Antibiotic Stewardship in Outpatient Telemedicine
The expansion of outpatient telemedicine has transformed how patients receive health care and has created new opportunities to optimize antibiotic use during telemedicine visits. CDC published guidance describing how health systems and direct-to-consumer telemedicine companies can enhance the implementation and impact of antibiotic stewardship in outpatient telemedicine. This guidance describes how the Core Elements of Outpatient Antibiotic Stewardship can be used as a framework for improving antibiotic use in outpatient telemedicine.*
Telehealth: A broad term to describe the delivery of health care, health education, and health information services via remote technologies.
Telemedicine: The use of technology and telecommunication systems to administer health care to patients who are geographically separated from healthcare providers, including the facilitation of remote diagnoses and treatment of patients.
Synchronous visit: Healthcare services provided using real-time communication, such as virtual visits provided through video, phone, or online chat.
Asynchronous visit: Communication that does not occur in real time (i.e., “store and forward”), such as a virtual visit facilitated using a messaging service or online portal.
E-visit: An asynchronous encounter where a patient fills out an intake form, later reviewed by a healthcare provider, to determine the plan of care.
Health systems and direct-to-consumer telemedicine companies can adapt antibiotic stewardship interventions supported by implementation research and expert opinion to help improve antibiotic use in outpatient telemedicine. The following healthcare delivery strategies can support the implementation of stewardship interventions in outpatient telemedicine1:
Telemedicine healthcare service delivery may occasionally require a physical examination or laboratory testing to establish a clinical diagnosis. The availability of additional services to overcome these shortcomings vary. It can be important to provide clear guidance to clinicians regarding when it may be acceptable to use telemedicine to establish a clinical diagnosis and when it may be ideal for patients to receive in-person health care.
- Establish standards for antibiotic prescribing during virtual visits.
Organizational adaptation and promotion of practice guidelines for antibiotic prescribing during virtual visits for conditions which commonly result in an antibiotic prescription is essential for establishing clear expectations for appropriate antibiotic prescribing. Health systems and direct-to-consumer telemedicine companies can establish these standards through adapting national clinical practice guidelines or developing local- or system-specific guidelines for common conditions.
- Use the highest level of audio/visual technology available during virtual visits.
When practical, prioritize live video for virtual visits to optimize information gathering, diagnostic accuracy, and treatment planning. When available technology does not allow for sufficient information to establish a diagnosis, clinicians can redirect the virtual visit to healthcare services which can appropriately diagnose and manage the condition.
- Use triage systems to redirect conditions requiring additional support beyond a virtual visit to an alternative care site.
If a virtual encounter or the virtual care platform is unable to meet the needs of a patient encounter, and access to partner services is not available, clinicians should refer patients to an alternative healthcare site. Some health systems-based telemedicine programs further reduce barriers to appropriate prescribing by waiving or minimizing fees for visits requiring a higher level of care.
- Identify populations at risk of being underserved or excluded by antibiotic stewardship efforts.
Clinicians should proactively identify populations who may be unintentionally or systematically disadvantaged by antibiotic stewardship efforts in virtual settings. Possible actions to reduce this effect include provision of health equity training for clinicians, consideration of health equity impact during telemedicine workflows, and equitable messaging and promotion of outpatient telemedicine services and digital health advocacy efforts.
The Core Elements of Outpatient Antibiotic Stewardship provide a framework for antibiotic stewardship for health systems and direct-to-consumer telemedicine companies that routinely provide antibiotic treatment in outpatient telemedicine.
Commitment refers to the demonstration of dedication to and accountability for improving antibiotic use among organizational leaders, clinicians, and patients. The following are considerations for implementing antibiotic stewardship commitments in outpatient telemedicine.
- Ensure leadership support and identify a champion for telemedicine antibiotic stewardship. Leadership support has been associated with improvements in antibiotic prescribing2-5 and can help ensure that the necessary human, financial and information technology resources are dedicated to implement, support, and sustain antibiotic stewardship efforts.6 Depending on the structure of the healthcare organization, engaging with executive, operational, service line, or clinical leaders in clearly defining and enlisting support for telemedicine antibiotic stewardship can be important. Ideally, leadership or champion support would include individuals with antibiotic stewardship expertise or access to such expertise.
- Adapt, communicate, and promote public commitments across virtual platforms to demonstrate dedication to antibiotic stewardship. Public commitments through a poster placed in clinical exam rooms have been used as part of multi-faceted outpatient stewardship interventions5,7,8 and have been associated with reductions in unnecessary antibiotic prescribing.9 Clinicians can adapt these public commitment posters to virtual “waiting rooms,” or other audio or visual formats during clinician or patient user interface to demonstrate commitment to antibiotic stewardship. This intervention may help set patient expectations regarding appropriate antibiotic use, highlight stewardship as an organizational priority, and improve antibiotic prescribing practices.
- Include telemedicine antibiotic stewardship duties in job descriptions and performance reviews for clinicians and accountable leaders. Formalizing antibiotic stewardship duties and accountability can assist leaders and staff in prioritizing stewardship and justifying resource commitment to accomplish quality improvement goals.
Health systems and direct-to-consumer telemedicine companies can adapt antibiotic stewardship implementation, policies, and interventions to virtual settings The following are considerations for implementing antibiotic stewardship actions for policy and practice in outpatient telemedicine.
- Use clinical decision support tools to prompt or nudge clinicians to prescribe antibiotics appropriately during virtual visits. Clinical decision support refers to systems or applications integrated into clinician workflows to assist in diagnostic and therapeutic choices.10 This can include clinical order sets for common infections, treatment guidelines, or listing treatments (including non-antibiotic treatments) in preferential order to nudge prescribers toward recommended therapies. Health systems telemedicine companies can further nudge clinicians by requiring written justification for antibiotic prescribing for conditions for which they are not recommended11 or requiring justification for the diagnosis of conditions which require a physical exam or diagnostic testing.
- Use delayed prescribing and other observation strategies to safely decrease antibiotic prescribing during virtual visits, where appropriate. Delayed antibiotic prescribing is recommended for specific conditions which typically resolve without treatment but may benefit from antibiotics if no improvement occurs (e.g., acute uncomplicated sinusitis or non-severe acute otitis media [AOM]).12 Delayed antibiotic prescribing and watchful waiting improve antibiotic use when used in accordance with clinical practice guidelines;13,14 have been included as antibiotic stewardship improvement targets in telemedicine settings;15 and appear amenable to quality improvement efforts.15 Telemedicine visits can further enable timely follow up with patients if improvements do not occur.
- Ensure access to necessary diagnostic and laboratory testing. If a physical exam or laboratory test is necessary for appropriate diagnosis and treatment (e.g., for diagnosing streptococcal pharyngitis, AOM, or urinary tract infection [UTI]), telemedicine services should partner with laboratories, health systems, in-person clinics, or other healthcare service providers and organizations to coordinate and complete recommended care. Integrated health systems offering virtual visits have successfully deployed this strategy.16
- Offer communication skills training for clinicians performing virtual visits. Communication skills training for clinicians has been proven effective for improving prescribing practices with sustained benefits over time.17 Effective communication can help improve patient satisfaction and address patient expectations and concerns about treatment plans. CDC offers communication skills training in an online antibiotic stewardship course , which is based upon the Dialogue Around Respiratory Illness Treatment (DART) training. The DART training method has been associated with reductions in inappropriate prescribing when paired with audit and feedback.18
Tracking and reporting antibiotic prescribing effectively reduces inappropriate prescribing in outpatient telemedicine settings.19-22 The following are considerations for implementing antibiotic stewardship tracking and reporting in outpatient telemedicine.
- Identify antibiotic prescribing quality measures to monitor and benchmark antibiotic use for high-priority conditions. Integrated electronic health record (EHR) systems and information technology within telemedicine platforms combined with advanced data analysis capabilities can enable effective tracking of antibiotic prescribing and audit and feedback to guide improvements. Metrics for tracking outpatient antibiotic use [PDF – 14 pages] include National Committee on Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) measures, composite antibiotic prescribing metrics, condition-specific antibiotic prescribing rates, overall antibiotic prescribing metrics, and quality measures assessing guideline concordance.
- Include appropriate antibiotic prescribing quality measures in incentive programs for providing high-quality care. Financial incentives have been associated with improvements in overall outpatient antibiotic prescribing and antibiotic selection.23-25 In one health-systems-based telemedicine platform, small bonuses and easily achievable improvement targets have demonstrated a beneficial and meaningful impact on antibiotic prescribing (CDC, unpublished data).
- Report antibiotic prescribing quality measures to individual prescribers. Audit and feedback have been shown to effectively reduce inappropriate prescribing in outpatient settings.17 Engaging clinicians on improvement targets and reporting mechanisms can help guide modifications and improve buy-in and advancement of stewardship goals. Health systems can share prescribing feedback with clinicians regularly via virtual dashboards, emails, peer-to-peer education, or performance reviews. Health systems can provide reports to local leadership4,8 or to leadership across multiple facilities.3,4
- Include peer comparisons of antibiotic prescribing to top-performing clinicians managing common conditions during virtual visits. Peer comparisons, especially those involving comparisons to top performers, have been associated with improvements in appropriate antibiotic prescribing in both in-person5,7,8 and telemedicine visits.19,20 Peer comparisons on antibiotic prescribing may involve targeted outreach or academic detailing to improve practice- or system-level performance on antibiotic stewardship measures, such as dashboards in which all clinicians view individual-level antibiotic prescribing.
Patient and clinician education on appropriate antibiotic use is an important component of antibiotic stewardship in outpatient telemedicine.26,27 The following are considerations for implementing antibiotic stewardship education and expertise in outpatient telemedicine.
- Provide peer-to-peer education (academic detailing) on appropriate antibiotic prescribing. This may include academic detailing for clinicians who are not meeting performance measure targets for antibiotic stewardship. When facilitating peer-to-peer education, consider designating as the academic detailer a clinician or antibiotic stewardship champion who achieves antibiotic prescribing goals while maintaining acceptable patient volume or patient satisfaction targets. Ideally, academic detailers have excellent interpersonal skills and a foundational knowledge of clinical decision-making.28 Health systems and telemedicine companies should address barriers to appropriate antibiotic prescribing openly and adapt practical recommendations to the needs and clinical approach of the prescriber-learner.28,29
- Support participation in continuing medical education or maintenance of certification activities that improve antibiotic prescribing. This may include activities which review appropriate antibiotic prescribing for common conditions or promote appropriate antibiotic use in outpatient settings. CDC offers a free online training course which provides continuing education opportunities for clinicians.
- Provide timely access to expertise to assist antibiotic prescribing decision-making for unique or challenging cases. This expertise may include pharmacists, infectious disease consultants, or online clinical resources that can assist clinicians in improving antibiotic prescribing, including for patients with conditions requiring specialty care.
- Provide patient educational materials on symptom relief recommendations, appropriate antibiotic use, adverse drug events, and
antimicrobial resistance during virtual visits. Qualitative research suggests that patients and parents place value on being informed about adverse drug events associated with antibiotic therapy.30
*Final publication is available from Mary Ann Liebert, Inc.: http://dx.doi.org/10.1089/tmj.2023.0229
- Sanchez GV, Kabbani S, Tsay SV, et al. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2023, doi:10.1089/tmj.2023.0229
- Drees M, Fischer K, Consiglio-Ward L, et al. Statewide Antibiotic Stewardship: : An eBrightHealth Choosing Wisely Initiative. Dela J Public Health 2019;5(2):50-58, doi:10.32481/djph.2019.05.009
- El Feghaly RE, Burns A, Goldman J, et al. 126. Implementation of the core elements of an outpatient antimicrobial stewardship program in pediatric emergency departments and urgent care clinics. Open Forum Infectious Diseases 2020;7(Supplement_1):S76-S76, doi:10.1093/OFID/OFAA439.171
- Gross AE, Hanna D, Rowan SA, et al. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infectious Diseases 2019;6(3):ofz067, doi:10.1093/ofid/ofz067
- Laude JD, Kramer HP, Lewis M, et al. Implementing Antibiotic Stewardship in a Network of Urgent Care Centers. The Joint Commission Journal on Quality and Patient Safety 2020;46(12):682-690, doi:10.1016/J.JCJQ.2020.09.001
- CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. Available at https://www.cdc.gov/antibiotic-use/core-elements/hospital.html.
- Madaras-Kelly K, Hostler C, Townsend M, et al. Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes. 2021;73(5), doi:10.1093/CID/CIAA1831
- Yadav K, Meeker D, Mistry RD, et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. Academic Emergency Medicine 2019;26(7):719-731, doi:10.1111/acem.13690
- Meeker D, Knight TK, Friedberg MW, et al. Nudging Guideline-Concordant Antibiotic Prescribing. JAMA Internal Medicine 2014;174(3):425, doi:10.1001/jamainternmed.2013.14191
- Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Current Infectious Disease Reports 2019;21(8), doi:10.1007/s11908-019-0683-8
- Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. Jama 2016;315(6):562-70, doi:10.1001/jama.2016.0275
- Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recommendations and Reports 2016;65(6):1-12, doi:10.15585/mmwr.rr6506a1
- Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964-99, doi:10.1542/peds.2012-3488
- Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery 2015;152(2_suppl):S1-S39, doi:10.1177/0194599815572097
- Frost HM, Monti JD, Andersen LM, et al. Improving Delayed Antibiotic Prescribing for Acute Otitis Media. Pediatrics 2021;147(6), doi:10.1542/peds.2020-026062
- Hersh AL, Stenehjem E, Daines W. RE: Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics 2019;144(2), doi:10.1542/peds.2019-1786B
- King LM, Fleming-Dutra KE, Hicks LA. Advances in optimizing antibiotic prescribing in outpatient settings. BMJ (Clinical research ed) 2018;363(k3047-k3047, doi:10.1136/BMJ.K3047
- Kronman MP, Gerber JS, Grundmeier RW, et al. Reducing antibiotic prescribing in primary care for respiratory illness. Pediatrics 2020;146(3):e20200038-e20200038, doi:10.1542/PEDS.2020-0038
- Ray KN, Martin JM, Wolfson D, et al. Antibiotic Prescribing for Acute Respiratory Tract Infections During Telemedicine Visits Within a Pediatric Primary Care Network. Academic Pediatrics 2021;21(7):1239-1243, doi: https://doi.org/10.1016/j.acap.2021.03.008
- Du Yan L, Dean K, Park D, et al. Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial. Journal of General Internal Medicine 2021;36(2):305-312, doi:10.1007/s11606-020-06134-0
- Pedrotti CHS, Accorsi TAD, De Amicis Lima K, et al. Antibiotic stewardship in direct-to-consumer telemedicine consultations leads to high adherence to best practice guidelines and a low prescription rate. International Journal of Infectious Diseases 2021;105(130-134, doi:10.1016/j.ijid.2021.02.020
- Wasylyshyn AI, Kaye KS, Chen J, et al. Improving antibiotic use for sinusitis and upper respiratory tract infections: A virtual-visit antibiotic stewardship initiative. Infection Control and Hospital Epidemiology 2022;1-4, doi:10.1017/ice.2022.19
- Balinskaite V, Johnson AP, Holmes A, Aylin P. The Impact of a National Antimicrobial Stewardship Program on Antibiotic Prescribing in Primary Care: An Interrupted Time Series Analysis. Clinical Infectious Diseases 2019;69(2):227-232, doi:10.1093/cid/ciy902
- Ellegård LM, Dietrichson J, Anell A. Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? Health Economics 2018;27(1):e39-e54, doi:10.1002/hec.3535
- McIsaac W, Kukan S, Huszti E, et al. A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada. BMC Family Practice 2021;22(1), doi:10.1186/s12875-021-01536-3
- Sanchez GV, Roberts RM, Albert AP, et al. Effects of Knowledge, Attitudes, and Practices of Primary Care Providers on Antibiotic Selection, United States. Emerging Infectious Diseases 2014;20(12):2041-2047, doi:10.3201/eid2012.140331
- Rose J, Crosbie M, Stewart A. A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing. Perspect Public Health 2021;141(1):19-27, doi:10.1177/1757913919879183
- Avorn J. Academic Detailing. JAMA 2017;317(4):361, doi:10.1001/jama.2016.16036
- O’Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007, doi:10.1002/14651858.cd000409.pub2
- Roberts RM, Albert AP, Johnson DD, Hicks LA. Can Improving Knowledge of Antibiotic-Associated Adverse Drug Events Reduce Parent and Patient Demand for Antibiotics? Health Services Research and Managerial Epidemiology 2015;2(0):233339281456834, doi:10.1177/2333392814568345