Choosing Wisely interventions reduce overuse of antibiotics at safety-net hospitals

Key takeaways:

• Interventions at two safety-net hospitals led to a 17.2% absolute reduction in antibiotic prescribing for viral respiratory infections.
• The interventions were not associated with unintended negative effects.

Interventions based on Choosing Wisely guidelines significantly reduced rates of antibiotic prescriptions for acute respiratory tract infections at safety-net hospitals participating in a pay-for-performance program, researchers found.

“This has important implications for responsible antibiotic use for the tens of millions of patients served by U.S. safety net health systems each year, and also represents an important advancement in health equity by ensuring that our newest medical practices actually lead to improvements in health for all communities in the U.S.,” Richard K. Leuchter, MD, an internist at the University of California, Los Angeles (UCLA) Health, said in a press release.

According to Leuchter and colleagues, many interventions have demonstrated potential in curbing inappropriate antibiotic prescribing — which accounts for 25% to 50% of all U.S. antibiotic prescribing — but “few of these initiatives have been evaluated within safety-net systems.”

“This is concerning given that efficacy studies often translate poorly to safety-net systems, and quality improvement and pay-for-performance programs (eg, 30-day readmissions) have a history of unintentionally penalizing safety-net systems and worsening health care disparities,” they wrote in the American Journal of Managed Care.

Thus, the researchers conducted a nonrandomized trial evaluating five staggered interventions based on the American Board of Internal Medicine Foundation’s Choosing Wisely guidelines, an initiative aimed at reducing unnecessary treatment, at two academic safety-net hospitals in Los Angeles. The interventions were implemented in response to a statewide pay-for-performance program that California Medicaid launched in 2016 to reduce inappropriate antibiotics for acute bronchitis.

The interventions, which were implemented at different points between 2016 to 2018, consisted of clinician case-audit feedback, clinician education, suggested nonantibiotic alternatives for acute respiratory tract infections (ARTIs), the use of procalcitonin to determine antibiotic use and clinician commitment to not unnecessarily prescribe antibiotics.

Leuchter and colleagues examined changes in mean antibiotic prescribing rates and Healthcare Effectiveness Data and Information Set (HEDIS)-inappropriate prescribing. They also looked at five possible unintended effects: reductions in HEDIS-appropriate prescribing, diagnosis shifting, substation of antibiotics for steroids, increases in antibiotics for ARTI not targeted by the intervention’s measures and withholding of antibiotics.

The analysis included 3,583 patients with an ARTI who received treatment at LA General Medical Center (formally known as Los Angeles County + University of Southern California) and Olive View-UCLA hospitals.

After implementation, the researchers reported a 17.2% absolute reduction in total antibiotic prescribing for viral respiratory infections at the hospitals.

Overall, mean antibiotic prescribing rates for ARTIs following interventions decreased from:

• 35.9% to 22.9% (OR = 0.6; 95% CI, 0.39-0.93) at LA General; and
• 48.7% to 27.3% (OR = 0.81; 95% CI, 0.7-0.93) at Olive View-UCLA.

In addition, HEDIS-inappropriate prescribing rates decreased from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at Olive View-UCLA.

There was no significant change in HEDIS-inappropriate prescribing at LA General, “likely a reflection of limitations in using claims-based quality metrics,” Leuchter and colleagues wrote.

The researchers added that no unintended effects were recorded, and the findings “directly address the paucity of studies testing effectiveness of initiatives to reduce antibiotic prescribing for ARTIs among socioeconomically disadvantaged safety-net populations.”

“The effect sizes seen in our results were at the upper limit of those reported in successful multicomponent interventions and exceeded what are generally seen for single-component education/feedback interventions,” they wrote.

Ultimately, the lack of unintended outcomes suggests “that [pay-for-performance] initiatives can motivate interventions to safely reduce antibiotic prescribing within safety-net settings,” Leuchter and colleagues concluded.

References:

• “Choosing Wisely” interventions can reduce antibiotic overuse at safety-net hospitals, UCLA-led research suggests. https://www.uclahealth.org/news/choosing-wisely-interventions-can-reduce-antibiotic-overuse. Published June 12, 2023. Accessed June 20, 2023.
• Leuchter R, et al. Am J Manag Care. 2023; Volume 29; Issue 10.