Using rapid qualitative methods to inform implementation of two system-level interventions to reduce antibiotic prescribing duration among children with acute otitis media
Authors: Rinehart Deborah J , Gilbert Aiden , O’Leary Sonja , Katz Sophie E , Frost Holly M ,   for the RELAX Study Group
Published: January 2025

Abstract

Corresponding Author: Deborah J. Rinehart, PhD, Center for Health Systems Research, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO 80204, 303-602-2743, deborah.rinehart@dhha.org
Alternate Corresponding Author: Aiden Gilbert, MPA, Center for Health Systems Research, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO 80204, 303-602-2709, aiden.gilbert@dhha.org
Abbreviations:
AOM: Acute otitis media
PRISM: Practical Robust Implementation and Sustainability Model
Conflicts of Interest Statement: The authors have no conflicts of interest to disclose.
Source of Funding: This project was funded under grant number 1R01HS029153-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS.
Contributors: RELAX Study Group: Kashope Anifowoshe5, Humza Agha8, Ritu Banerjee5, Ivanna Bell5, Alexis Calvert5, Shaun Cosgrove1, Sherry Dodd8, Christina Evans8, Evan E. Facer8, Sharon Graham8, Hanna Hoover5, Timothy C. Jenkins7,8, Amy Keith1, Nancy Koenig8, Cindy M. Terrill8, Theresa Morin1, Jason G. Newland8, Jasmine Prater8, Luke Starnes8, Amy B. Stein1, Gale Thomas5

Background
Acute otitis media (AOM) is the most common indication for antibiotics in children. In 2019, national guidelines were published recommending a 5-7-day antibiotic duration for non-severe AOM for children ≥2 years of age. However, over 94% of children are still prescribed longer than recommended durations for AOM, and nearly half of antibiotic exposure days are unnecessary. Unnecessary antibiotic use may result in the emergence of antibiotic-resistant pathogens and adverse patient outcomes. This study identified facilitators and barriers to implementation of two low-cost pragmatic interventions designed to improve guideline-concordant antibiotic prescribing.

Methods
Clinicians and administrators from two large healthcare systems were invited to participate in semi-structured qualitative interviews. The Practical Robust Implementation and Sustainability Model (PRISM) guided the study. Interviews were analyzed using the Rapid Assessment Process, an iterative team-based approach. Team members listened to one another’s interviews, completed a summary organized by key domains, and met weekly to discuss emergent themes. Overall findings were consolidated into a matrix and themes within each domain were identified.

Results
To date, 15 providers and 4 administrators participated. Over half (58%) were from primary care, 32% from urgent care, and 11% from retail clinics. Most participants felt this was important work and the interventions would improve care and reduce antibiotic durations. Many providers were not aware of and/or had not implemented the shorter 5-day recommended duration. Factors influencing antibiotic prescribing included patient history, years of practice, connection and familiarity with the child/family, and feelings on patient medication compliance. Organization-level characteristics that influenced prescribing included the type of practice (academic vs private; primary vs urgent care). Implementation feedback specific to the two pragmatic study interventions was positive and several simple modifications were identified.

Conclusions
These preliminary findings suggest that providers and administrators are supportive of reducing antibiotic durations with the proposed interventions. Rapid qualitative analysis was helpful in quickly identifying salient themes and important factors related to implementation facilitators and barriers. Implementation science greatly benefits antibiotic stewardship efforts through identifying multilevel factors that influence adoption of guidelines in practice.