Novel Tool Supports Appropriate Outpatient Antimicrobial Use

A health system in North Carolina has turned its prescribing data into a visual tool to help reduce the inappropriate prescribing of antimicrobials in the outpatient setting.

Atrium Health — formerly Carolinas HealthCare System — launched its antibiotic prescribing dashboard in March 2018. The dashboard is part of a larger effort to reduce the prescribing of antimicrobials in outpatient settings by 20% over two years, said Erin Gentry, Clinical Pharmacy Manager for Atrium Health’s antimicrobial support network.

The dashboard displays data on antimicrobials prescribed for upper respiratory tract infections at more than 150 of the health system’s outpatient sites.

Gentry said the dashboard allows users to “look at their own prescribing rates and patterns, compare them to those of their peers, and see where they’re having success and where they may need to have to pay more attention to details.”

She said initial data from August indicated that the prescribing of antimicrobials at targeted practice sites was down by about 5 percent relative to baseline levels.

“We’ve seen a lot of improvement,” she said.

The dashboard is a flexible tool, updated monthly, that shows actual prescribing rates alongside evidence-based targets for prescribing. Users can view data by indication, medication, practice site, specialty, and other characteristics. Gentry said clinical practice leaders can print reports and share them with colleagues to help improve their facilities’ prescribing.

She said the dashboard is something clinicians asked for, and it was developed with their input and refined in response to their feedback. For example, she said, dashboard users requested that the tool display, for each targeted illness, the specific antimicrobials prescribed broken down by percentage.

Gentry said that function can help identify specific diagnoses, such as sinusitis or otitis media, that require extra attention from prescribers.

Gentry is a member of the dashboard working group, and she said pharmacists have also been part of a strategy team at Atrium Health that develops outpatient antimicrobial stewardship initiatives.

The stewardship effort is called the Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), an interprofessional collaborative that works with Atrium Health’s outpatient practice sites.

Gentry and her colleagues presented data on CHOSEN and the dashboard during a poster session in October at the Infectious Diseases Society of America’s 2018 IDWeek forum, held in San Francisco.

She said CHOSEN is an extension of Atrium Health’s “very robust inpatient stewardship program.”

To guide the development of the dashboard, the CHOSEN strategy team and analytics specialists identified outpatient diagnosis codes for upper respiratory tract infections that are associated with the inappropriate prescribing of antimicrobials. The team then determined prescribing rates for these conditions at Atrium Health’s urgent care centers and internal medicine, family medicine, and pediatric clinics.

An educational program was developed alongside the dashboard to teach clinicians at those sites how to use the tool and to provide resources to help improve prescribing practices.

Gentry said one of the gratifying parts of the dashboard project is that clinicians want to follow evidence-based prescribing practices and are eager to learn from the stewardship team.

“We had so much buy-in and support that the challenge was actually facing the sheer volume of requests ... to come out in person” to the clinical sites, she said. In addition to onsite visits, Gentry said, the stewardship team has held webinars to accommodate the demand for education and training.

She said obtaining and responding to feedback from clinicians about the dashboard has been critical to their support of the project.

“This isn’t something that providers are used to, this type of data,” she said. “So everyone is very excited about it.”

Gentry said CHOSEN’s approach to antimicrobial stewardship is based on the 2016 Centers for Disease Control and Prevention (CDC) publication Core Elements of Outpatient Antibiotic Stewardship.

CDC described the document as a framework for antimicrobial stewardship in outpatient settings where antimicrobials are routinely prescribed.

The document states that consultations with pharmacists who have expertise in antimicrobial use can be a valuable part of efforts to improve the appropriate prescribing of these medications.

[This news story appears in the March 15, 2019, issue of AJHP.]