Use of a Behavioral Economic Intervention to Reduce Antibiotic Prescription for Upper Respiratory Infections

Study Overview
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Brief Summary
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In an effort to implement Choosing Wisely guidelines and decrease patient harm, we will implement and evaluate a clinician audit-feedback and behavioral nudge initiative to reduce low-value antibiotics for URIs. Using a quasi-experiment (pre-post) design, antibiotic prescriptions for URI at LAC+USC Urgent Care Center (intervention site) vs. Olive View-UCLA Urgent Care Center (control site) will used to test the effects of behavioral nudge on antibiotic prescribing.

Detailed Description
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National prescription rates for low-value antibiotics for uncomplicated upper respiratory infections (URIs) remain unacceptably high, including at LAC+USC Medical Center-one of the largest safety net medical centers in the U.S. Using a quasi-experiment (pre-post) design, antibiotic prescriptions for URI at LAC+USC Urgent Care Center (intervention site) vs. Olive View-UCLA Urgent Care Center (control site) will be compared. A three-part intervention at LAC+USC consists of (1) the urgent care medical director emailing Choosing Wisely® guidelines and presented journal club to all 16 urgent care clinicians, and then (2) leveraging EHR performance data to provide individual clinicians with case-specific audit-feedback (both via emails and in-person while precepting nurse practitioners) on low-value antibiotic prescribing, and (3) using a behavioral nudge, urgent care clinicians will sign a large poster committing to avoid prescribing low-value antibiotics for uncomplicated URIs, which will be displayed in the clinic. In contrast, the control site (Urgent Care Center at Olive View-Medical Center) will receive Centers for Disease Control prescription pads for non-antibiotic treatments (e.g., decongestants) that offer patients alternatives to antibiotics, in a broader health system effort to reduce antibiotic prescribing. Patient with URIs (e.g., acute bronchitis, bronchitis NOS, excluding guideline-based red flags such as COPD, HIV) will be identified using electronic health record clinical billable data and low-value antibiotic prescriptions rates per visit will be monitored at both sites. Differences in prescriptions rates will be determined using an interrupted time-series analysis comparing utilization between sites using a repeated measures logistic regression model. .

Official Title
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Use of a Behavioral Economic Intervention to Reduce Antibiotic Prescription for Upper Respiratory Infections

Conditions
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Antibiotics, Upper Respiratory Infections, Safety-Net Hospitals, Behavioral Economics, Choosing Wisely

Intervention / Treatment
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* Behavioral: Nudge using Behavioral Economic Interventions
* Behavioral: Standard Practices to Reduce Health System Antibiotic Prescription


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: all patient receiving treatment for Upper Respiratory Infections (defined by ICD codes EHR billable codes) at both LAC+USC Medical Center Urgent Care or Olive View-UCLA Medical Center Exclusion Criteria: Patients not receiving treatment for Upper Respiratory Infections at both LAC+USC Medical Center Urgent Care or Olive View-UCLA Medical Center

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention Site<br>The intervention Site (Urgent Care Center at LAC+USC Medical Center) will receive a three part intervention consisting of (1) Email Choosing Wisely® guidelines and presented journal club to all 16 urgent care clinicians, (2) leveraging EHR performance data to provide individual clinicians with case-specific audit-feedback (both via emails and in-person while precepting nurse practitioners) on low-value antibiotic prescribing, and (3) using a behavioral nudge, urgent care clinicians will sign a large poster committing to avoid prescribing low-value antibiotics for uncomplicated URIs displayed in the clinic. | Behavioral: Nudge using Behavioral Economic Interventions<br> <br> |
| Active Comparator: Control Site<br>The control site (Urgent Care Center at Olive View-Medical Center) will receive broader health system efforts to reduce antibiotic prescribing consisting of Center for Disease Control prescription pads for non-antibiotic treatments (e.g., decongestants) that offer patients alternatives to antibiotics. | Behavioral: Standard Practices to Reduce Health System Antibiotic Prescription<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Low-value antibiotic prescriptions rates per visit | Changes in inappropriate antibiotic prescriptions rates per visit before and after implementation of intervention at both sites | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Coding Shift (ie, a shift in use of diagnostic codes to conditions that are more antibiotic appropriate) in URI diagnosis | Change frequency of proportion of antibiotic appropriate diagnoses before intervention and after at both sites. | 1 year |