Antibiotic stewardship to reduce inappropriate antibiotic prescribing in integrated academic health-system urgent care clinics.

OBJECTIVE: To develop and implement antibiotic stewardship activities in urgent care targeting non-antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patient satisfaction. PATIENTS AND SETTING: Patients and clinicians at the urgent care clinics of an integrated academic health system. INTERVENTION AND METHODS: The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits. RESULTS: From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, -22%; 95% confidence interval [CI], -23% to -22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (-28%; 95% CI, -28% to -27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (-20%; 95% CI, -20% to -20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction. CONCLUSIONS: Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non-antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians' antibiotic prescribing rates.

Measured Performance and Vaccine Administration After Decision Support and Office Workflow Changes for Influenza Vaccination.

Influenza vaccination is underused. We examined changes in vaccination following decision support and workflow changes in a cross-sectional analysis of three vaccination seasons among adult primary care patients from 21 practices. Interventions included clinical decision support changes to facilitate documentation; changes to rooming workflow for medical assistants and licensed practical nurses to promote vaccination, prepare orders, document care done elsewhere; and record patient refusals. We measured rates for a national vaccination performance measure and receipt of onsite vaccination. Approximately 120,000 patients were eligible each season. Performance on the quality measure increased each year (40.6% to 62.5% to 76.4%). Corresponding rates of onsite vaccination were 27.7%, 28.8%, and 31.5%. The adjusted odds ratio for onsite vaccination in the second season compared with the first was 0.94 (95% confidence interval [CI] 0.92, 0.96). Onsite vaccination was more likely in the third season compared with either previous season-adjusted odds ratio for third versus second 1.14 (95% CI, 1.12, 1.16) or adjusted odds ratio for third versus first 1.07 (95% CI 1.05-1.09). Sequential changes in decision support and patient rooming process workflows were associated with large improvements in measured performance and with a significant increase in clinic-administered influenza vaccination by the third season.