Reviewed by: David Cluck, PharmD; East Tennessee State University
Witt and colleagues sought to assess the association between peer comparative inpatient antibiotic prescribing feedback and changes to antibiotic prescribing rates among hospitalists in the Emory Healthcare Network.1 The authors cited a previously developed patient risk–adjusted metric for comparing hospitalist antibiotic prescribing2 resulting in a quality improvement initiative to reduce excessive prescribing of empiric antibiotics with antipseudomonal activity. Using a stepped-wedge design, the intervention consisted of a 1-time educational session on the report and antibiotic de-escalation and bimonthly email prescribing reports. These reports contained observed-to-expected ratios (OERs) for days of therapy (DOT) of prescribed antibiotics calculated for each hospitalist per period and reported back in a peer comparative report disseminated via email. The study included 169 hospitalists across five hospitals with a median of approximately 30 per hospital. Billing data combined with electronic antibiotic administration data and patient clinical data was used to produce a standardized antibiotic prescribing ratio for hospitalists. The primary outcome was the observed hospitalist-specific antibiotic prescribing rate, defined as billed DOT of broad-spectrum hospital-onset antibiotics per 1000 billed patient days (bPDs). Secondary outcomes included C. difficile infection occurring during the inpatient stay or within 8 weeks after discharge, 30-day readmission, in-hospital death, or prolonged length of initial hospital stay (defined as >7 days). Generalized linear models generated OERs adjusted for proportions of patients with sepsis, end-stage kidney disease (ESKD), and UTIs. In multivariable models accounting for these variables and the trend over sequential periods, the intervention was not significantly associated with lower prescribing rates (RR, 0.97; 95% CI, 0.91-1.04).
This study demonstrated that peer clinician feedback was not associated with a change in hospitalists’ prescribing rates of broad spectrum antibiotics but perhaps serves as a partial “blueprint” on what is needed to guide future change. Programs in which comparisons are with top-performing peers rather than with average-performing practitioners have been particularly successful among primary care practices; however, the authors highlight inpatient antimicrobial prescribing is particularly complex.3
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