Tracking Physicians' Prescribing Habits Reduces Antibiotic Overuse

Study results presented at IDWeek 2012 show that education and prescription monitoring can cut inappropriate antibiotic prescribing for respiratory infections in half.

Doctors used antibiotics to treat children with common ailments less often when their prescribing patterns were monitored and they received quarterly updates on best practice guidelines, according to a cluster-randomized trial that looked at antibiotic overuse in a large pediatric network.

Clinical education, quarterly monitoring, and feedback on prescribing patterns for treatment of common acute respiratory infections reduced by nearly half the practice of inappropriate antibiotic prescriptions outside of recommended guidelines, said lead researcher Jeffrey Gerber, MD, assistant professor of pediatrics at Children's Hospital of Philadelphia, who presented the findings during a press conference at IDWeek 2012 in San Diego.

The gathering is the first joint annual meeting of the Infectious Diseases Society of America (ISDSA), Society for Healthcare Epidemiology of America (SHEA), HIV Medicine Association (HIVMA), and Pediatric Infectious Diseases Society (PIDS).

Gerber and his colleagues accessed data from 29 practices in a Children’s Hospital of Philadelphia-affiliated primary care network and ultimately tracked a subgroup of 18 practices. The crux of the study, which looked at three common respiratory tract infections in children, used electronic health records to audit prescribing habits and give confidential feedback to the participating practices. “They were private; nobody could see except the individual prescriber and it showed how they were prescribing relative to national guidelines,” Gerber said.

While hospitals have curbed overuse of antibiotics, it is clinicians in the community who write the majority of prescriptions, often for children with common ailments, according to Gerber. So the best way to attack the problem is to intervene in those outpatient settings, he said.

Monitoring antibiotic use is important because it helps ensure that kids get the right drug to treat their infections appropriately at the right time, said Gerber. It is also a safeguard against giving them drugs they don’t need, which could lead to negative adverse effects and contribute to drug resistance and the creation of untreatable organisms.

When the study began, the first records review of practices revealed that some prescribed as they should but others prescribed a lot of broad-spectrum antibiotics for some conditions that called for a narrow spectrum. “Establishing that, we wanted to figure out how we could improve this prescribing,” said Gerber.

The study randomly divided the 18 practices that tended to prescribe broad-spectrum antibiotics into two groups, intervention and control, based on practice location and patient volume, and tracked prescriptions through electronic records. The intervention sites were given an hour-long refresher on the latest prescribing guidelines and were monitored quarterly and given feedback based on guidelines for prescribing antibiotics for sinusitis, Group A strep throat, and pneumonia. The control group was told only that the study had begun.

Researchers excluded from the review children with chronic medical conditions, antibiotic allergies and those who had taken antibiotics in the previous three months. They compared prescribing rates of antibiotics between intervention and control sites before and after the intervention. Among the 18 practices that participated in the study, there were 1,435,605 office visits by 185,212 patients to 174 clinicians during the study period.

Early on, data indicated that 28% of all children were inappropriately prescribed a broad-spectrum antibiotic for a targeted condition. However, 12 months after the intervention the rate of off-guideline antibiotic prescribing had a statistically significant decrease, dropping from 32% to 17%. The control group dropped from 33% to 24%, Gerber said.The sharpest drop was in antibiotics inappropriately prescribed for pneumonia, which dropped from 16% to 4%.

Gerber said many doctors go about their work without ever knowing what percentages of any given medication they prescribe. He said this study, which he believes can be scaled to other populations, shows that electronic health records can be used in a relatively simple way to track and improve prescribing.The next step will be to test the study’s staying power to see if the practices continue to stick closer to guidelines or return to past habits, said Gerber.