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Analysis

Intermountain, CDC Develop 4-Part Antibiotic Stewardship Initiative for Urgent Care

By Christopher Cheney  
   January 22, 2020

The CDC awarded a $1.8 million contract to Intermountain and the University of Utah to improve antibiotic stewardship at urgent care centers.

With funding from a federal contract, Salt Lake City–based Intermountain Healthcare is developing a four-part set of best practices for antibiotic stewardship in its urgent care clinics.

Urgent care centers are a growing segment of the healthcare sector, with the Urgent Care Association recently pegging the number of clinics nationwide at more than 9,000. In 2018, a Centers for Disease Control and Prevention-led research team published a study on antibiotic-inappropriate respiratory diagnoses at emergency departments, medical offices, retail clinics, and urgent care centers. The researchers found inappropriate antibiotics prescribing was highest at urgent care centers.

In October 2018, the CDC awarded a first-of-its-kind $1.8 million contract to Intermountain and the University of Utah designed to improve antibiotic stewardship at urgent care centers. A top goal is to develop a model for antibiotic stewardship at urgent care centers that other organizations and clinics can adopt across the country.

"Previous studies were conducted in one or two urgent care clinics—this is the first large-scale initiative with the CDC Core Elements for antibiotic stewardship in an urgent care network," says Edward Stenehjem, MD, MSc, medical director of antimicrobial stewardship at Intermountain.

Two factors were pivotal in the CDC accepting Intermountain's bid for the contract, he says. "One, we are a fully integrated health system, so all 39 urgent care clinics are on the same electronic health record, which allows us to capture data. Second, Intermountain is focused on what we call One Intermountain. So, if you present to a rural clinic or an urban clinic, you can get the same standard of care. We have a dedicated urgent care service line that can prioritize initiatives and make antibiotic stewardship a focus across our urgent care clinics."

In addition to following the CDC's request to incorporate the agency's core elements for outpatient antibiotic stewardship, Intermountain reports updates to the CDC every three months. The $1.8 million awarded in the contract is being used primarily to support project management, support the initiative's media and communications team, and support salaries for investigators and an urgent care physician champion.

University of Utah researchers are playing active roles in the initiative. For example, Adam Hersh, MD, PhD, is a pediatric infectious disease physician at the university who serves as the co-principal investigator on the contract with Stenehjem.

4-part antibiotic stewardship initiative

Intermountain has developed four interventions to improve antibiotics prescribing at all of the health system's urgent care clinics, which include Intermountain's urgent care telemedicine platform, Connect Care. The focus of the effort is on treatment of respiratory conditions.

1. Educating clinicians and patients. Intermountain is teaching antibiotics prescribing best practices to physicians, advanced practice practitioners, and patients.

"We are educating patients about when an antibiotic is needed, about delayed prescription, and about symptomatic therapy they can do for their conditions that are not antibiotics. For delayed prescription, a clinician may give patients an antibiotic prescription, but they are asked to wait three to five days to see whether they are getting any better. If patients are getting better, they don't take the medication," Stenehjem says.

2. Electronic health record (EHR) modifications. "We have made some modifications to our EHR to ensure that doing the right thing is also the easiest thing. We have made modifications to streamline the workflow and be able to nudge our providers to do the best thing for the patient," he says.

For example, when an antibiotic is necessary, the EHR helps make sure the antibiotic that is given is the right medication, in the right dose, and in the right duration, Stenehjem says. Order sentences were added to the EHR to help achieve all three prescribing goals.

3. Real-time antibiotic prescribing data. All urgent care clinicians are provided with fully transparent antibiotic prescribing data. "They can log on and look at a dashboard to see how they compare to their peers in their clinic and peers in other clinics across the state of Utah. It allows them to see whether they are a high prescriber compared to their peers or whether they are doing a good job. It also allows them to know areas where they can improve," Stenehjem says.

4. Media campaigns. Intermountain urgent care centers have in-clinic antibiotic stewardship signage in waiting rooms and exam rooms. "In addition, we are using traditional media and social media to try to reach patients and engage them, so when they see one of our physicians or advanced practice providers, the clinician is not the first to tell them about not needing an antibiotic," he says. 

Early results

Since launching the four-part initiative in July 2019, Intermountain has achieved significant results at its urgent care clinics, Stenehjem says. Respiratory antibiotic prescribing has been reduced by nearly 30%, and the health system estimates 10,000 antibiotic prescriptions have been avoided.

"That's a lot of antibiotics not going into our communities," he says.

The main metric for the initiative is antibiotic prescribing in respiratory patient encounters—any encounter that includes a respiratory condition whether it is pneumonia, sinusitis, bronchitis, or any other respiratory condition. Intermountain is looking at the percentage of those encounters that involve the prescribing of an antibiotic.

The health system purposely decided not to base data collection on ICD-10 codes, Stenehjem says. "We wanted to keep our primary metric broad because we know that there is incredible variation in the way clinicians code encounters, especially for respiratory encounters."

Studying respiratory condition prescribing is an ideal way to gauge antibiotic stewardship in the urgent care setting, he says. "Urgent care sees a relatively homogenous patient population—the severely ill patients go to emergency departments and urgent care sees lower acuity patients who are often presenting with coughs, colds, and flus. So, we can use a respiratory prescribing measure and look at variation across the health system's urgent care clinics."

Urgent concern

Improving antibiotics prescribing at urgent care clinics is a major front in the battle against antimicrobial resistance, Stenehjem says. "Urgent care clinics are increasing, and we don't have any oversight in terms of antibiotic prescribing in many of those centers. Most clinics are privately owned, and there are not strong incentives for privately owned clinics to prescribe antibiotics well."

The financial incentives at urgent care centers run counter to good antibiotic stewardship, he says. "Think about a private urgent care, where providers make money by fee for service. If a patient comes in and the clinician gives an antibiotic, they can bill at a higher level, which means higher reimbursement. If they give an antibiotic, the visit is often shorter, which means you can see more patients and bill more."

Last year, the Urgent Care Association (UCA) started an initiative to strengthen incentives for antibiotic stewardship at the country's urgent care centers. The Warrenville, Illinois–based trade association and the UCA-affiliated College of Urgent Care Medicine launched their Antibiotic Stewardship Commendation program, which recognizes urgent care organizations that follow best practices for antibiotics prescribing.

Patient experience at urgent care centers is also problematic for antibiotic stewardship, Stenehjem says. "There is a perception that when you give an antibiotic, patients are happier. So, you get a higher patient satisfaction score and better reviews on Google and Yelp. We are going to have to engage payers and others to incentivize antibiotic stewardship in the urgent care setting."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Since launching the initiative in July 2019, antibiotic prescribing at Intermountain Healthcare's urgent care clinics has been reduced nearly 30%.

Recent research found that inappropriate antibiotic prescribing at ambulatory settings is highest at urgent care centers.

"Most clinics are privately owned, and there are not strong incentives for privately owned clinics to prescribe antibiotics well," says the Intermountain medical director of antimicrobial stewardship.


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