Antibiotic Prescribing at CHOP: Primary Care

Antibiotic Prescribing at CHOP: Primary Care Jeffrey S. Gerber MD, PhD, MSCE Division of Infectious Diseases The Children’s Hospital of Philadelphia

Study Team • Primary Care Pediatrics Bob Grundmeier, Alex Fiks, Mort Wasserman • General Pediatrics Lou Bell, Ron Keren • Pediatric Infectious Diseases Theo Zaoutis, Priya Prasad, Jeff Gerber • Biostatistics/data management Russell Localio, LihaiSong • PeRC Administrator Jim Massey

Agenda • Rationale for assessing antibiotic use • Antibiotic prescribing data • across-practice analyses • within-clinician analyses • Intervention

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: • conditions for which abx are not effective • broad-spectrum antibiotic use when narrow-spectrum antibiotics are indicated

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

Antibiotic Resistance

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

Antimicrobial Stewardship • Antimicrobial Stewardship Programs recommended for hospitals • most antibiotic use (and misuse) occurs in the outpatient setting • is outpatient “stewardship” achievable?

Study Setting: CHOP Care Network • 5 urban, academic • 24 “private”practices • urban, suburban, rural • common EHR

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)

Broad-Spectrum Antibiotics • amoxicillin-clavulanate • cephalosporins • azithromycin* *not considered broad-spectrum therapy for pneumonia

Table 1. Demographic characteristics of the study cohort, by site

1,296,517 Encounters 666,015 phone, refills 230,709 preventive 630,502 office visits 399,793 sick visits 36,744 visits w/ CCC 363,049 sick visits 260,947 no antibiotics 8,204 prior ABX 102,102 antibiotic Rx 14,298 ABX allergy 51,421 narrow ABX 29,635 broad ABX

Antibiotic Prescribing for Sick Visits Excluding: preventive visits, CCC Standardized by: age, sex, age-sex, race, Medicaid

Antibiotic Prescribing: Std for ARTI Dx Excluding: preventive visits, CCC Standardized by: age, sex, age-sex, race, Medicaid, ARTI Dx

Broad Antibiotic Prescribing Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid

Broad Antibiotics: Std ARTI Dx Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid, ARTI Dx

Diagnosis rate of AOM Excluding: preventive visits, CCC, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid

Broad Antibiotics for AOM Excluding: preventive visits, CCC, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid

Broad Antibiotics for Sinusitis Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid

Broad Antibiotics for GAS pharyngitis Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid

Broad Antibiotics for Pneumonia Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics Standardized by: age, sex, age-sex, race, Medicaid

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

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

Antibiotic Prescribing by Patient Race Receipt of antibiotic prescription per SICK VISIT: • Excluding: CCC, asthma • Adjusted for: age category, sex, Medicaid

Visit Rate by Patient Race Sick visits per year by race:

Antibiotic Prescribing by Patient Race Receipt of antibiotic prescription per CHILD: • Excluding: CCC • Adjusted for: age category, sex, Medicaid

Diagnosis by Patient Race Diagnosis of various ARTIs: • Excluding: CCC, asthma • Adjusted for: age category, sex, Medicaid

Antibiotic Prescribing by Patient Race Receipt of broad-spectrum antibiotic (if any antibiotic prescribed) • Excluding: CCC, asthma, allergy • Adjusted for: age category, sex, Medicaid

Antibiotic Prescribing by Patient Race Receipt of broad antibiotics for ARTI: • Excluding: CCC, asthma, allergy • Adjusted for: age category, sex, Medicaid

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)

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?

Specific Aim • To determine the impact of an outpatient antimicrobial stewardship bundle within a pediatric primary care network on antibiotic prescribing for common ARTI: • Antibiotic prescribing for viral infections • Broad-spectrum antibiotic prescribing for conditions for which narrow-spectrum antibiotics are indicated.

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

Intervention • guideline development • education • audit and feedback

Why Might Unnecessary Prescribing Occur? Parental Expectations Antibiotic Prescribing Diagnostic Challenges Time Constraints Knowledge Gaps Prescribing Awareness

Hypotheses • 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 • clinicians are unaware of/have not been presented with data regarding their own prescribing of antibiotics

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

Guidelines • review AAP and Red Book guidelines • pediatric primary care/ID/clinical pharmacy • modified if necessary • generate benchmarks

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

Guideline Access • email (pdf) • EPIC link: • linked to chief complaint • NOT decision support • optional • no workflow interruption PARTI

Study Setting: CHOP Care Network • 5 urban, academic • 24 “private” practices • urban • suburban • rural

Outcomes VIRAL common cold URI acute bronchitis tonsillitis pharyngitis (non-strep) no antibiotics BACTERIAL acute sinusitis Strep pharyngitis pneumonia penicillin/amoxicillin

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

Antibiotic Prescribing at CHOP: Primary Care