Appendix B:

Aspects of Ambulatory Antimicrobial Stewardship Interventions as Applied to Components of the Ambulatory Work System (SEIPS 2.0).13*

ReferenceSEIPS 2.0 Element
Study TypeTools / Technology ComponentsPerson(s) ComponentsOrganizational ComponentsTask ComponentsPhysical Environment ComponentsExternal Environment Components
Litvin et al20Qualitative analysis of quasi-experimental study• CDSS through EHR note template
• Hyperlink to patient education
• EHR audit and feedback
• Limited printing capabilities
• Not tailored to multiple complaints
• Facilitates discussion
• Tool adaptability
• Network issues
• Patient symptoms
• Patient age
• Commitment to use CDSS
• Agreement with CDSS
• Technically savvy staff
• Comfort with prior ARI templates
• CDSS alters practice workflow
• Role of person initiating CDSS is different in different clinics (ie, triage nurse, medical assistant, and clinician)
• Improves efficiency• Computer location• External clinician guidelines
Persell et al212 × 2 × 2 RCT of patients with ARIs comparing (1) accountable justification, (2) suggested alternatives, and (3) peer comparison with educational module• EHR used for accountable justifications and suggested alternatives (pop-up of alternatives and educational material)• Monthly peer comparison emails
• Other clinicians see accountable justification
• Ordering an antibiotic in EHR
Hux et al22RCT of PCPs in Ontario randomized to mailed intervention combining prescribing feedback with educational bulletins• Mailed intervention• Prescribing feedback
Hallsworth et al23Randomized 2 × 2 factorial trial of GPs who prescribed antibiotics in the upper 20th percentile randomized to (1) patient educational leaflet and feedback and (2) patient-focused intervention• Patient education leaflet
• Patient-focused information
• Feedback intervention given letter saying they prescribed >80% of local practices
Strykowski et al24Spanish RCT of GPs: acute exacerbation of COPD or chronic bronchitis, comparing (1) multifaceted intervention and CRP POC, (2) multifaceted intervention alone, and (3) usual care• CRP POC testing• Both groups had follow-up meetings with individual feedback
• Both groups had training on ARIs
• Brochures and posters in waiting rooms
Foxman et al25RCT of nonelderly patients in 6 areas in United States assigned to insurance plans varying by level of cost sharing• Insurance policies regarding cost sharing
Long et al26Shanghai RCT of patients with suspected CAP, randomized to procalcitonin or guidelines alone• Procalcitonin testing• Guidelines for CAP treatment
Arakaki et al27Nonblinded RCT of adults diagnosed with cellulitis by PCP, randomized to outpatient dermatologic consultation• Dermatologic consultation
Taylor et al28RCT of educational intervention aimed at parents of children <2 years of age• Pamphlet, videotape with local pediatrician promoting judicious antibiotic use
Torres et al29Observer-blinded RCT parallel-group study of clinical prediction rule of which children have bacterial pneumonia• More chest X-rays in the control group• Alternative: management based on institutional guidelines
Le Corvoisier et al30RCT of GPs: interactive seminar presenting evidence-based guidelines for ARIs• Subgroups: 2-day evidence-based medicine course only or with 1-day problem-solving course• Specific French guidelines
Meeker et al31RCT in 5 adult primary care clinics to posted commitment letter or usual care in ARIs• Letters/posters about avoiding inappropriate antibiotic prescribing included clinician photos and signatures• Poster-sized commitment letters in exam rooms
Brittain-Long et al32Swedish randomized open label study to receive a rapid (next day) or delayed (8 to 12 days) result of PCR throat swab• Multiplex PCR for respiratory viruses
Christakis et al33RCT of primary care pediatricians for POC evidence delivery on otitis media• Computerized patient flow manager and online prescription manager• NPs, physicians, and housestaff• Computerized patient flow manager designed by clinics• Computer workstations
Dahler-Eriksen et al35Danish randomized crossover trial of CRP measured within 3 minutes or with results in 1 to 2 days• Intervention group: measure CRP within 3 minutes and got results 1 to 2 days later• Needed hospital lab
De la Poza Abad et al36Pragmatic open label RCT among 23 Spanish primary care centers and ARIs to (1) delayed patient-led prescription, (2) delayed prescription collection strategy requiring patients to collect prescription from PCP, (3) immediate prescription, or (4) no antibiotics• All patients given information about antibiotics
• Delayed prescription: prescribe antibiotics to take only if symptoms worsen
• Patients told it was normal to feel worse at first, depend on patient to decide to take antibiotics• Patients told it was normal to feel worse at first
Hemkens et al37Swiss pragmatic randomized trial of PCPs with highest antibiotic prescribing randomized to quarterly prescription feedback over 2 years or usual care• Website required physicians to log in with individual access code• Personalized feedback by mail and online• 1 time provision of evidence-based guidelines for ARIs and UTIs
Samore et al38Cluster RCT in rural communities in Utah and Idaho comparing community intervention with CDSS on paper and CDSS with handheld computer• Mailings to parents
• Refrigerator magnets
• Spiral bound flip chart for ARI self-management
• 3 CDSS tools made for ARIs
• Patient-initiated documentation tool
• CDSS generated diagnostic and therapeutic recommendations
• Local clinicians led initiative at local hospital medical staff meetings
• Continuing medical education
• Clinicians compensated for each visit and could keep handheld computers
• Exam room posters and brochures• Meetings with community leaders
• News releases on self-management of ARIs
• Self-care materials distributed at health fairs
• Education at pharmacies and offices
Gerber et al39 and Gerber et al40Cluster randomized trial of pediatric practices focusing on ARIs,39 and follow-up for 18 months after intervention terminated40• ARI guidelines available as links in EHR• Quarterly personalized feedback and audit• 1 hour on-site clinician education
• Practice-specific antibiotic prescribing rates
• Used prescribing guidelines
Gonzales et al413-arm cluster randomized trial, with 11 practices in each group: (1) printed CDSS, (2) computerized CDSS, and (3) control.• Arm 1: printed CDSS for acute cough
• Arm 2: EHR CDSS
• Arm 3: no decision support
• Arm 1 and 2: printed patient education material
• Arm 1 and 2: template for ARI clinic visits
• Provider education and feedback in both intervention groups• Half-day training session• Provider education
• Practice guidelines
• Clinical champions
• Audit and feedback
Jenkins et al42Cluster randomized study of 8 primary care clinics randomized to CDSS pathways and patient education or usual care• 1 page CDSS pathway incorporated into EHR encounter template
• Patient education
• Peer champion provider at each clinic
Finkelstein et al43Cluster randomized trial: 12 pediatric practices in 2 MCOs in eastern Massachusetts and Washington State• Parents mailed CDC brochure on antibiotic use• Physician peer leaders reviewed prescribing guidelines in practice meetings
• Given feedback on practice prescribing
• Education displayed in waiting rooms• CDC campaigns for judicious antibiotic use
Meeker44Cluster randomized study of 47 primary care practices randomized to receive 0, 1, 2, or 3 behavioral interventions: (1) suggested alternatives, (2) accountable justification, and (3) peer comparison• Suggested alternatives: electronic order sets suggesting nonantibiotic treatments
• Accountable justification: prompts to enter justifications for prescribing antibiotics for nonindicated diagnoses
• Peer comparison: emails comparing antibiotic prescribing rates with those of top performers• Accountable justification: written justification would be seen in EHR as a note
• All groups received online ARI diagnosis and treatment education
Yang et al45Matched-pair cluster randomized trial in China• Disclosed prescribing status monthly to patients, health authorities, and health workers
Schnoor et al46Cluster randomized trial of 8 German clinical centers and 4 computer-based interventions• All received printed versions of poster and electronic version of guideline• Every other month, GPs given peer comparison• All received poster
Finkelstein et al47 and Ackerman et al75Controlled, community-level cluster randomized trials in 16 Massachusetts communities: physician behavior change strategy47 with follow-up75• Discussion guide at well-child visits
• Prescription pads for treatment of viral infections
• Stickers, lapel pins, and otoscope insufflators
• Bimonthly educational briefs
• Patient brochure
• Introductory letter to pediatricians and family practitioners• Educational coordinator visited practices
• Kick-off dinners
• Advertisements at child care centers and pharmacies
Huang et al48Cluster randomized trial of 3-year community-wide intervention for parents of children in 16 communities11• Educational newsletters• Educational materials in pediatrician offices, pharmacies, and child care settings
Vervloet et al49Matched randomized study of meeting with PCPs and pharmacists, 4 groups with intervention, and 4 matched controls• PCP communication skills training
• Antibiotic prescribing agreements in EHR
• Feedback session about group's prescribing
• More variation between physicians than within practices
Linder et al50Cluster randomized trial of 27 primary care practices to receive an EHR-integrated ARI CDSS• CDSS tool integrated into EHR
Linder et al51Cluster RCT of 27 primary care practices, by using an ARI quality dashboard• ARI quality dashboard• Audit and feedback
Cals et al52 and Cals et al53Pragmatic cluster randomized trial of Dutch PCPs of the impact of POC CRP testing and communication skills on antibiotic use in LRTIs,52 with follow-up of 3.5 years53• POC CRP testing• Communication training for physicians• Peer review of colleague transcripts with simulated patients
Mainous et al54Quasi-experimental design with 3-month baseline data collection period and 15-month follow-up in 9 intervention and 61 control practices• EHR CDSS tool is populated when ARI diagnosis entered
• CDSS installed on each practice's EHR progress note template
• Hyperlinks to patient and provider education
• Performance review
• Audit and feedback
• Quarterly meetings with audit and feedback
• Academic detailing
• Monthly phone calls with staff
• NIH and CDC guidelines to improve antibiotic prescribing for ARIs
• CDC Get Smart program
Slekovec et al55Quasi-experimental study of French GPs on quinolone prescription for UTIs• Guidelines mailed to GPs and available on website• 200 GPs attended training sessions• Regional guidelines
Gonzales et al56Quasi-experimental community-level study of mass media campaign in Colorado with comparison communities• Providers signed postcard soliciting support• Mass media campaign including outdoor and radio advertisements, billboards, bus tails, bus stop posters, interior bus signs, health fairs, and opinion pieces
Hurlimann et al57Swiss quasi-experimental study of sustained feedback of antibiotic prescription for ARIs and UTIs• Sustained individual feedback• New guidelines written
Vinnard et al58Quasi-experimental study with concurrent control groups of academic detailing and educational mailings• Educational mailings to providers and patients
• Prescription pads for symptomatic treatments
• Providers signed letters to patients
• Intensive intervention for highest prescribers• Academic detailing of providers (visits from pharmacist and antimicrobial stewardship expert)
Gonzales et al59Nonrandomized controlled trial, with (1) full intervention, (2) limited intervention, or (3) usual care• Full intervention: household and office-based patient education materials
• Limited intervention: office-based educational materials
• Full intervention: educational refrigerator magnets
• Full intervention: patients mailed pamphlet and letter from medical director
• Full intervention: clinician education
• Full intervention: clinic-specific antibiotic prescription rate for acute bronchitis
• Full intervention: 30 minutes of staff meeting
• Full intervention: setting clinic goals
• Full intervention: education on acute bronchitis management
• Full intervention: clinicians taught how to refuse antibiotic prescriptions
• Both intervention groups: educational posters in exam rooms
Gonzales et. al60Nonrandomized controlled trial of elderly patients with ARIs: 4 intervention practices and 51 control practices in Denver• Mailed campaign to patients
• Office-based materials
• Introductory letter from Department of Public Health
• Patient reference card on ARIs
• Patient refrigerator magnet
• Patient brochures on antibiotic resistance
• Focus groups with elderly volunteers for feedback• Individual prescribing profiles• Colorado-wide initiative to provide PCPs with performance feedback• Office-based materials: CDC posters, patient reference cards, and exam room posters
Formoso et al61Community-level, controlled, nonrandomized trial in northern Italy of educational campaign• Region-wide posters, brochures, and local media advertisements
• Region-wide physician and pharmacist newsletter
Yardley et al62Process analysis of RCT of GPs in study of LRTI antibiotic prescribing, including web-based training in use of CRP• Training software modifiable
• Patient booklet with checklist
• CRP intervention helpful
• Symptoms important to patients• Completing patient booklet checklist
Szymczak et al63Semistructured interviews with pediatricians, following an intervention39• Parental pressure as a barrier to stewardship• Skepticism of audit and feedback reports
• One respondent admitted to gaming behavior
Mustafa et al64Semistructured interviews of family doctors on ARIs• Avoiding confrontation
• Negotiating with patients
• Hedging
• Physical traits
• Exaggerated symptoms
• Patient expectations
• Clinicians ask patients about antibiotic expectations
• Pride
• Rapport
• Use physical exam findings to minimize signs
• Careful word choice
• Thorough exam
• Education
• Setting expectations
Grondal et al65Semistructured interviews of GPs regarding pharyngitis• GPs believed rapid Streptococcus test to be unreliable, as it only detects one bacterium
• CRP used to diagnose bacterial pharyngitis as way to screen for all bacterial infections
• Clinical presentation outweighs test results
• Streptococal pharyngitis should be diagnosed based on appearance
• All bacteria must be treated• Clinical presentation outweighs guidelines for management of Streptococcal pharyngitis
Munoz-Plaza et al66In-depth interviews of 6 PCPs and 3 urgent care providers about acute sinusitis• Need to find guideline when needed
• Visual cards and graphs to show patients when they will improve
• EHR with web-based patient education
• Help patients understand symptoms
• Patients want reward for copays and taking off work
• Patients see physicians with different practices
• No protected group education time
• Large health systems enable system-level alerts
• Limited time during patient visits
• Large educational posters in exam rooms• External pressures for patient satisfaction
• Patient can get antibiotics elsewhere
• Information overload with updated guidelines
• Copays for visits
Tonkin-Crine et al67Semistructured interviews of experts involved in GP ARI guideline development across 5 countries• Complementary patient education
• Computer reminders to reinforce guidelines
• Address GP concerns and explain the need for guidelines
• GPs worry about patients becoming ill without prescription
• Prescribing feedback helpful
• Academic detailing
• GPs assume practice already follows guidelines
• GPs may not engage with mandatory meetings
• Flexible interventions increase feasibility
• Interventions should engage GPs
• Develop guidelines based on research, not to save money
• Guidelines should be consistent
• Guidelines difficult to locate and lengthy
• Local versions of national guidelines
• Governmental funding and national campaigns
Wood et al68Qualitative interviews with PCPs in 9 European countries• Request access to local resistance data• Most PCPs did not see antibiotic resistance as a problem in their practice• Antibiotic resistance seen as issue for secondary care rather than primary care• Other countries thought to be responsible for resistance
• Self-prescribing of antibiotics
• Prescribing by dentists and hospital physicians leads to resistance
Mauffrey et al70Qualitative study of French PCPs about preferences for interventions• Dedicated prescription for antibiotics considered excessive
• Limit antibiotic availability in outpatient settings
• Computerized prescription aids
• Educational resources for patients in office
• Physician training
• Patient characteristics
• Avoiding prescribing antibiotics is dangerous
• Older prescribers: prescriptions influenced by habit
• Practice evaluation is difficult due to competing demands
• Prior approval of ID physician would make practice harder
• Restricted susceptibility testing
• Explain and repeat key messages
• Role of PCPs in educating patients
• Too many other health ministry-required tasks
• Performance-based incentives
• Public campaigns reinforce what they tell patients
• Physician awareness campaigns
Ronnerstrand et al71Qualitative semistructured interviews: patients asked to imagine seeing a physician for ARI, and how long they would delay filling prescription• Given prescription to fill later• More trust means patients would delay prescription• Willing to postpone treatment if told others would do the same
• Social capital
Dempsey et al72Semistructured interviews of 13 PCPs• Prefer of CDSS
• Prefer over-the-counter prescription pad
• Prefer patient educational materials
• Meet patient expectations• No accountability for prescribing
• Other clinicians' misconceptions about acute bronchitis
• Previsit triage and education by nurses may prevent visits
• Prescribe antibiotics to save time and money
• Diagnostic uncertainty
• Reporting of quality measures may help
Huddy et al69Qualitative focus group study of barriers and facilitators to use of CRP for diagnosing CAP among European GPs• Want not just POC CRP but other lab testing in the same system
• Need to test equipment and stay aware of shelf life of cartridges
• CRP as aid to communication• Centralized labs
• Different people perform test in different clinics (GP, nurse, and in-house lab)
• Quality control tasks
• Responsibility of GP
• Although CRP is cost-effective, individual practices may be liable for the cost of the test
• Loss of income to central labs
Rowbotham et al73Semistructured interviews and focus groups of UK NPs about experience with ARIs• Used drawings or information leaflets to teach patients• New NPs worried about making mistakes
• Patients exaggerated symptoms
• Peer support helpful with demanding patients
• Previous experiences with getting antibiotics from other providers
• Protocols support decision making
• Visits are time consuming and complex
• Provide self-management education
• Educate patients to prevent return visits
• Legal protection of NPs versus GPs
Kuzujanakis et al74Parenteral surveys• Parents demand antibiotics
• Privately insured and with more or older children had more knowledge
• Alternatives to antibiotics• Media information about antibiotics
• School or day care requires antibiotics
Murphy et al76Qualitative interview of GPs reviewing own charts of ARI encounters• Children less likely to receive antibiotics• Amoxicillin as placebo if physician did not think they need antibiotics
• Uncertainty in prescribing antibiotic
• External guidelines
Anthierens et al77Qualitative study using think-aloud approach with European GPs about using online tool for CRP ordering• Online intervention
• CRP used as evidence for patients on condition's seriousness
• Tailoring for individual countries and languages
• Considering needs of patients
• Level of attention and time taken needs to be brief
• Managing patient demands, fewer visits, decreased income
• GPs use communication skills
• Clarity of intervention
• Physical exam used to communicate to patients
• Countries differ in how involved patients expect to be in the decision
• Study in one country may not help in other countries
  • PCP, primary care provider; CDSS, clinical decision support system; RCT, randomized controlled trial; POC, point of care; ARI, acute respiratory infection; EHR, electronic health record; NIH, National Institutes of Health; CDC, Centers for Disease Control and Prevention; GP, general practitioner; LRTI, lower respiratory tract infection; CRP, C-reactive protein; ID, infectious diseases; MCO, managed care organization; CAP, community-acquired pneumonia; COPD, chronic obstructive pulmonary disease; NP, nurse practitioner; UTI, urinary tract infection; PCR, polymerase chain reaction; GAS, Group A Streptococcus; CAP, community-acquired pneumonia; UTI, urinary tract infection.

  • * Studies described include rigorously designed quantitative and qualitative studies describing antibiotic stewardship interventions and the context around antibiotic prescribing decisions, included through November 7, 2016.