When primary care providers at The Aroostook Medical Center (TAMC) in Maine chose to focus on reducing the use of antibiotics for patients with acute sinusitis as their performance improvement project for 2013, they believed they were already doing an effective job of avoiding unnecessary prescriptions. An informal poll of TAMC’s primary care providers revealed a unanimous belief that they already consistently followed the Choosing Wisely® recommendation from the American Academy of Family Physicians (AAFP) against prescribing antibiotics for sinusitis unless symptoms lasted more than seven days or worsened after initial improvement.
The data that came back during the first month of the project took the practice group by surprise: their actual concordance with the recommendation was only 11 percent.
“We thought we were doing it right all the time but we were really doing it right almost none of the time,” said Jay Reynolds, MD, TAMC’s Chief Operating Officer and Chief Medical Officer.
The antibiotics project involved a single clinician intervention: providing monthly reports to physicians that included unblinded prescribing data for all clinicians in the practice, which were discussed at monthly primary care provider meetings. There was also a patient-facing intervention: TAMC posted laminated copies of Consumer Reports’ patient education handout about antibiotics in exam rooms.
The project began in TAMC’s five outpatient primary care clinics practice and later expanded to its walk-in clinic and emergency room, to include a total of 49 clinicians. At first, progress was slow, with substantial improvement occurring only after a year. From the starting point of 11 percent, compliance with the Choosing Wisely recommendation rose steadily to regularly exceed 80 percent and ultimately reached a high of 96 percent in August 2016.
David Weed, DO, a pulmonologist at TAMC, said the key to changing clinician attitudes was finding advocates within the practice groups.
“Once we had champions, we got traction and the project took off,” he said.
The project leaders said that although a majority of the primary care clinicians had voted for the antibiotics project, some providers initially opposed it. Dr. Weed said Choosing Wisely was unfamiliar to TAMC’s clinicians at that point, and some clinicians did not agree with the recommendation and complained about “cookbook medicine.” In addition, he said providers were not used to having their practice patterns monitored.
TAMC is part of EMHS, a 9-hospital network, and has about 60 physicians (most of whom it employs) and about the same number of midlevel providers. Although it had a policy of launching a new provider-driven performance improvement project each year, Dr. Reynolds said it was “always a struggle to get physicians to agree to a meaningful measure.” He added that Choosing Wisely had helped change that, because it offers “real clinical indications that a provider can use.”
Cherri Fitzpatrick, the chief quality officer for TAMC, said that the antibiotics campaign marked a turning point.
“Our providers may once have been uncomfortable with change but are now moving steadily toward a strong culture of transparency, performance improvement and evidence-based medicine,” she said.
Based on the success of the antibiotics project, TAMC is in the final stages of planning for a new initiative to reduce imaging for low-back pain.
“I think it will be easier this time around,” Dr. Weed said. “We’re going to keep coming back with more Choosing Wisely recommendations.”