Antibiotic Approaches: What Works for Choosing Wisely Grantees

In 2015, the Robert Wood Johnson Foundation awarded funding to support seven projects across the country that aimed to create and implement interventions based on Choosing Wisely recommendations, including reducing the use of antibiotics for viral infections by 20 percent.

About halfway through their 34-month projects, grantees and participating health systems, hospitals and medical groups in their regions have met or made progress toward this goal. Detroit Medical Center PHO has reduced inappropriate antibiotic use by 64 percent, while its community partner Henry Ford has reduced antibiotic use by 42 percent. On the West Coast, Sutter Health has seen a 9 percent reduction and Group Health has seen a 12 percent reduction in antibiotic use. Those two reductions account for more than 2,500 patients not receiving an inappropriate prescription for antibiotics for viral infections.

Across all of these organizations, project leaders say there are common approaches that have led to success and planned interventions:

Incorporating clinical decision support

• Group Health has created scripts for clinician-patient conversations about why antibiotics might not be warranted.
• Greater Detroit Area Health Council is implementing best-practice alerts at the point of care. Clinicians receive alerts if they attempt to order a test, medication or procedure that conflicts with the established standard, and they must complete a non-electronic clinical decision support form to order the item. 
• At Henry Ford Health System (HFHS), seven Choosing Wisely recommendations were implemented using the Clinical Decision Support tools for outpatient and inpatient physicians. HFHS also implemented various countermeasures related to possible fatigue from so many alerts and utilized analytics provided by this platform to refine existing best-practice alerts. All participating health systems are using or have plans to use clinical decision support to encourage appropriate antibiotic use, including electronic health records (EHR) alerts or reminders, paper-based clinical decision support or reminders from support staff.

Providing clinicians with feedback and benchmarking

• Sutter Health, a partner of grantee Integrated Healthcare Association in California, has been convening in-person meetings with participating physicians, led by a trained facilitator, to discuss unblinded data from EHRs on practice variation. Monthly follow-up reports are emailed to participating physicians.
• Washington Health Alliance is providing transparent feedback to clinicians about their ordering practices. The Washington State Choosing Wisely Task Force, which includes medical leaders from 24 state health care organizations, recently released its 2016 report that reviewed utilization of 10 tests or treatments discouraged by Choosing Wisely in Washington, including antibiotics for upper respiratory infections. Based on the experience of Task Force member Virginia Mason and supplemental data from Medicare, the Task Force revised the antibiotics measure to encompass all viral illnesses and help clinicians avoid choosing another diagnosis rather than choosing not to prescribe an antibiotic. The report shows that variation remains high across Washington, especially among Medicaid enrollees.

Engaging physician champions

• Maine Quality Counts is identifying opinion leaders and clinical champions in both primary care and specialty settings to help raise awareness about Choosing Wisely and to model high-value care.
• Froedtert & the Medical College of Wisconsin, a partner to grantee Wisconsin Collaborative for Healthcare Quality, is defining clinical quality practice guidelines by clinical experts within the organization.
• At Cornerstone Healthcare, a partner of North Carolina Healthcare Quality Alliance, the Chief Quality Officer and quality staff have visited all 40 locations to encourage participation and adoption of Choosing Wisely.

Clinician and patient education

• Integrated Healthcare Association is encouraging shared decision-making between patients and clinicians to address patient expectations. Partner Sharp Rees-Stealy Medical Group will disseminate Choosing Wisely materials through its website and member portal. The Center for Healthcare Decisions reported out the results of its Doing What Works program, interactive small-group discussions that touched on antibiotic use.
• North Carolina Healthcare Quality Alliance has distributed “Five Questions to Ask Your Doctor Before You Take Antibiotics” posters to local health directors to display in all 98 local health departments in the state.