Antibiotic resistance related to the misuse and overuse of antibiotics has emerged as a growing public health concern, with at least 2 million people infected with resistant bacteria each year. To date, most efforts to promote more judicious use of antibiotics have been based in the inpatient hospital setting, aimed at preventing hospital-acquired infections such as Clostridium difficile (C. difficile). But with more than half of the antibiotics prescribed in outpatient facilities unnecessary, addressing antibiotic misuse and overuse in those settings is critical. The Centers for Disease Control and Prevention has highlighted this need with an array of online resources for providers and consumers, and in March 2015 the Obama administration’s National Action Plan challenged providers to halve inappropriate antibiotic use in outpatient settings by 2020.

There’s good reason to bring concerted efforts to this new arena: recent evidence suggests that a modest reduction of just 10 percent in adult outpatient antibiotic prescribing can yield a 17 percent decrease in community-acquired C. difficile rates. That’s why United Hospital Fund (UHF) has launched the Outpatient Antibiotic Stewardship Initiative as part of our quality improvement and capacity-building—as well as grant-making—efforts.

Collaboratives Breed Success

Improving the quality of care has been a philanthropic and programmatic priority of UHF over the past ten years. UHF, in partnership with the Greater New York Hospital Association, has supported and guided efforts to engage clinicians in inpatient settings in quality improvement activities aimed at reducing hospital-acquired infections. More than eighty hospitals across the New York metropolitan region have been participants in these learning and information-sharing collaboratives.

The results have been important, including a 54 percent decrease in central line-associated bloodstream infections among thirty-six hospitals and a 19 percent decrease in hospital-acquired C. difficile among thirty-three hospitals. In each of these efforts, hospital-based clinicians came together to implement evidence-based interventions known to reduce these specific infections, and they shared best practices, lessons learned, and useful tools and strategies as they embarked upon this work.

Our grants program always seeks to identify opportunities that move quality efforts to new ground, as well. Now, with care increasingly shifting away from inpatient to community settings, UHF has prioritized expanding our quality improvement initiatives to ambulatory care. There are distinct challenges in attempting to move such activities to outpatient settings, where there is much less of an infrastructure for quality improvement—despite the critical need to focus on that and to promote better alignment between inpatient and outpatient settings.

Given our history and successes, however, we think UHF is well-positioned to focus on this important challenge. Over the past several years, New York State has been a leader in the adoption of the patient-centered medical home model. UHF has been documenting this trend and is helping stakeholders address related policy and implementation challenges. We will capitalize on this knowledge in the quality work we pursue.

First Steps toward Change

UHF has awarded $310,180 to eight hospitals and health systems in diverse communities in and just outside New York City, to support efforts to better understand the primary factors affecting antibiotic prescribing practices and the challenges and barriers to more appropriate practice. Participating sites—twenty-four hospital-owned outpatient practices, including resident internal medicine clinics, family medicine clinics, and specialty clinics—will also identify and develop targeted plans to test interventions for improving antibiotic prescribing appropriateness.

All practice sites will focus on patterns of prescribing for adult patients with acute upper respiratory infections, a diagnosis with evidence of a high degree of inappropriate antibiotic use within outpatient settings. UHF will develop a set of structured instruments to collect antibiotic use data to inform participants’ quality improvement activities. Each of the sites will

  • Perform an internal investigation of its prescribing practices by conducting chart reviews of adult patients with acute upper respiratory infections, as well as key informant interviews with a variety of clinicians (physicians, nurse practitioners, physician assistants, pharmacists, and nurses) within the practice. These efforts will yield both quantitative and qualitative data and will identify drivers of the decisions that providers make in prescribing, antibiotic selection, dose, and length of time patients are on the medicine;
  • Evaluate current interventions to promote the judicious use of antibiotics by using a UHF-developed assessment tool;
  • Use the data collected to develop a comprehensive action plan to pilot test, implement, and evaluate an intervention for improving antibiotic use for the site’s adult patients with acute respiratory infections.

In addition to providing critical data about prescribing practices that will drive design of each participant’s intervention, these organized data collection and analysis activities will enhance outpatient providers’ quality improvement skills and lay the foundation for collaboration and interdisciplinary team involvement within participating outpatient settings. In keeping with the approach of past UHF grant initiatives, and with our view that bringing grantees together and using common tools maximizes the value of limited resources, the sites will all participate in a learning collaborative designed to drive internal improvements. A broad range of clinicians—including outpatient physicians and nurses, infectious disease physicians, clinical pharmacists, quality improvement personnel, and members of the hospital outpatient leadership team—will attend webinars and in-person meetings to share successes, challenges, ways to overcome barriers, and best practices.

At the end of the ten-month initiative, UHF will develop and broadly disseminate a comprehensive report containing aggregate results from the data collected, as well as overall findings and lessons learned from this effort. Each practice will also share its results internally and externally, to spread lessons learned beyond the twenty-four participating sites.

Antibiotic stewardship in any setting is complex, and there is no “one-size-fits-all” approach to implementation. Nevertheless, we hope that the UHF Outpatient Antibiotic Stewardship Initiative will lay the foundation for similar programs—in both outpatient practice sites and other ambulatory care settings—that can learn from our experiences.