Patient-Centered Stewardship to Improve Antibiotic Use in Ambulatory Care

Background: Antibiotic overuse threatens patient safety by causing adverse effects and threatens the effectiveness of antibiotics through the development of antibiotic resistance. Although our research team and others have been successful in improving antibiotic prescribing during office visits using behavioral economics and communication strategies, the improvements have generally been modest and generally focus on clinician behavior. Patient-directed interventions have usually been visit-based, educational, and generic. We have written about a need for patient-centered stewardship, which would use a theory-informed approach to engage directly with high- inappropriate-antibiotic-utilizing patients outside of visits about their own concerns and behavior. Research Strategy: To understand and address high-inappropriate patient antibiotic use, we will conduct a mixed-methods project including controlled cohort studies, qualitative analyses, and a pilot randomized controlled trial (RCT) of a patient-centered behavioral nudge. Specific Aim 1 is to perform retrospective, patient-focused, controlled cohort studies of adults and children in 2 health systems (over 1.5 million patients) to categorize high-antibiotic-use as appropriate, partially appropriate, potentially appropriate, and inappropriate. Specific Aim 2 is to conduct qualitative interviews with high inappropriate-antibiotic-utilizing patients to identify social and behavioral factors that influence care-seeking and antibiotic use, informed by the Theoretical Domains Framework (TDF) framework. Specific Aim 3 is to – based on findings from Aims 1 and 2 – develop, refine, and evaluate in a controlled pilot RCT the impact of a patient-centered stewardship behavioral nudge intervention to reduce inappropriate antibiotic use among high-antibiotic-utilizing patients. The primary outcome will be the number of inappropriate antibiotic prescriptions over 8 months. Secondary outcomes will include non-antibiotic medication prescribing, implementation outcomes (feasibility and acceptability), spillover effects, and unintended consequences. Implications and Future Directions: We seek to understand and intervene on patient care-seeking and inappropriate antibiotic use. This project will lay the groundwork for a future, larger RCT testing the effectiveness of components of the intervention in a broader patient population. The ultimate goals of this project and subsequent interventions and evaluations are to better understand patient concerns, care-seeking, and antibiotic use; enable effective engagement with care; improve diagnostic accuracy; and ensure antibiotic prescribing quality to improve patient safety, decrease adverse drug events, and limit the spread of antibiotic resistant bacteria.