Improving Care Through Research: Combating Antibiotic Overuse

Thanks to their bacteria-fighting abilities, antibiotics have been important in combating serious diseases such as tuberculosis, as well as more common conditions such as ear infections. However, as useful and effective as antibiotics are, taking them when they are not necessary can be harmful. The problem often can be traced to patients who think antibiotics are the answer to their ailment, as well as physicians who succumb to pressure to prescribe them, even when not necessary. 

To understand what drives the overuse of antibiotics as well as determine approaches to improving physician prescribing practices, Corrine Munoz-Plaza, MPH, and Adam L. Sharp, MD,  from the Kaiser Permanente Southern California Department of Research & Evaluation led a research effort aimed at improving quality and care efforts within Kaiser Permanente. 

The researchers focused specifically on antibiotic prescriptions for acute sinusitis (also known as a sinus infection), which affects more than 30 million people each year in the United States. It is estimated that 85 percent to 98 percent of people with acute sinusitis receive a prescription for antibiotics, even though current guidelines do not recommend antibiotics for most patients. 

We spoke with Dr. Sharp, an emergency department physician and researcher, to learn more about the study and how the research resulted in changes within Kaiser Permanente to help reduce unnecessary antibiotic prescriptions. 

Q: Tell us more about your study and the rationale behind it. 

This specific study builds on our earlier research, which found there was room for improvement in our antibiotic prescribing rates at Kaiser Permanente. But we wanted to understand what was driving physician prescribing patterns. To do this, we utilized both quantitative and qualitative research methods. In the quantitative phase, we analyzed data from adult health plan members who were diagnosed with acute sinusitis. We used the findings from this analysis to inform the qualitative phase of the study, which included interviews with prescribing physicians. 

The research was led by the Care Improvement Research Team at Kaiser Permanente, which is focused on collaborating with clinicians, patients and other stakeholders to identify gaps in care delivery and utilize research to help close these gaps. 

Q: What were the key findings?

As part of our quantitative research, we found unnecessary antibiotic prescribing was common and that primary-care and urgent-care visits resulted in more antibiotic prescriptions than emergency department visits. Based on these findings, we focused our interviews for the qualitative research portion on primary-care and urgent-care physicians. 

During these face-to-face interviews, we learned physicians wanted to help patients better understand their symptoms and recommended treatments for uncomplicated sinusitis. However, a challenge was finding enough time to effectively convey the current recommendations against unnecessary antibiotics, particularly with newer patients with whom the physician may not have a relationship. In addition, physicians faced multiple barriers to not prescribing antibiotics, including patients’ expectations for receiving a prescription as well as a perception that providing a prescription may increase patient satisfaction ratings. 

Q: How did you use this research to help improve care within Kaiser Permanente?

Armed with these findings, we designed and implemented the following to reduce the use of unnecessary antibiotics:

  • An educational presentation targeting acute-care providers to highlight current recommendations for diagnosing and treating acute sinusitis
  • A system-level best-practice alert within the Kaiser Permanente electronic medical record to remind physicians about guideline recommendations for treating acute sinusitis
  • A patient-friendly publication embedded within the best-practice advisory that physicians could share with their patients to help in discussions with those seeking unwarranted antibiotics

 Q: Have you seen a tangible difference in prescribing patterns as a result of these efforts?

We have seen a decline in the number of unnecessary antibiotic prescriptions and these results are currently under review for publication. We look forward to sharing specific results in the coming months. 

Our work serves as a pragmatic example of the benefits of embedded research and showcases one of the strengths we have at Kaiser Permanente of using an integrated approach to improve health care. Thanks to this collaborative effort, we were able to translate our research into meaningful clinical practices that can truly benefit patients.