A longtime urgent care physician, Park Willis has seen firsthand the overprescribing of antibiotics in these settings. In his work with the Intermountain Healthcare system, based in Salt Lake City, Willis has long had an interest in ensuring these drugs are used appropriately. To him, that goal just “felt like it was good patient care.”
So when Willis had the opportunity to help improve antibiotic prescribing within these settings as part of a stewardship program at Intermountain—funded in part by the Centers for Disease Control and Prevention—he jumped at the chance. The program launched in July 2019, and Willis has already seen signs of improved prescribing practices at Intermountain facilities in Utah and Idaho.
Willis prescribes fewer antibiotics than any other doctor in Intermountain’s urgent care system. He recently talked with Pew about antibiotic use in urgent care and his network’s stewardship program. These efforts help ensure that antibiotics are used only when necessary and that they are prescribed appropriately. That means prescribing the right drug at the right dose at the right time for the right duration. The conversation has been edited for length and clarity.
A. In urgent care, we deal with a lot of conditions—mostly upper respiratory conditions, but also things like urinary tract infections—where people come in thinking an antibiotic may be needed because physicians may have prescribed antibiotics for them in the past. But, increasingly, the data and research show us that upper respiratory infections rarely require antibiotics.
Stewardship helps facilitate better prescribing and spurs important conversations with patients, which are both critical because the more we can reduce unnecessary antibiotic prescriptions, the more we can slow the emergence of resistant bacteria. And slowing the emergence of resistance keeps the antibiotics we have effective longer—which has never been more important, because we don’t have a whole lot of antibiotics in development right now.
When talking to patients, I explain that taking an antibiotic unnecessarily can do more harm than good. For example, it puts them at risk for C. diff—a severe infection that can lead to life-threatening diarrhea. I also tell them that preserving the effectiveness of these antibiotics is in their best interest because they could develop an antibiotic-resistant infection later in life.
A lot of physicians feel patients expect an antibiotic, but when you give them the opportunity to speak and delve a little deeper, a lot of times that’s not the case. We do a disservice when we’re trying to meet an expectation that we’ve decided they have, whether or not they actually have that expectation.
A. Our program has many of the core elements that you would see in most stewardship programs, such as tracking and reporting antibiotic use, and educational resources. Something unique about ours, though, is our outpatient antibiotic prescribing dashboard. Our urgent care practitioners can use this tool to look at their past year of antibiotic prescribing data by month, and by diagnosis, compared with other Intermountain providers.
Every urgent care encounter is categorized based on diagnostic codes into one of three tiers: Tier 1: antibiotics are always appropriate (for things like bacterial pneumonia, strep pharyngitis), Tier 2: antibiotics are sometimes appropriate, but often not (middle ear infections, sinus infections), and Tier 3: when antibiotics are never appropriate, for conditions such as upper respiratory infections, bronchitis, or when someone codes something as simple as “cough.” The dashboard shows clinicians’ antibiotic prescribing rate for each tier and for all tiers combined.
Intermountain created this tool based on surveys with our providers, and since its creation, we’ve found preliminary data show it is really helping our doctors improve their antibiotic prescribing.
A. Our electronic health record (EHR) system includes additional tools to help doctors prescribe antibiotics appropriately. For example, we have folders within our EHRs where doctors can easily access local disease-specific guidelines and use pre-populated antibiotic orders with the correct drug and duration when they are needed. With just a couple of clicks, doctors can pull down and prescribe the first- or second-line antibiotic depending on a patient’s specific situation. We also have “Quick Visits” resources within the EHR that allow the clinician to easily select the diagnosis code, prescribe the appropriate antibiotic, or provide a delayed prescription to give a patient several days to see if symptoms persist, while also providing patient education—all from one page.
The patient education resources include a handout explaining why a delayed antibiotic prescription might be beneficial in some cases and another outlining what types of nonantibiotic therapies can be used to help with respiratory symptoms. Our patients especially like this information because we found that they often just want a plan for treating their symptoms; that solution doesn’t always have to be an antibiotic. These resources demonstrate to the patient that we’ve heard them and have designed a treatment regimen specifically for them.
A. I’m a liaison between the stewardship team at Intermountain and urgent care practitioners throughout the system. I visit clinics and talk to providers about Intermountain’s stewardship program and the tools that we’ve instituted for this project so they have an ease of understanding and familiarity with how to use them and how to check and interpret their data. I pass their feedback back to the infectious disease doctors that run our stewardship program to help them understand what we do on the front line.
Clinicians seem particularly excited to see the dashboard. A lot of what I’ve done is to show doctors how to easily access it.
A. The vast majority of doctors, even ones that prescribe antibiotics at very high levels, support the idea of the program. Most clinicians recognize that there may be times they prescribe an antibiotic more readily to a patient at the end of the day or when a patient is pushing back too much. For example, when patients want the same thing they’ve had many times before—even if there’s not a sign of a bacterial infection—changing their mind is challenging. In addition, urgent care providers are always busy, so there is also that stress of needing to see that next patient. Clinicians will point out some of these behavioral constraints that lead them to sometimes prescribe when they know they should probably not prescribe. As a result, most are very open to the idea of stewardship and welcome the tools we’re providing.
A. The transparency of our program and tools is extremely helpful. Our providers can see their antibiotic prescribing numbers compared to their peers and that, regardless of whether a provider is a high or low prescriber, that doesn’t affect whether patients come back at any higher rate. That transparency adds a little bit of peer pressure. Being able to compare themselves to what they know to be guideline-based medicine helps inform their prescribing.
One challenge is that Intermountain urgent care doctors are not at the same location every day. We move among clinics, work on weekends and holidays, and can be too busy to check emails consistently, so it can be tough to get the message out to everybody as we ramp up the stewardship program.
However, we’re already seeing some initial positive results. When we started in July, roughly 50 percent of patients with a respiratory condition were prescribed an antibiotic. Our goal is to reduce this because many of these prescriptions are unnecessary. Clinicians are reporting that the stewardship tools are helpful with their workflow. Some have offered suggestions about how to improve our tools, a clear signal of their engagement. We are optimistic that this work will benefit patients in our community and that what we learn can be adapted to other communities and outpatient settings.