Adding to our long list of continuing medical education (CME) programs that have positive outcomes on improving evidence based care, a recent program of education and feedback for pediatricians cut inappropriate antibiotic use by about half, reported MedPage Today.
We have previously reported that CME has led to improvements in clinical care in area such as hypertension, COPD, ICU patients, improved taking of family history by physician assistants, Sepsis, healthcare-associated infections, reduction in CT scans, MS, and several other areas.
In a cluster-randomized trial, the off-guideline use of broad-spectrum antibiotics for acute respiratory infections fell 48% in nine practices that got the intervention, according to Jeffrey Gerber, MD, of the Children’s Hospital of Philadelphia. In contrast, the use of broad-spectrum drugs in nine control practices fell by 18%, Gerber told reporters at the IDWeek meeting.
While so-called antibiotic stewardship programs have been successful in hospitals, Gerber said, most antibiotics are prescribed in an outpatient setting, especially for children. “It made sense to see if we could extend some of these principles to the outpatient setting,” Gerber said.
The Children’s Hospital of Philadelphia, he noted, is associated with 29 pediatric practices that share a common electronic health records system. He and colleagues recruited 18 of them, including 174 clinicians, to take part in the trial. During the study period, there were more than 1.4 million office visits by more than 185,000 patients.
Practices in the intervention arm got an education session with Gerber or a colleague to discuss guidelines for three diseases – sinusitis, group A streptococcal pharyngitis, and pneumonia – that are best treated, according to guidelines, with narrow-spectrum drugs.
The education session was followed with three reports over a year to each clinician in the nine practices, privately outlining how well he or she complied with the guidelines, using data extracted from the electronic records. The reports also compared each doctor’s patterns with those of other doctors in the practice group, as well as with the network as a whole, Gerber said.
At the end of the year, the rate of off-guideline prescribing had fallen from 32% to 17% in the intervention practices and from 33% to 24% in the control practices. The difference was significant at P=0.001. Evidence of from this kind of educational intervention should be encouraging to government officials who have increased their pressure and oversight of off-label promotion. This kind of research may demonstrate that one way to combat inappropriate or improper off-label use is through educational interventions with activities such as CME.
The most dramatic difference, he said, was in prescribing for pneumonia, where the rate of off-guideline use of antibiotics fell by 75% in the intervention practices, but just 6% in the control practices.
This kind of research should be encouraged further to demonstrate the true impact on reducing off-label use of products that do not have scientific or evidence-based support for such use. If further educational research could demonstrate an impact, future corporate integrity agreements (CIAs) imposed by the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) might consider requiring the funding of independent, accredited, third-party CME programs that educate doctors about the improper off-label uses.
Gerber told MedPage Today that the study was not completely blinded, since members of the control practices got no intervention, although they knew they were taking part.
“They were not completely in a vacuum,” he said, but the participating practices were widely separated geographically, which provided some degree of blinding.
The researchers are currently following the 18 practices for another year to see how long the change lasts and to measure any differences in patient outcomes that might have taken place. He told MedPage Today that it’s difficult to pinpoint whether the education session or the feedback had more effect. But, he noted, “as a practitioner, no one ever tells you how you actually practice; no one ever presents you with data.”
The finding, he suggested, is probably applicable to any situation in which electronic health records allow easy tracking of physician prescribing habits.
“The education component of (antibiotic) stewardship is extremely important,” commented Liise-Anne Pirofski, MD, of the Albert Einstein College of Medicine in New York City, who was not part of the study but who moderated a press conference at which details were presented. And it is the development of electronic health records system that “enables” such education, Pirofski said. “I think this is a very powerful finding,” “and probably pretty ground-breaking.”