This project focuses on implementing findings from the PCORI‐funded study on use of narrow‐spectrum versus broad‐spectrum antibiotics to treat children’s acute respiratory tract infections (Principal Investigator: Jeffrey Gerber), in the context of existing evidence on this topic.
COVID-19-Related Project Enhancement
The COVID-19 pandemic has resulted in dramatic shifts from in-person visits to telemedicine in pediatric outpatient practices. Children with acute respiratory tract infections (ARTIs) may be especially affected by the transition to telemedicine. The dynamics of a telemedicine clinical encounter present unique challenges for clinicians caring for children with ARTIs because most diagnoses require either physical examination or laboratory testing.
The enhancement will adapt the project’s antibiotic stewardship program to function in a telehealth environment. Specifically, it will update clinician education to promote appropriate antibiotic prescribing for ARTIs during telemedicine visits. It will also update the audit and feedback reports that clinicians receive to track telemedicine prescribing.
Enhancement Award Amount: $499,375*
1. What is the eligible evidence proposed for implementation?
Antibiotics are the most common medications prescribed for children. Although antibiotics can be lifesaving drugs, up to half of all antibiotic use is inappropriate. Excessive antibiotic use can lead to antibiotic‐resistant bacteria, which sicken at least 2 million Americans each year and are hard to treat. Prior PCORI‐funded work by this project team compared the effectiveness of broad‐spectrum (like cephalosporins) vs. narrow‐spectrum (like amoxicillin) antibiotics in children treated for three common types of acute respiratory tract infections (ARTIs)—ear infections, sinus infections, and sore throats. They found that the broad‐spectrum antibiotics did not improve patient outcomes compared to narrow‐spectrum antibiotics, but did increase harmful side effects like diarrhea, rash, or upset stomach. In spite of this evidence, as well as national professional recommendations, clinicians vary widely in how they prescribe antibiotics, and more than half of antibiotics prescribed remain broad‐spectrum.
Certain interventions can help increase appropriate antibiotic prescribing, but these have not been implemented widely. The current project team successfully used education for clinicians coupled with report cards to clinicians on their own and their colleagues’ antibiotic prescribing (called the PARTI intervention) to decrease rates of unnecessary broad‐spectrum antibiotic prescribing for ARTIs. With this intervention, rates of inappropriate broad‐spectrum antibiotic prescribing were nearly cut in half. However, that study was in a single group of primary care practices. The study of the PARTI intervention concluded that it should be spread to other pediatric practice settings around the country, which is the goal of this implementation project. Practices that have not yet implemented programs to improve outpatient antibiotic prescribing for children are eager to join projects that address antibiotic prescribing.
2. What is the goal of this implementation project?
The primary goal of this project is to broadly implement an evidence‐based intervention (PARTI) to improve how clinicians caring for children in outpatient settings make decisions about antibiotics for ARTIs. Specific aims include:
- To examine the acceptability, feasibility, and utility of a focused implementation strategy on improving adoption and impact of the PARTI intervention in varied outpatient settings
- To measure the effectiveness of the PARTI intervention to reduce broad‐spectrum antibiotic use for children 6 months to 12 years of age with ARTIs in varied outpatient settings
3. What is the project team doing?
The overarching goal of this project is to implement the PARTI intervention broadly. Several implementation strategies are needed to achieve this goal. Members of the project team and stakeholders (parents, clinicians, health system leaders) at implementation sites will participate in three core implementation activities: create and produce three 30‐minute engaging, online educational modules based on the PARTI intervention and current evidence for broad‐spectrum antibiotic prescribing for ARTIs and barriers to their use; adapt audit and feedback prescribing reports from the PARTI intervention to make sure that they are useful to local prescribers and can be implemented long‐term; the CHOP‐based team will provide support to local system stakeholders and practice‐based clinician champions (leaders at individual practice sites) via a two‐day site visit to each health system in Year 1 of the project to generate enthusiasm for the intervention, gather information about expected barriers to implementation, and provide training to practice champions about how to be an effective facilitator plus follow‐up webinars every three months to provide ongoing support, troubleshooting, and to gather information about the implementation process. In turn, practice‐based champions will provide internal facilitation by developing a local communication plan about the importance of the intervention and the source and credibility of the audit and feedback reports; ensure clinicians have time to complete the online educational modules; and encourage commitment to the project through written and verbal statements that they share.
The participating sites were chosen for their distinct patient populations and practice type (primary care, family practice, urgent care, emergency department—the major settings where children are treated for ARTIs); willingness to participate; and opportunity for improvement. Specifically, although all of the sites are motivated to improve their antibiotic prescribing, none have yet implemented major initiatives to improve prescribing, nor focused efforts on promoting narrow-spectrum as opposed to broad‐spectrum prescribing. Overall, the team expects more than 900 clinicians at more than 115 practice sites (including primary care, urgent care, and EDs) to participate. Using this approach, the PARTI team expects to improve antibiotic prescribing at more than 350,000 ARTI visits, resulting in fewer side effects such as diarrhea, rashes, and upset stomach.
4. How is the team evaluating this project?
Outcomes will measure both how well the implementation approach worked and how much antibiotic prescribing changed during the project period. To evaluate how well the implementation approach worked, the team will use interviews and surveys. The team will then measure rates of broad‐spectrum (off‐guideline) antibiotic prescribing for the targeted ear, sinus, and throat infections. By using data from electronic health records, the researchers will be able to measure antibiotic treatment for all children at participating sites, allowing for a detailed and large‐scale assessment.
5. How is the team involving patients and others in making sure the findings reach people who can use them?
A primary goal is to make sure that the patients and their caregivers who deal with these infections as well as the clinicians (doctors and nurse practitioners) who treat them help to design and implement this project. The team has developed this project with input from a family consultant at CHOP with extensive experience bringing the patient and family voice to research. In addition to coordinating activities with parent stakeholders, which will come from each of the participating sites, the family consultant will help to frame research results to be meaningful to families. The project also is being coordinated through the PROS network at the American Academy of Pediatrics (AAP). Through AAP, the team has already engaged 30 pediatricians who informed the proposed project. AAP groups working on antibiotic prescribing guidelines, practice implementation, and health insurance will be engaged through the project period in order to support the spread of the PARTI intervention following project completion.
6. How will this project help ensure future uptake and use of the evidence?
The proposed sites were selected to help the team understand how to best implement the PARTI intervention in diverse primary care settings as well as in nonprimary care ambulatory settings, including urgent care and the emergency department. The sites use different electronic health records and quality reporting tools so that the team can learn lessons applicable to future implementation sites. The project also includes a maintenance phase that, following training of the participating sites, involves withdrawing outside support and having the participant sites continue to deliver report cards to clinicians. Finally, by partnering with the AAP, the team will be connected with this organization’s well‐established quality improvement networks that can bring the intervention to practices across the United States. Therefore, through the variety of settings involved, the design of the project, and the partnership with the AAP, the team will learn how best to effectively scale the intervention, creating a clear path to bring it into wider use.
Related PCORI-funded Research Project
Implementation of Findings from PCORI's Major Research Investments
*All proposed enhancement projects, including requested project plans, budgets and milestone schedules, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award modification.