• across-practice analyses• within-clinician analyses
3. Intervention
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Specific Aim
• To determine the impact of an outpatient antimicrobial stewardship bundle within a pediatric primary care network on antibiotic prescribing for common ARTI:1. Antibiotic prescribing for viral infections2. Broad-spectrum antibiotic prescribing for conditions
for which narrow-spectrum antibiotics are indicated.
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Study Design
• cluster-randomized controlled trial• bundled intervention vs. no intervention• unit of observation will be the practitioner
but randomized at practice level– natural distribution of physicians– avoids intra-practice contamination
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Intervention
1. guideline development2. education3. audit and feedback
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Why Might Unnecessary Prescribing Occur?
Prescribing Awareness
Antibiotic Prescribing
Parental Expectations
Knowledge Gaps
Diagnostic Challenges
Time Constraints
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Parental Expectations
Diagnostic Challenges
Time Constraints
Knowledge Gaps
Prescribing Awareness
Why Might Unnecessary Prescribing Occur?
Antibiotic Prescribing
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Hypotheses
1. clinicians have incomplete knowledge of the data regarding the effectiveness of antibiotics for respiratory tract infections
GAS and broad spectrum antibiotics antibiotic activity against pneumococcus prevention of bacterial superinfection role of moraxella and Hflu in disease
2. clinicians are unaware of/have not been presented with data regarding their own prescribing of antibiotics
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Education
• on site, interactive sessions for each practice randomized to the intervention– present the purpose of the study– discuss guideline development/contents– instruct how to access guidelines– explain audit & feedback– present baseline data– gather feedback
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Guidelines
• review AAP and Red Book guidelines• pediatric primary care/ID/clinical pharmacy• modified if necessary• generate benchmarks
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GAS: Rationale for penicillin/amox
• GAS resistance to pcn has NEVER been seen • azithromycin and cephalosporins
have NOT been shown to be superior for pharyngitis or for prevention of sequelae
data does not support increased patient compliance over oral penicillin or amoxicillin.
exposure promotes resistance to these and other antibiotics.
AAP/Red Book endorsed
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Guideline Access
• email (pdf)• EPIC link:
linked to chief complaint NOT decision support optional no workflow interruption
PARTI
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Study Setting: CHOP Care Network
5 urban, academic
24 “private” practices urban suburban rural
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VIRALcommon coldURIacute bronchitistonsillitispharyngitis (non-strep)
Outcomes
no antibiotics
BACTERIALacute sinusitisStrep pharyngitispneumonia
penicillin/amoxicillin
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Case Definitions
• ICD9 codes for common infections (+/- GAS testing, antibiotic use)verified by chart review and provider feedback
• Excluding:– antibiotic allergy– visit within prior 3 months with antibiotic– concurrent bacterial infection
• AOM, SSTI, UTI, lyme, acne, chronic sinusitis, mycoplasma, scarlet fever, animal bite, proph, oral infections, pertussis, STD, bone/joint
– children with complex chronic diseases
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Data Collection
• EPIC EMR• ICD9 coding
– diagnoses– chronic medical conditions
• antibiotic orders• telephone encounters• age, race/ethnicity, sex, insurance, allergies• provider: degree, yr grad, sex, % effort, practice
volume, support staff
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Analysis/Sample Size
• descriptive analysis of changes within and among sites.
• multivariable repeated measures analysis using generalized linear models
• 140 clinicians; 70 each arm• power > 0.9 to detect 10% improvement in
prescribing
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Randomization
• 22 of 24 Enrolled (18 “sites”)• 143,254 patients; 512,943 encounters
– 49.5% female– 69% White
• each site enumerated by location and volume• block-randomized 9 sites to each arm
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Intervention: Timeline
12 months ofaudit/feedback
12 months afterfeedback ends
12 monthsbaseline data
Site presentation
Feedback reports
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**
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Some Limitations
• ICD9 codes– misclassification of outcome– intervention may change coding
• contamination of intervention• lack of “buy-in” by practitioners• generalizability
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Future Directions
• complete analysis• assess durability of effect (if there is one)• gather qualitative data from providers
• predictors of prescribing• clinical pathways/decision support?