Running head: PILOT FOR IMPROVED ANTIBIOTIC PRESCRIBING 1 Evidence-Based Pilot for Improved Antibiotic Prescribing BaoTram

The nature and burden of inappropriate antibiotic prescribing for self-limiting respiratory tract infections (RTIs) in primary care settings, continues to pose great threats to public health. This high prevalence leads to an increase of antimicrobial resistant infections, which calls for more Evidence-Based Practice (EBP) educational strategies. The practice’s problem was identified as high rates of antibiotic prescribing for acute RTIs, without specific indications for antibiotic treatment. This project was implemented with multi-faceted approaches by identifying strategies to improve provider-patient communication; increasing providers’ knowledge and awareness of current treatment guidelines, and disseminating educational information to patients about the importance of appropriate antibiotic treatment. These educational strategies are the core principles in addressing quality care concerns within this practice, which aimed to reduce unnecessary antibiotic prescriptions in eight weeks. This study used a descriptive observational method where the preand post-interventional design was used to measure the effectiveness of EBP educational information through the delayed antibiotic prescribing strategy. The findings supported the prominence of delayed antibiotic strategy for self-limiting RTIs recommended by the EBP Clinical Guidelines No. 69, entitled “Respiratory Tract Infections – Antibiotic Prescribing” developed by the National Institute for Health and Care Excellence (NICE). These findings suggested that there was a change in knowledge and awareness in prescribing practices through the combined-educational interventions for providers and patients in delaying the antibiotic treatment. This change in knowledge and awareness of antibiotic indications demonstrated that education affects providers’ awareness about their prescribing practices, as evident by antibiotic prescribing rates dropped immediately post-intervention stage. PILOT FOR IMPROVED ANTIBIOTIC PRESCRIBING 5 Evidence-Based Pilot for Improved Antibiotic Prescribing Overuse of antibiotics in primary care settings has been a long-term problem, which continues to pose significant public health threats. Sanchez et al. (2016) suggested that antibiotic resistance leads to an estimated two million infections in the United States (U.S.) which caused 23,000 deaths annually. Further statistical data from Sanchez et al. (2016) indicated that inappropriate antibiotics use in the outpatient care setting in the U.S. alone is 30%, and approximately 60% of the U.S. antibiotic expenditures are received in this care setting. Despite some significant statistical data about the magnitude of the unnecessary antibiotic use in primary care settings, the emerging prescription rates for antibiotics for respiratory viral pathogens continue to remain at a significantly high percentile for multiple reasons. According to the Center for Disease Control & Prevention (CDC) (2012), patient education was thought to be one of the most significant contributing factors in facilitating a drop in inappropriate antibiotic use up to 18.5%. As a result, this quality improvement project aimed to develop an effective intervention in addressing a substantial proportion of inappropriate antimicrobial drug use, which was through the implementation of various educational measures to promote antibiotic stewardship interventions within this specific outpatient primary care setting. This method mentioned was one of the educational strategies that was implemented by adopting the Evidence-Based Practice (EBP) guidelines for delayed antibiotic prescribing for uncomplicated respiratory tract illnesses. Other measures included an effort to understand barriers that potentially have an impact on practitioners’ decisions to prescribe, their clinical support system, as well as disseminated evidence-based educational materials to primary care adult patients during their visits for self-limiting RTIs. The project aimed to reduce the PILOT FOR IMPROVED ANTIBIOTIC PRESCRIBING 6 unnecessary or inappropriate antibiotic prescribing through a combined-educational method for the providers and patients in primary care setting. Significance of the Practice Problem It is important to first recognize and discuss the significance of the antimicrobial resistance rates from a macrosystem level prior to discussing the effects of the antimicrobial resistance on the microsystem level. In 2013, it was documented that 269 million antibiotic prescriptions were dispensed from outpatient pharmacies, which is a daunting number (Sanchez, 2016). Not only is this a substantial impact in terms of costs alone, it was indicated in the report of the Division of Healthcare Quality Promotion, Center for Disease Control and Prevention (CDC) that Clostridium Difficile (C. diff) was documented at an estimated 453,000 cases in the U.S. in 2011 (Sanchez et al., 2016). The Agency for Healthcare Research and Quality (AHRQ) has documented a significant number of acute respiratory tract infections (ARTIs) seen in an outpatient care setting, in which it has accounted for approximately 70% of primary diagnoses in adults, who have a chief complaint of cough (AHRQ, 2014). These ARTIs include some viral syndromes, such as acute bronchitis, otitis media, rhinitis, sinusitis, and pharyngitis. Many evidence-based practice guidelines have been developed that discouraged practitioners not to indicate antibiotic treatment for certain circumstances. For example, no antibiotic is recommended for self-limiting viral cases, unless there is a clear indication for bacterial infections, or only for some extraordinary circumstances defined as per standardized guidelines. The practice’s problem was identified as high rates of antibiotic prescribing for acute respiratory tract infections, without specific indications for the antibiotic treatment. This practice provides healthcare services for employees and their dependents. The population includes children, as young as two years old, as well as adults. One of the greatest benefits that brings PILOT FOR IMPROVED ANTIBIOTIC PRESCRIBING 7 people here to utilize these medical services is a low-priced $5.00 co-pay. This lowered co-pay fee covers sick or wellness visits, some laboratory studies, minor invasive procedures, and other onsite point-of-care (POC) tests. It also covers routine generic medication refills, including common antibiotics that are being dispensed onsite at no additional costs to patients. Since the practice offers both primary care and urgent care services, a large portion of patients are seen for acute conditions instead of preventative care. They utilize the practice quite frequently for ARTI visits, where the antibiotics can be distributed onsite at no additional cost. The providers had a good understanding of ARTIs management and were well-aware of the delayed prescribing strategy, however, it was highlighted for multifactorial etiologies in terms of influential factors as to how this delayed antibiotic strategy was not implemented successfully. It was documented in several studies that one of the biggest reasons that this delayed prescribing strategy was not fully implemented as an alternative approach, was thought to be the pressure of time constraints within busy primary care practice sites, which does not allow sufficient time to fully educate patients on the ineffectiveness of antibiotic treatment on the course of viral respiratory illnesses. Some other reasons also included a sense of obligation to prescribe antibiotics to young children when they are confronted with aggressive parents. In the adult population, there is often a greater level of uncertainty about the severity of their presenting symptoms. In order to maintain a good patient-provider relationship, and more importantly a quality change in prescribing practices, a combined evidence-based education for providers and patients about antimicrobial resistance was developed. PILOT FOR IMPROVED ANTIBIOTIC PRESCRIBING 8 Financial Implications Whether the financial implications are inflicted on this practice or on the healthcare system at a general level, the impact related to the lost productivity cannot be underestimated. The impact of lost productivity is referring to the antibiotic-resistant infections that adds considerable costs to the U.S. healthcare system. Ventola (2015) indicated that when “first-line and then second-line antibiotic treatment options are limited or unavailable, health care professionals may be forced to use antibiotics that are more toxic to the patient and frequently more expensive” (“The Clinical and Economic Burden of Antibiotic Resistance”, para 2”). Even in cases of effective antibiotic treatments, the medical expenditures for patients with resistant infections are still significant. These expenditures include longer hospital stays, lengthier recuperations, which may lead to potential long-term disability because of the antimicrobial resistant infections. Therefore, the indirect long-term effects of these infections are linked to other implications of patients’ work productivity, such as missing more workdays, subsequently leaving them with substantial financial hardships. According to a report published by the CDC (2013), the economic burden of resistant antimicrobial cases was estimated at $20 billion annually and an additional cost of $35 billion lost in productivity. Froth (2013) performed a similar study to examine the impacts of the antimicrobial overuse in primary care settings. It was interesting to look at Froth’s report about the productivity loss in this student’s residential area, Kentucky. Although the exact statistics of productivity lost were not indicated in Froth’s report, it was reported that Kentucky ranks as one of the highest regions in the U.S. for use of antibiotics. Given this fact about the high rates of antibiotic treatment in Kentucky at a general level, coupled with other significan