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Boise Veteran Affairs Medical Center

Antimicrobial Prescribing Improvement in Patients with Acute Respiratory Infections through Pharmacist Intervention in the Ambulatory Care Setting

Jefferson G. Bohan, Pharm.D., BCPS; Lindsey M. Hunt, Pharm.D.; Robert McKie, M.D.; Karl Madaras-Kelly, Pharm.D., M.P.H.; ARI Campaign Implementation Team

Boise Veteran Affairs Medical Center, Boise, Idaho

The Centers for Disease Control and Prevention (CDC) estimates that 30-50% of all outpatient antimicrobial prescribing may be inappropriate with acute respiratory infections (ARIs) accounting for the most outpatient antimicrobial prescriptions.  In response, the CDC developed the “Get Smart: Know When Antibiotics Work” campaign, focusing on acute pharyngitis, acute bacterial rhinosinusitis, acute bronchitis, and nonspecific upper respiratory tract infection (URI-NOS).  Based on previous data from a local medication utilization evaluation (MUE) identifying poor documentation of ARI diagnostic criteria and inappropriate prescribing of antimicrobials, the antimicrobial stewardship program (ASP)  developed and implemented  a bundle of interventions (i.e., ARI Campaign) designed to improve management of ARIs during the 2015-2016 winter season.

The ARI Campaign utilized a multidisciplinary approach including the CDC proposed key elements of outpatient antimicrobial stewardship to improve ARI symptom documentation, diagnosis, and ordering of therapies. Behavioral intervention directed towards providers primarily located in the Emergency Department and Episodic Care clinics was also provided. Two intervention intensities were developed and implemented. The standard intervention elements, made available to all providers, included group-level provider education, patient education materials, and computer decision support in the form of “best practice” order menus through the facility’s electronic health record. The extensive intervention included individualized provider academic detailing with audit and feedback based on each provider’s prior ARI antimicrobial prescribing rates. Group-level feedback was also provided through a facility-wide Grand Rounds lecture and brief monthly reminder sessions in the clinics provided by the infectious diseases and ambulatory care pharmacists.

Overall, 687 ARI visits from 2014-2015 and 560 ARI visits from 2015-2016 were included in the analysis. Total antimicrobial prescribing for all ARIs decreased from 63.0% in 2014-2015 to 39.6% in 2015-2016 (P<0.01), an overall reduction of 23.4%.  Providers who received academic detailing with audit and feedback had an absolute reduction in ARI antimicrobial prescribing of 32.8% (P<0.01), while providers who received the standard intervention decreased by 10.9% (P=0.01).  Antimicrobial prescribing for acute pharyngitis, acute rhinosinusitis, acute bronchitis, and URI-NOS decreased by 23.4% (P<0.01), 2.2% (P=0.54), 30.4% (P<0.01), and 6.1% (P=0.10), respectively.  No significant difference was found with respect to 30-day respiratory-related return visits in the standard intervention compared to extensive intervention groups (12.2% vs 11.2%, P=0.48).

This innovative program highlights how pharmacists across multiple subspecialties can promote antimicrobial stewardship within their health-care facility and paves a new path expanding ASPs to the outpatient and ambulatory care settings.  Pharmacists were intimately involved throughout this process demonstrating the importance pharmacy plays in not only the outpatient primary care setting, but also in the setting of quality improvement.

Boise Veteran Affairs Medical Center

Boise Veteran Affairs Medical Center

Left to right: Josh Gerving, Robert McKie, Paul Black, Lindsey M. Hunt, Jefferson G. Bohan, Karl Madaras-Kelly, Garrett Smith, Sarah Naidoo, Tim Santos, Donovan Victorine, Robyn Cruz, Eileen Twomey