DART QI learning intervention may be a solution

Introducing a distance learning intervention into pediatric practices can reduce unnecessary outpatient antibiotic prescribing for pediatric acute respiratory tract infection, researchers have found.

This intervention, which combined communication training, evidence-based antibiotic prescribing education, and individualized prescribing feedback, contributed to a 7% reduction in the probability of antibiotic prescribing for acute respiratory infection.

The study, led by Matthew P. Kronman, MD, MSCE, Seattle Children’s Hospital, Seattle, Washington, was published in Pediatrics.

A common clinical response to childhood acute respiratory tract infections (ARTIs) is antibiotic prescribing, which occurs at an annual rate of 421 prescriptions per 1,000 population and accounts for 70% of all antibiotics prescribed to ambulatory children. And, according to studies, approximately ⅓ of all antibiotic prescriptions for ARTIs are inappropriate and account for over 10 million potentially preventable prescriptions for children in the U.S., annually.

Kronman and colleagues have developed the Dialogue Around Respiratory Illness Treatment (DART) quality improvement (QI) program, consisting of evidence-based online tutorials, webinars, booster video vignette sessions, and individualized antibiotic prescribing feedback reports. In this study they evaluated the effectiveness of this intervention across 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University Health System.

Overall, 50 pediatricians and seven nurse practitioners participated in the trial, with the number of participating clinicians at each practice ranging from one to six.

The study included visits by children between the ages of 6 months and 11 years with a diagnosis of either acute otitis media, bronchitis, pharyngitis, sinusitis, or upper respiratory infection. Over the period of the trial (November 2015 to June 2018) there were 72,723 ARTI visits by 29,762 patients, with 46.2% of those patients having one ARTI visit, 21.5% having two visits, and 9611 32.3% having three or more.

Of the ARTI visits 39.5% involved antibiotic prescribing. Intention-to-treat analysis showed that with the intervention a 7% decrease in the probability of antibiotic prescribing for ARTI occurred overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90–0.96).

Kronman and colleagues also found that the DART QI intervention resulted in sustained reductions in antibiotic prescribing during viral ARTI visits (aRR 0.60 95% CI, 0.51–0.70), and second-line antibiotic prescribing for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50–0.87) and sinusitis (aRR 0.59; 95% CI, 0.44–0.77). The intervention did not result in sustained reductions in second-line antibiotic prescribing for acute otitis media (aRR 0.93; 95% CI, 0.83–1.03), nor in antibiotic prescribing for all pharyngitis visits (aRR 0.96; CI, 0.91–1.02).

The authors noted that if extrapolated on a national level, the 7% reduction in in prescribing for all ambulatory ARTI visits represents 1.5 million pediatric antibiotic prescriptions annually. “Providing online communication training and evidence-based antibiotic prescribing education in combination with individualized antibiotic prescribing feedback reports may help achieve national goals of reducing unnecessary outpatient antibiotic prescribing for children,” Kronman and colleagues concluded.

In a commentary accompanying the study, Rana F. Hamdy, MD, MPH, MSCE, Division of Infectious Diseases, Children’s National Hospital, Washington, DC, and Sophie E. Katz, MDc, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, suggested there are several reasons for inappropriate antibiotic prescribing in ambulatory pediatrics, including patient pressures and demand.

The DART QI intervention, they pointed out, highlights steps clinicians can take to improve communication between providers and families, particularly in cases where parents expect an antibiotic prescription, but clinicians don’t think one is warranted.

These steps include reviewing physical examination findings aloud and providing a clear diagnosis. “These 2 steps help to explain why antibiotics are not needed,” Hamdy and Katz wrote, adding that a third step — using positive treatment recommendations – will reassure parent that antibiotics are not needed if that message is combined with suggestions of how to make their children feel better. Finally, having a contingency plan available is more likely to put patients and parents at ease, and increase their satisfaction, in cases when antibiotics are not prescribed.

Research has shown that this kind of training is “effective in addressing parental pressures and demand and in leading to increased patient satisfaction as well as shorter patient encounter times,” they wrote.

  1. Introducing an adult distance learning intervention called DART QI into pediatric practices reduced overall antibiotic prescribing for pediatric acute respiratory tract infections.

  2. Implementing such a program on a broader scale could help meet the national goal of reducing unnecessary antibiotic prescribing.

Michael Bassett, Contributing Writer, BreakingMED™

None of the experts cited in this article had any disclosures.

Cat ID: 138

Topic ID: 85,138,730,138,192,653,152,155,195,924,925