ABSTRACT
Objective: This study examines the effectiveness of an educational intervention that used audit and feedback to influence physician assistant (PA) antimicrobial utilization in an emergency department (ED).
Methods: Twelve ED PAs participated in this pre- and post-intervention study. Their prescribing patterns were retrospectively reviewed and classified as appropriate, effective but inappropriate, or inappropriate using a previously developed methodology. A hospitalist physician conducted a 1-hour academic detailing intervention session with each PA that reviewed inappropriate prescribing practices and provided feedback for improvement based on current guidelines. After the meetings, the prescribing patterns of the providers were followed prospectively and comparisons were made between the proportions of antimicrobials prescribed appropriately and inappropriately before and after the intervention.
Results: The percentage of appropriate prescriptions increased from 64% (95% CI, 58-72) to 81% (95% CI, 75-86), whereas the proportion of inappropriate prescriptions decreased from 36% (95% CI, 31-43) to 19% (95% CI, 14-23) across the study periods (both P < .001).
Conclusion: PA antimicrobial utilization was responsive to an academic detailing initiative that relied heavily on audit and feedback of past performance. Targeting PAs in quality improvement initiatives may be a highly effective way to influence change in health care utilization.
Inappropriate antimicrobial use in hospitals is a major public health issue. The overuse and incorrect use of antimicrobial drugs increases health care costs, both absolute drug costs and the costs related to secondary complications such as adverse reactions (side effects, allergic reactions, and drug interactions), increased prevalence of multidrug-resistant organisms, and secondary infections.
1-4 Patients infected with drug-resistant organisms have longer hospital stays and higher mortality rates.
5Clostridium difficile colitis is becoming more common, at least in part because of antimicrobial overutilization.
6-8
Antimicrobial stewardship involves taking steps to ensure that antimicrobial therapies will be prescribed appropriately. The goals of stewardship are to make sure that antibiotics are prescribed only when necessary, that medications are selected wisely and appropriately, and that dosages and duration of therapy are chosen correctly.9,10 To improve outcomes for hospitalized patients, physician groups are increasingly engaging in quality improvement initiatives;11-15 and encouraging appropriate antimicrobial use is a high-priority area. Although this area has traditionally been under the purview of infectious disease (ID) specialists,16 ID services are often too understaffed to provide extensive antimicrobial stewardship, especially at smaller hospitals. Recent research indicates that hospitalist-driven antimicrobial stewardship interventions may prove effective when targeting physicians and nonphysician clinicians, including physician assistants (PAs), in the hospital.17 To date, the effectiveness of antimicrobial stewardship activities targeted specifically at PAs has not been explored. This lack is especially noteworthy as PAs increasingly provide larger proportions of direct patient care in various clinical settings, including the emergency department (ED).18-20
The ED was chosen as a setting for the current study because the ED is where the first doses of antimicrobials are prescribed and because at many institutions (including the authors'), ED PAs write most of the initial antimicrobial orders for patients. Prior studies have shown that the antimicrobial prescribing choices made by ED providers could be improved.21-23 Given these circumstances, this study examines the implementation and effectiveness of an audit and feedback intervention designed to improve PAs' antimicrobial utilization in the ED.