The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial

Background: The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient-and physician-facing feedback and behavioral nudges embedded in the electronic health record. Methods: Teladoc (R) clinicians are assigned to one of 9 arms in a 3 x 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Bench-mark Peer Comparison, Trending, Control). After randomly selecting 1/3 of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have > 80% power to detect 1-7% absolute differences in antibiotic prescribing among groups. Discussion: Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use.

Automated summary

This study aims to reduce inappropriate antibiotic prescriptions for acute respiratory infections (ARI) using telehealth. A large randomized quality improvement trial is conducted to test the effectiveness of patient and physician feedback, as well as behavioral nudges embedded in the electronic health record. The findings from this trial may inform telehealth stewardship strategies and provide guidance for safe and effective antibiotic use.