KP Washington reduces use of antibiotics for upper respiratory infections

Dr. Angie Sparks describes key strategies of peer-comparison reporting and leaders supporting a learning community

by Angie Sparks, MD, Kaiser Permanente Washington family physician and Medical Director, Clinical Knowledge Development & Support for Kaiser Permanente Washington’s Clinical Improvement and Prevention team

Health care should help our patients become healthier. But some tests, treatments, and procedures do more harm than good. That’s why we at Kaiser Permanente Washington have been partnering with Choosing Wisely to reduce low value tests and treatments that are unnecessary in most cases and can cause harm. Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation in partnership with Consumer Reports to advance a national dialogue on avoiding wasteful or unnecessary health care.

We’re proud that as part of this effort we’ve helped to cut the proportion of our visits for upper respiratory infections (URIs) that lead to prescribing antibiotics. The overuse of antibiotics for viral URI is a national problem. In the United States, antibiotics are prescribed for URI about 40 million times each year, and there is wide regional variation in prescribing rates. We’ve helped Kaiser Permanente Washington clinicians reduce their prescribing rates from 37 percent to 27 percent. We are approaching our goal for 2018 of less than 20 percent.

To achieve this, we took many actions. These are the ones that have been most effective:

• We gave our clinicians monthly reports on their performance, with comparison to their peers.
• Our leadership made presentations to our clinicians. In addition to providing support for providers with high rates, they have also celebrated successes and recognized those with excellent antibiotic stewardship practices.
• Our clinicians participated in continuing medical education sessions (CME) on this topic.
• We also helped update the technical specifications for the Washington state metric to the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 and incorporated Kaiser Permanente Washington provider feedback to improve data capture. Interventions elsewhere have led to some “diagnostic drift” (changing diagnoses from viral URI to sinusitis, for example). To avoid this practice, the Washington state metric includes sinusitis as a URI.

Transparent data sharing helps each clinician know how they compare to the rest of the group in prescribing rate and who can help them improve their practice. At baseline, peer-comparison reporting showed wide variations between providers, in their antibiotic prescribing rates for URIs, even within the same clinic office.

We found that antibiotic ordering for URI decreased (approaching goal) in our retail, urgent care, and primary care medical offices. Clinicians are eager to improve — and recognize their role in reducing low-value care. Communicating with patients about low-value care is an important skill for all providers. And our leaders are supporting this learning community.

Other efforts, and why they matter

Many people throughout Kaiser Permanente are working to reduce antibiotic over-prescription. For instance, Adam Sharp, MD, MS, and colleagues at the Kaiser Permanente Department of Research & Evaluation in Southern California recently published “Improving Antibiotic Stewardship: A Stepped-Wedge Cluster Randomized Trial” in the American Journal of Managed Care. Dr. Sharp also works as an emergency department physician at the Kaiser Permanente Los Angeles Medical Center.

In an effort similar to our own at Kaiser Permanente Washington, they reduced the odds of prescribing an antibiotic for sinusitis by 22 percent through physician education and intervention, including computer alerts to inform doctors when antibiotics may not be the best course of treatment.

This work matters because it means fewer prescriptions for medications that patients don’t need. Because viruses cause most URIs, antibiotics (which kill bacteria) don’t help. Antibiotics can cause side effects and make more bacteria resistant to antibiotics. URI is common and occurs 2 to 3 times a year for adults and up to 8 to 12 times a year for children. Because of this, overuse of costly treatments and visits as well as side effects caused by those treatments can really add up.

The bottom line?

In 2016, we avoided about 3,800 unneeded antibiotic prescriptions ($12,000) and 1,600 outpatient visits ($270,400). We estimate this resulted in avoiding approximately:

• 950 diarrhea cases;
• 760 skin reactions;
• 4 emergency department visits; and
• 1 anaphylactic reaction.

Even more importantly, our work helps curb the spread of antibiotic-resistant bacteria. Reducing low-value care such as this helps us be able to give more people the high-value care that they need.

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