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Sustained feedback to doctors may help maintain appropriate antibiotic usage in children

CHOP experts: Benefits may fade after end of audit and feedback to clinicians

Children's Hospital of Philadelphia

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IMAGE: Jeffrey S. Gerber, M.D., Ph.D., is an infectious diseases specialist at The Children's Hospital of Philadelphia. view more

Credit: The Children's Hospital of Philadelphia

A program that provides guidance to primary care physicians about appropriately prescribing antibiotics for children is effective, but its improvements wear off after regular auditing and feedback are discontinued.

"Our findings suggest that interventions with outpatient healthcare providers should include continued feedback to clinicians to remain effective," said study leader Jeffrey S. Gerber, M.D., Ph.D., an infectious diseases specialist at The Children's Hospital of Philadelphia (CHOP).

Gerber and colleagues from CHOP published their research online Oct. 10 in the Journal of the American Medical Association and presented their findings the same day at the IDWeek 2014 meeting in Philadelphia. IDWeek is an annual meeting of infectious diseases specialists.

Because disease-causing microorganisms have been developing resistance to commonly used antibiotics, public health experts advocate more selective usage of those medications. The "antimicrobial stewardship" program in the current study included prospective audits of prescription patterns--evaluating prescriptions based on current prescribing guidelines for specific conditions issued by professional organizations. The program staff then provided personalized, private feedback reports to the practitioners, advising them whether their prescriptions followed current recommendations.

The study team analyzed electronic health records of 1.2 million office visits at 18 community-based primary care offices within the CHOP pediatric network, focusing on prescriptions for common bacterial respiratory infections in children. The researchers randomized the 18 practices into two groups--one receiving the intervention (an hour-long session of clinician education, followed by audit and feedback) and the other group receiving no intervention.

The researchers previously reported in June 2013 that inappropriate prescribing decreased significantly in the intervention group, from 26.8 percent to 14.3 percent, compared to a decrease from 28.4 percent to 22.6 percent in the control group.

Because the previous study covered a 12-month intervention period, the current study evaluated the durability of the effects. The team followed antibiotic prescription patterns for 18 months after the auditing and feedback ended.

Prescribing of broad-spectrum antibiotics, which according to guidelines are typically reserved as second-line treatments, increased over the extended time period, reverting to above-baseline levels. After adjusting the data set for the additional 18 months after intervention ended, the study team found inappropriate prescribing rose from 16.7 percent to 27.9 percent in the intervention group, and from 25.4 percent to 30.2 percent in controls.

"Our results suggest that audit and feedback were crucial parts of this intervention," said Gerber, who added, "For the initial benefits of this program to persist, there needs to be continued, active feedback to the clinicians in primary care offices."

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The U.S. Agency for Health Care Research and Quality supported this study (contract HHSA290020070013).

Gerber et al, "Durability of Benefits of an Outpatient Antimicrobial Stewardship Intervention After Discontinuation of Audit and Feedback," JAMA, published online Oct. 10, 2014.

About The Children's Hospital of Philadelphia: The Children's Hospital of Philadelphia was founded in 1855 as the nation's first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program receives the highest amount of National Institutes of Health funding among all U.S. children's hospitals. In addition, its unique family-centered care and public service programs have brought the 535-bed hospital recognition as a leading advocate for children and adolescents. For more information, visit http://www.chop.edu.

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