Shannon P.: Good afternoon. We have a group assembled here to talk a little bit more about antibiotic stewardship and some of the really innovative work we've got going on here at Intermountain and some of the national needs and trends. Maybe let me have our distinguished panel introduce themselves. How about our Intermountain team first and then we'll have our guests?
Whitney Buckel: Sure. I'm Whitney Buckel, and I'm the System Antibiotic Stewardship Pharmacist Lead and the Infectious Diseases Pharmacist Manager for Intermountain Healthcare.
Adam Hersh: I'm Adam Hersh, and I'm a pediatric infectious diseases physician at Primary Children's Hospital.
Eddie Stenehjem: And I'm Eddie Stenehjem, I'm an infectious disease physician and I'm a Medical Director of Stewardship in the Office of Patient Experience.
Shannon P.: Katherine, do you want to introduce herself?
Katherine: Yes. So, I'm Katherine Fleming-Dutra. I'm the Deputy Director of CDC's Office of Antibiotic Stewardship and I am a pediatric emergency physician.
Shannon P.: Okay, so we've got two pediatricians here, three pediatricians here. So careful. You are totally outnumbered. So be aware: Katherine maybe let me start with you. The centers for disease control and prevention probably are one of the most important voices in healthcare today. Why is the CDC focused on antibiotic stewardship?
Katherine: Well, so as you all know, antibiotics are life saving medicines and they underpin modern medicine. So, having effective antibiotics is critical to being able to perform surgeries, transplant, chemotherapy, the things that we've all come to rely on. And so that's why antibiotic resistance is one of the most pressing global public health threats. And stewardship, which is the effort to measure and improve antibiotic use is a key strategy in combating antibiotic resistance. But it's also a key strategy in delivering high quality healthcare, protecting patients from avoidable adverse events and getting them the right care. And so that's why CDC is focused on antibiotic stewardship as an important public health priority.
Shannon P.: And when I think about antibiotic prescribing, and we have focused very much in hospitals, I think we have just big guns and more and more opportunities to create resistance. But in fact, isn't it true that most antibiotic prescribing happens in the ambulatory setting? And what are our biggest, most pressing issues in ambulatory stewardship?
Katherine: Right. You're correct. By volume, most antibiotics used in human healthcare are used in the outpatient setting probably 85 to 95% by volume is what we estimate of antibiotics in human healthcare are used in outpatients. There are a lot of opportunities to improve antibiotic use in outpatient settings. We estimate that about 30%, at least 30% of outpatient antibiotics are unnecessary, meaning no antibiotic was needed at all. And we know that there are certain conditions that are key drivers of inappropriate antibiotic use, so acute respiratory infections, things like colds, acute bronchitis, sinus infections, ear infections are key drivers of antibiotic use, and there's lots of opportunities to improve antibiotic use and reduce unnecessary prescribing for those conditions.
Shannon P.: So, I think providers, physicians, APPs want to do the right thing. Three out of 10 is not highly reliable, right? That feels like a big opportunity, shall we say. What do you think is getting in the way of being closer to 10 out of 10 use in the right circumstances?
Katherine: I think there's a number of reasons that clinicians don't prescribe antibiotics as they should or as is recommended by guidelines. I think there may be in the outpatient setting, most conditions for which antibiotics are prescribed are fairly common conditions and most clinicians know what they're supposed to do with those conditions. So, knowledge gaps are probably not the major driver of inappropriate use in the outpatient antibiotic setting, but other drivers are diagnostic uncertainty. So, the clinician's not entirely sure what the patient has. So, they may prescribe an antibiotic to feel safe. Other potential or other reasons that we hear from clinicians that they use antibiotics when they maybe shouldn't is that they're worried about what the patient expects. So, if they think the patient expects an antibiotic, they are more likely to prescribe an antibiotic even if that patient doesn't need one. I think clinicians, they want to do the right thing. They want their patients to be happy. And so patient demand is a driver for inappropriate antibiotic use.
Shannon P.: So, let me ask our Intermountain team. We, I think have really taken on prescribing in the outpatient setting. And as Katherine mentioned, the respiratory infection piece. So that's our bullseye, right? That's our target. She's mentioned diagnostic uncertainty, meeting patient's expectations. Are those some of the things that we're seeing in our early work in this space?
Eddie Stenehjem: Yeah, I'll take that. It is. And so, one of our key interventions was to get out and talk to our clinicians and talk to them about what is driving their prescribing and why they prescribe. And Katherine hit it on the head that they all want to do the best thing for the patient. Without a doubt. They're caring physicians. And so, it's talking to them about what are their drivers and how can we potentially change some of those to really get at optimal prescribing. And patient satisfaction, patient expectation came out time and time again. And so how can we communicate with our patients so that we hear them, and we understand them, and we can still provide them the best care that they have. And from our standpoint, from our office, it's developing the tools needed for them to be able to take care of their patients. And you're right, respiratory prescribing is the bullseye. And that is our main focus right now.
Shannon P.: The patient expectation, have we created that image for ourselves or do we know that patients expect an antibiotic when they see a doctor in an urgent care setting for an acute illness?
Eddie Stenehjem: Yeah, we've talked to patients and we've asked what their expectation is when they come to see us in urgent care and their expectation is that we care for them, that we listen to them and we provide them an expert opinion from a trusted professional. They're not coming for an antibiotic. Very rarely have we heard that and that is a message that we're really trying to get to our providers because I think there is a discrepancy there in terms of the providers, whether it be a physician or APP, thinks one thing about the expectation of the patients and the patients are thinking another. And we've really have not heard that theme from our patients. They want to be cared for. They want to be listened to.
Whitney Buckel: Right. Clearly, there are some patients who do come in demanding antibiotics, and I think that those few patients, like Eddie mentioned, probably speak loudly in the minds of the clinicians when they're encountering patients. It's not like they've made up that patients are expecting antibiotics. There are those that do. It's just understanding that they're the minority and not the majority. That I think will be helpful in terms of our education.
Shannon P.: Is there anything about pediatric care that's different, do parents expect something different or are they more nervous for their kids than themselves?
Katherine: It's interesting. I'm parents probably are more nervous for their children than they are for themselves, but that feeling goes both ways. They're also more nervous about giving unnecessary medications. So parents, in some of the data we have looked at have been more concerned about antibiotic adverse events than adult patients, and they're more wary of getting a medicine that their child may not need. So I think, yes, they're more nervous, but I think they want more of that communication and making sure their child's receiving the best care for their illness.
Shannon P.: So, we've talked a bit about focusing on antibiotic stewardship in urgent care settings and acute needs such as respiratory conditions. Are there other aspects to stewardship in addition to the yes or no decision about antibiotics that we want people to pay attention to?
Katherine: Right. So, improving antibiotic use is about prescribing the right antibiotic or prescribing an antibiotic when it's needed and only when it's needed and if it's needed, picking the right antibiotic, giving the right dose, giving it for the right duration. And so other important targets that we see in the national data are improving antibiotic selection to align with guideline recommendations for what should be used first line, as well as reducing the duration of antibiotic prescriptions when they're needed to the minimum effective duration. So, what guidelines say is needed to treat the illness and then not extending that duration beyond that time frame.
Shannon P.: Have we seen... So, I think about the right time, the right dose, duration. I feel like there's an opportunity to leverage electronic health records or the workflow that exists to put the right information in front of people at the right time. So, I imagine there are regional, for some conditions, regional differences and what first line means there. And how are we making it easy in healthcare today for people to know what's right, have it in front of them, maybe default lengths of prescription if you're going to give a drug to the shortest important, complete, but shortest course, are we doing that well enough today?
Eddie Stenehjem: We're certainly trying, and a number of our interventions are really focused on making it easy for our providers to do the right thing and leveraging the EHR to do that. And so building out order sets and order sentences that are automatically defaulted to the correct duration and the correct drug. And steering clinicians to utilize those tools because it saves them time and allows them to do the right thing. It's been a major focus of ours and we've gone through and revamped all of our care process models for these common conditions to ensure that we're including the lowest duration of therapy, and then educating to those. And not only that is that we then measure and assess the appropriateness of care based on those care process models. And so, we then reflect that data back to clinicians and they can see how they're doing in comparison to their peers. It's all trying to do the best thing at the easiest cost.
Shannon P.: So, Adam, I think about data and transparency and I imagine there's a lot of power. I mean, I think as physicians we all want an A on the test. And I imagine Intermountain's not different than many places where we have people who prescribe a lot and people who don't prescribe very much at all. And what's your sense of how the data helps us drive getting to the right place with our caregivers?
Adam Hersh: It's an extremely powerful tool for a couple of reasons. Number one, clinicians are inherently something like competitive. All clinicians want to feel like they're really good at their job and we know not only from antibiotic stewardship but from other areas of medicine that benchmarking and peer comparison are really effective strategies to help clinicians look inwardly and realize that there may be in some circumstances a better way to deliver care. So, the power of peer comparison with antibiotic prescribing is something that we're leveraging in our work in outpatient stewardship. Complete transparency about a variety of antibiotic prescribing metrics has been a really powerful tool to allow clinicians to realize that hey, there are peers of mine who are doing it differently and successfully. And sort of in a related way the power of peer comparison as a way to measure safety of a certain practice style that for instance, we can learn from our peers that prescribing antibiotics less often for the same conditions does not result in untoward bad health outcomes and adverse events. And that's also a really powerful way for us to be able to communicate to clinicians that it's safe in most circumstances to prescribe antibiotics less often for uncomplicated respiratory tract infections, and you can see that your peers are doing it. They're doing it often for lots of patients and safely.
Shannon P.: So, we're giving lead measures, right? So, the prescribing, how often we do that. My natural gut is that they also are wanting to know the lag, right? So, did someone suffer an untoward event? Did they actually get sicker and it was bacterial? Are we able to provide in this urgent care work, that kind of data to our prescribers as well?
Eddie Stenehjem: We will. Unfortunately we can't do that in real time. And it speaks to the fact that to Katherine's point, these conditions that we're seeing are very common conditions that don't typically lead to poor health outcomes. And so, you're right, our lag measures include hospitalizations, complications from sinusitis, which include meningitis and things like that. Incredibly rare events in terms of these conditions. And so, we've looked at this and have shown that there is no difference in these conditions when you receive an antibiotic and when you don't, and these lag measures. And so, there'll be something we'll be continuing to monitor. But because they're such rare events, it's not something we can monitor in real time like we can with our leading measures, which are just the nature of leading and lag measures.
Shannon P.: Right. So, health care thankfully is changing. We have depended so much on going to see someone physically to get care. We have often asked our patients to come to us in the times we're open. If you think about primary care offices and the opportunity to get care where, when and how you want in the sort of digital transformation of healthcare is very powerful. So not only do you still have a primary care medical home, we also have opportunities for you at off hours to go to an urgent care setting where people will, again, see you physically and support your needs urgently. And then we have of course the exploding field of telehealth where many urgent conditions can be dialed up on your phone and you can have a conversation with a clinician to understand your current needs. How do we see that? Where is antibiotic stewardship in that continuum? Has it been jogging right alongside it? Are we feeling really good about primary care, but tele-health's still a little squishy? How have we been able to transition with the digital pivot that healthcare's taking?
Katherine: So, from the national perspective, I would say that there's lots of opportunities to implement stewardship in all of those settings. Certainly, I think a lot of the evidence and what works has come out of primary care settings, but we still have a lot of opportunity to improve antibiotic use in primary care settings and a lot of primary care settings that need to implement stewardship. The same is true of urgent care of retail health settings and of tele-health as well. My hope is that we have an opportunity now with tele-health really just starting to take off to try to get stewardship and from the beginning. And I think wherever you receive care, the goal is always that you get an antibiotic only if needed and the right one at the right dose, the right duration and that's what we hope to do in all settings.
Shannon P.: Do we feel like the approach to that is different or getting to people or will it be about transparency? Is that the magic regardless of the setting, what might be different?
Eddie Stenehjem: I think for us, and we've looked and had been partners with our tele-health group called Connect Care, is that we're a part of an integrated healthcare system. And so, our Connect Care service is part Intermountain Healthcare. And so the incentives for clinicians on that service may be a little different in the fact that if they're seeing a patient that they feel requires an in person evaluation because they have ear pain and they may need somebody to look in their ear to diagnose otitis media, that they can refer them into our indoor the network. And so, they can be seen by their primary care in their home or wherever they can seek care. And I think that's a subtlety that's really important to call out in terms of how we approach stewardship in that setting because we can offer them the services that can address their need most effectively. And when you talk about other models of tele-health, when you're not part of an integrated healthcare system, I think that's different. And we've shown within our work that our tele-health platform does relatively well from an antibiotic stewardship standpoint and is one of our best practicing essentially urgent care clinics in terms of the respiratory prescribing rate and other measures of quality.
Whitney Buckel: I think it's really interesting that you bring this up because it's a little different in the outpatient than the inpatient setting in that there's this opportunity for the patient to shop around, to go to their primary care, to go to an urgent care, to go to tele-health or even to go to their pharmacy because there are now pharmacies that are offering these services for certain uncomplicated infections.
Shannon P.: [inaudible] Right? Yeah.
Whitney Buckel: Yeah. So, I think we have to really think about, especially as a health system, not having a we're only going to focus on this one setting approach but doing something comprehensive so that our stewardship efforts in one area compromise in another area. And that's what we're focused on.
Shannon P.: Katherine, is this CDC thinking about integrated delivery systems like Intermountain, right? We, as I think Eddie said, we're transparent and paying attention regardless of the modality, what channel someone's using, what's the stewardship capability, what are we doing, we'll look at that. Retail direct to consumer tele-health are set up for different reasons, and I think there's going to be some real positive out of that. I also think it's a different group of people and they aren't the people that probably CDC has traditionally spending time with. Right? So, by nature you're with health systems, you're with hospitals, you're with those folks. Is there some intention on the part for a national look at this to really engage the companies that are out there direct to consumer?
Katherine: Yes. And so, one example of how CDC is trying to work across the spectrum of health care, making sure that we're engaging the right stakeholders is the recently completed antimicrobial resistance or AMR challenge, which you may have heard about. That was a year long effort, a global year long effort really from the US government at large to engage stakeholders on how they're going to step up to combat antibiotic resistance. And there's been some really exciting and significant commitments from health systems, from urgent care organizations, retail health clinic providers, tele-medicine providers as some examples of how they're going to be including stewardship going forward. And so, the answer is that, yes, that CDC's very intentionally trying to make sure that we're reaching out to all of those stakeholders to engage them in stewardship efforts.
Shannon P.: Great. The urgent care work here at Intermountain, I think you guys will correct me if I wrong, but has had intention around transparency to data, listening to providers about what they experience, what's important to them, and giving great care and has focused on embedding as much as possible, doing the right thing in their workflow, supporting them to be successful. And what I love is on top of that, we've asked those we serve what matters to them. And so, to be able to say with confidence, not everybody's coming in for an antibiotic, I think Whitney put that forward. Tell me a little bit about how the voice of those we serve has impacted our thinking around effective stewardship in the urgent care setting.
Eddie Stenehjem: Yeah, that's a good point that I think has been really come out of our work is that we went and we talked to the patients and we talked to patients, and said, "What do you value when you come to urgent care?" And we, as we kind of ventured into this, had one set of ideas and then when we went and talked to the patients, we turned out we were wrong. And we needed to really pivot and emphasize what the patient needs.
And the example of this is we had developed a patient symptomatic therapies' checklist, essentially a checklist for patients to say, or for a clinician to say for your symptoms, I want you to go to Walgreens and take these over the counter medications. And as we entered into this, we essentially minimized that tool. We didn't think that that was really going to have a big benefit because of work that we had done previously and read about just, it didn't rise to the top is one of our big interventions. But when we went to patients and we showed this tool patients, we got a completely different perspective. And what they said is that if a clinician used this tool with me, if they went through this tool and evaluated and heard my symptoms and then developed a treatment plan specifically for my symptoms using this tool, I would feel that I gained value, that I'd been listened to and that I'd be acceptable to not take an antibiotic for that because you as a professional developed a treatment plan for us. And that's just an example of how the patient's voice came through this and how it changed our implementation strategy in terms of what we emphasized. And we have other stories in terms of what different things they recommended. But I think that just highlights how important it is to listen to them and to go and talk to them.
Shannon P.: And Adam, I think there are lessons to learn from opiate prescribing where we have actually one of the most important things about diminishing opiate prescribing has been giving people tools to have a conversation, making them feel effective in saying why we don't do something right? Because the natural easy answer is, "Well it's easier to give a prescription." And so that time. And what do you think in our work here has been effective about helping our clinicians feel empowered to not prescribe?
Adam Hersh: I think there's a lot more work we need to do and we're early in this intervention and we've kind of targeted what we view as maybe the lowest hanging fruit, but one of the areas... and we've made some progress. In the first several months, we've found real, genuine evidence that antibiotic prescribing appears more appropriate in some cases, greater use of the recommended antibiotics for certain conditions. And in the grand scheme also just fewer antibiotics are being prescribed during urgent care encounters. And that is the direction that we think this needs to go.
But this is a continuous process and there are a lot of clinicians who for whom changing how they practice is a big challenge. And one of the big barriers is the fact that it's really fast and efficient to make a diagnosis of a respiratory tract infection and prescribe an antibiotic. And a lot of urgent care physicians are under incredible time pressures to see a lot of patients, the waiting rooms are really crowded. And one of the areas that we need to work with our clinicians, an area for future work is in helping clinicians develop communication strategies that can lead them to providing the right care, which in many cases is not prescribing an antibiotic, but to get to that end point efficiently and in a way that makes patients feel cared for and comfortable with the results of the visit. So that's an area for a lot of future work for us.
Shannon P.: Great. Katherine, you do this work, right? You are actually a real live pediatrician in this space. What do you see when you're wearing that hat as opposed to the CDC hat, among the people you work with and for yourself personally in this space?
Katherine: You're right. When I practice clinically, I practice on the urgent care side of a pediatric emergency room and I almost exclusively practice on nights and weekends. So, I am very sympathetic to the provider that has a busy waiting room, potentially some unhappy families who have waited a long time and who are concerned about their child, what's wrong with them and how they're going to make them better. And so, I think it's incredibly important in all of our stewardship efforts and I think you all are doing a great job of that to really understand what the real barriers are for the clinicians and how we can support them and make the right choice, the easy choice. And I think as we've talked about, provider patient communication is incredibly important and how can you support them in a way to make that an easy, efficient and effective conversation that leaves both the provider and the patient feeling good about the decision and the encounter at the end of that encounter is really critical. And I think can really be a big help. Tools like this symptomatic therapy pad, other things that help you get that message effectively across to the patient I think are really important and have been useful to me in real life patient encounter, late at night with, yeah, with families.
Shannon P.: And I think nights and weekends are when parents are the most scared, right?
Shannon P.: So, you have to put those skills, the fine-tuned communication skills to a point particularly at those times. So if I asked you all kind of in wrap up, each of you, what is in the work you've done in stewardship, what is the one pearl you might want to share with health systems, with retail, with any number of people who are doing this in the urgent care space specifically, what's a, hey think about this, get a start here, whatever that is. What strikes you? Because you all have done collectively an incredible amount of thinking in this space. So, what would you share?
Adam Hersh: I think you mentioned this earlier, Shannon, and I think it really is such an important observation that relates to antibiotic stewardship, which is the power of defaults. And for a long time, the default approach to delivering care for patients with, for example, respiratory tract infections was the idea that the safest and best plan was to prescribe an antibiotic. It might help and it's not going to hurt. And what we've learned really more than anything with antibiotic stewardship is that antibiotics do hurt. And in the setting of urgent care, treating uncomplicated respiratory tract infections, most of the time antibiotics don't help. And I think resetting and changing the default to an approach that says we're going to care for patients, but the default is generally going to be that we're not going to prescribe antibiotics. And there may be certain circumstances where we identify when antibiotics are actually necessary. But starting from a default of providing symptomatic care for patients and having a contingency plan, that's the new default. And that's what I think really kind of defines the work that we're putting into place.
Whitney Buckel: I think for me, one of the things I'd like to highlight from Intermountain is just the multidisciplinary approach that we've taken to tackle this problem. It could be easy to say it's only one specialty that needs to focus on it, but the fact that really patients hear messages from more than just the provider. They also hear messages from their pharmacy and even from the frontline staff, and really understanding that multidisciplinary approach I think will help other health systems and other groups be successful.
Eddie Stenehjem: I mean, I think as a system leader in this, the biggest takeaway from me has been listening, and going out and listening to providers and listening to patients and having that kind of growth mindset of, yes, we are experts in antibiotic stewardship, but I don't practice urgent care medicine. I am not an urgent care patient and going out and showing the clinicians that we care and we need their opinion and we need their engagement in this really shows to them that we're in this together and that we're a team and we can take all the great materials that CDC has created in their core elements and with their input, we can adapt that to meet the needs of our caregivers and our patients. And that's been, I think, my take away from the work we've been doing.
Katherine: I think the biggest pearl that I would want to pass on is that we can do this. There have been examples of success in antibiotic stewardship and improving antibiotic use. On the national level, we've seen tremendous improvements in antibiotic use in the care provided to children over the last couple of decades. In local areas, we've seen urgent cares be successful EDs be successful, primary cares be successful and it only gets easier as we all do this together. If the urgent care is giving the same message that the primary care doc's giving that they're getting at a retail clinic or from telehealth, it makes everyone's job easier. So, from the CDC standpoint, we want everybody to be moving in this direction and I'm hoping to see some great progress.
Shannon P.: Okay. So, I think I heard we can do this, that listening matters, that making it easy for people to do the right thing matters, and that everybody who cares for patients can participate in doing this well. And I love your comment about if we're all doing it, it's not going to feel different in one place than another, and I think that's an important place to aspire to. So, thank you. This is Shannon Phillips, Chief Patient Experience Officer at Intermountain Healthcare signing off.