Appropriate use of antibiotics reduces resistance and protects patients from unnecessary harm. Important advances in antibiotic stewardship have been achieved in outpatient settings, but little is known about stewardship in the rapidly growing telehealth sector. The Centers for Disease Control and Prevention promotes the ?Core Elements of Outpatient Stewardship?, an evidence-based guidance. The core elements are based on concepts of ?commitment? ( a public statement of dedication to judicious prescribing) and ?tracking? (performance feedback). Our pragmatic randomized trials have shown that core element interventions constructed using insights from decision and social psychology can greatly reduce inappropriate prescribing in outpatient settings. Yet these interventions have not been tested in the telehealth sector. As telehealth captures more and more of the outpatient market for acute respiratory visits, the need to adapt the Core Elements to the telehealth environment and test them increases so that patients can receive safe and effective care. RESEARCH STRATEGY: Our preliminary analyses of over ten thousand telehealth encounters and 1488 providers show high rates of antibiotic prescribing and substantial variation within and between providers? prescribing practices. Over 62% of telehealth encounters for acute respiratory infections resulted in antibiotic prescriptions. We will identify factors that explain variation in prescribing in a mixed methods analysis of retrospective data and subsequent targeted interviews. These factors will be used to inform the intervention and experimental design of a large-scale pragmatic randomized controlled trial evaluating the effectiveness of the Core Elements. We will assess the heterogeneity of treatment effects on provider subgroups to create evidence-based recommendations for stewardship programs targeting telehealth settings. IMPLICATIONS AND DELIVERABLES: This work will generate a better understanding of prescribing practices in the rapidly growing telehealth sector, including what factors are most associated with antibiotic overuse. Based on this information and relevant findings in decision science, we will adapt interventions tested in outpatient clinics that are consistent with CDC Core Elements to telehealth. We will evaluate interventions in a large-scale randomized controlled telehealth trial. We will evaluate the effectiveness of Core Elements and heterogeneity of treatment effects based on provider subgroups. Future stewardship interventions focused on telehealth settings will have the ability to use our findings to promote judicious use of antibiotics.

Public Health Relevance

Evidence-based antibiotic stewardship guidance for outpatient acute respiratory care is based on interventions that motivate appropriate prescribing behavior in office settings. As care for acute respiratory infections rapidly shifts away from office visits and towards telehealth encounters, we propose to adapt and evaluate these interventions within the telehealth setting. This project represents the first ever large-scale randomized quality improvement trial in telehealth.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Research Project (R01)
Project #
1R01HS026506-01
Application #
9643894
Study Section
Healthcare Information Technology Research (HITR)
Program Officer
Miller, Melissa
Project Start
2018-09-30
Project End
2023-07-31
Budget Start
2018-09-30
Budget End
2019-07-31
Support Year
1
Fiscal Year
2018
Total Cost
Indirect Cost
Name
University of Southern California
Department
Public Health & Prev Medicine
Type
Schools of Medicine
DUNS #
072933393
City
Los Angeles
State
CA
Country
United States
Zip Code
90033