In an urban, urgent care clinic that serves a predominantly minority, low-socioeconomic population, we have demonstrated that antibiotic prescribing for ARIs is high. The levels of antibiotic prescribing for nonspecific URIs and bronchitis are in the range that has been measured in other private practice settings. We have also demonstrated that antibiotic prescribing behavior for ARIs can be improved using a multimodal intervention strategy that consisted of provider education, examination room posters, and a computer-based education module, although an added value of the computer-based education module was not evident. Specifically, this multimodal intervention reduced antibiotic prescription rates for patients with diagnoses of predominantly viral conditions, and shifted the diagnostic criteria for antibiotic treatment of sinusitis toward that recommended by recently published national guidelines. During the intervention period, providers appeared to diagnose sinusitis less frequently in patients with <7 days of symptoms (i.e., 40 of 80 patients [50%] diagnosed with sinusitis in the baseline period had symptoms <7 days, compared to 27 of 115 patients [23%] diagnosed with sinusitis in the study period; P
= .001). Interestingly, nurse practitioners were less likely to prescribe antibiotics for ARIs than were physicians. In the WIC, provider assignment is not based upon degree of illness or vital-sign abnormalities, and therefore, patient selection bias would not have affected these results. Guideline use and guideline incorporation into practice habits may align more easily with nurse practitioner training than with physician training. In a subsequent analysis of a prior study in group-model HMO practices, we also found that nurse practitioners improved prescribing behavior to a greater degree than did physicians in the first year of the intervention; but physicians “caught-up” with nurse practitioners in the subsequent year.20
The decrease in antibiotic treatment of ARIs was independent of the distribution of specific ARI diagnoses that might justify antibiotic use. The changes that occurred in antibiotic prescribing during the study period correlated specifically with the emphasized educational points of the provider education session and examination room posters. The specificity of changes in prescription and diagnosis behavior supports the conclusion that these changes were a direct result of the intervention.
A major limitation of our study was that we did not include a concurrent control clinic in which no intervention was performed. On the basis of temporal trends of the influenza season in Denver during our study (January to February), we probably had more influenza visits during the intervention period than during the baseline period. Influenza diagnostic testing is not routinely performed in the WIC, and therefore most suspected influenza is labeled “viral syndrome,” URI, or bronchitis. During the study period there were no competing antibiotic campaigns targeted to our providers or patient population that would have influenced prescribing. The dramatic change in prescribing and the specificity of some of the changes in prescribing argue against the national temporal trend in ARI antibiotic prescription reductions as the cause for the change in prescribing habits, but without a concurrent control the magnitude of temporal trend effect is unknown.
It is also difficult to determine whether diagnostic shift by the provider could account for the reduction in prescriptions for URI and acute bronchitis. It is possible that during the intervention period, providers could have changed a URI diagnosis to sinusitis or a bronchitis diagnosis to atypical pneumonia in order to justify an antibiotic. Another limitation of our study was the lack of demographic data, such as comorbidities, insurance, education level, income, and housing status, which may confound the prescription rates. However we cannot hypothesize a reason why these variables would be distributed unevenly across the intervention groups. Patients diagnosed with chronic obstructive pulmonary disease or chronic sinusitis were not included in the sample. The use of systematic sampling of visits for the comparison groups (baseline and limited-intervention) was used to guarantee equal representation of work shifts and clinic days; however, this also could have resulted in bias if there was maldistribution of providers or illness syndromes as a result. We believe this was unlikely, given that we sampled a high frequency of visits (1 out of every third or fourth visit). A final limitation of our study was the lack of outcome data to suggest either a positive or negative effect of our intervention on our patients' health.
During the intervention period, we found that the total antibiotic prescription rate for all ARIs (bronchitis, sinusitis, pharyngitis, and nonspecific URI) fell to 32% from a baseline of 46%, which equates to 140 fewer antibiotic prescriptions per 1,000 ARI patient visits. In the study clinic, we estimate that the intervention resulted in approximately 500 fewer antibiotic prescriptions for ARIs over 4 months. The sustainability of this reduction in antibiotic prescribing is unknown in our study. A previous study6
in a different population did show a sustained effect over the subsequent ARI season.11
Real or assumed patient expectations have often been cited as one of the reasons for the excessive use of antibiotics in ARIs, and only interventions that have incorporated patient education components have been successful in decreasing total antibiotic use for ARIs. Traditional types of patient education often have relied heavily on patient literacy and English-language skills, two skills that are underrepresented in many public urban practice settings. ICE modules have reported good acceptability in patient populations with low-socioeconomic backgrounds, in part due to the nonthreatening nature of the education.14
ICE modules improve knowledge and involve patients in their own decision making,21
and could be cost-effective and efficient ways to deliver patient education at the point of care. A previous study of an ICE module to educate patients about the common cold reduced the time of health care visits for URIs, and the patients in that study felt the computer-based information was reliable and accurate.13
Our study failed to show any additional benefit from the ICE module, even though we were able to overcome some of the traditional barriers encountered in educating an urban underrepresented patient population by implementing a bilingual ICE module. There could be several reasons why an additive effect on prescribing patterns was not seen. First, provider awareness of the existence of such an educational tool in the waiting room could have caused a generalized effect on prescribing to all patients with ARIs. Second, the ICE module may have been effective in modifying patient expectations and demands for antibiotics, but providers generalized its effect to non-ICE module patients. Third, providers in a public health care setting may be less influenced by patient expectations than providers in a private setting. Overcoming patient expectations of antibiotics may be easier in a public hospital urgent care setting because the clinicians are in general less concerned, compared with private practice, with maintaining a practice population. There is also an inherent anonymity of a denial for antibiotics in an urgent care setting, since the same clinician is unlikely to se the patient for a revisit with worsening illness. Fourth, a change in patient expectations may not correlate with a change in the provider's perception of patient expectation. Fifth, the ICE module may not have provided effective education and therefore did not change expectations. Further studies are needed to determine if ICE modules change patient expectations.
The results of this study show that a multidimensional educational intervention can be effective in improving antibiotic use for ARIs in an urban urgent care clinic. The clinical specificity of our educational points may have been the key to the success of our clinician education. The educational session and the posters were designed with specific recommendations (acute bronchitis should not receive antibiotics; sinusitis less than 7 days should not be given antibiotics). These specific recommendations translated into specific alterations in prescribing habits. Clinician education alone, particularly among nurse practitioners, may be effective in changing clinical behavior in an urban urgent care setting, in which there is more “anonymity” and less financial pressure to maintain a practice population. The most complex and costly component of our education, the patient ICE tool, did not have a measurable additive effect on prescribing compared to clinician education alone. Further studies need to be done to better characterize what ICE module format would be most effective in patients with low literacy. Effective modules should reduce patient expectations for antibiotics and in turn reduce prescription rates for ARIs.