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Implementation and outcomes of a clinician-directed intervention to improve antibiotic prescribing for acute respiratory tract infections within the Veterans’ Affairs Healthcare System

Published online by Cambridge University Press:  15 August 2022

Karl J. Madaras-Kelly*
Boise Veterans’ Affairs (VA) Medical Center, Boise, Idaho College of Pharmacy, Idaho State University, Meridian, Idaho
Suzette A. Rovelsky
Boise Veterans’ Affairs (VA) Medical Center, Boise, Idaho
Robert A. McKie
Boise Veterans’ Affairs (VA) Medical Center, Boise, Idaho
McKenna R. Nevers
Salt Lake City VA Health Care System, Salt Lake City, Utah University of Utah School of Medicine, Salt Lake City, Utah
Jian Ying
Salt Lake City VA Health Care System, Salt Lake City, Utah University of Utah School of Medicine, Salt Lake City, Utah
Benjamin A. Haaland
Salt Lake City VA Health Care System, Salt Lake City, Utah University of Utah School of Medicine, Salt Lake City, Utah
Chad L. Kay
VA National Academic Detailing Service, St. Louis, Missouri
Melissa L. Christopher
VA National Academic Detailing Service, San Diego, California
Lauri A. Hicks
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
Mathew H. Samore
Salt Lake City VA Health Care System, Salt Lake City, Utah University of Utah School of Medicine, Salt Lake City, Utah
Author for correspondence: Karl J. Madaras-Kelly, E-mail:



To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.


Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.


Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded.


Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary.


We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity.


We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78–0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59–0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73–1.09). Return visits (OR, 1.00; 95% CI, 0.94–1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92–1.59) were not different before and after implementation within facilities that performed intensive implementation.


Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity–dependent manner. No impact on ARI-related clinical outcomes was observed.

Original Article
Creative Commons
This is a work of the US Government and is not subject to copyright protection within the United States. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America.
© Department of Veterans Affairs, 2022.

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Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:18641873.CrossRefGoogle ScholarPubMed
Hersh, AL, King, LM, Shapiro, DJ, et al. Unnecessary antibiotic prescribing in US ambulatory care settings, 2010–2015. Clin Infect Dis 2021;72:133137.Google ScholarPubMed
Jones, BE, Sauer, B, Jones, MM, et al. Variation in outpatient antibiotic prescribing for acute respiratory infections in the veteran population: a cross-sectional study. Ann Intern Med 2015;163:7380.CrossRefGoogle ScholarPubMed
Bohan, JG, Madaras-Kelly, K, Pontefract, B, et al. ARI Management Improvement Group. Evaluation of uncomplicated acute respiratory tract infection management in veterans: a national utilization review. Infect Control Hosp Epidemiol 2019;40:438446.CrossRefGoogle ScholarPubMed
Meeker, D, Linder, JA, Fox, CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016;315:562570.CrossRefGoogle ScholarPubMed
Gjelstad, S, Høye, S, Straand, J, et al. Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study). BMJ 2013;347:f4403.CrossRefGoogle Scholar
Madaras-Kelly, K, Hostler, C, Townsend, M, et al. Impact of implementation of the core elements of outpatient antibiotic stewardship within Veterans’ Health Administration emergency departments and primary care clinics on antibiotic prescribing and patient outcomes. Clin Infect Dis 2021;73:e1126e1134.CrossRefGoogle Scholar
Meeker, D, Knight, TK, Friedberg, MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014;174:425431.CrossRefGoogle ScholarPubMed
Mangione-Smith, R, Zhou, C, Robinson, JD, et al. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med 2015;13:221227.CrossRefGoogle ScholarPubMed
Little, P, Stuart, B, Francis, N, et al. Effects of Internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 2013;382:11751182.CrossRefGoogle ScholarPubMed
Van der Velden, AW, Pijpers, EJ, Kuyvenhoven, MM, et al. Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections. Br J Gen Pract 2012;62:e801e807.CrossRefGoogle ScholarPubMed
Yadav, K, Meeker, D, Mistry, RD, et al. A multifaceted intervention improves prescribing for acute respiratory infection for adults and children in emergency department and urgent care settings. Acad Emerg Med 2019;26:719731.CrossRefGoogle ScholarPubMed
Hemkens, LG, Saccilotto, R, Reyes, SL, et al. Personalized prescription feedback using routinely collected data to reduce antibiotic use in primary care: a randomized clinical trial. JAMA Intern Med 2017;177:176183.CrossRefGoogle ScholarPubMed
Ratajczak, M, Gold, N, Hailstone, S, et al. The effectiveness of repeating a social norm feedback intervention to high prescribers of antibiotics in general practice: a national regression discontinuity design. J Antimicrob Chemother 2019;74:36033610.CrossRefGoogle ScholarPubMed
Solomon, DH, Van Houten, L, Glynn, RJ, et al. Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center. Arch Intern Med 2001;161:18971902.CrossRefGoogle ScholarPubMed
Kelly, AA, Jones, MM, Echevarria, KL, et al. A report of the efforts of the Veterans’ Health Administration National Antimicrobial Stewardship Initiative. Infect Control Hosp Epidemiol 2017;38:513520.CrossRefGoogle Scholar
Suda, KJ, Hicks, LA, Roberts, RM, et al. Antibiotic expenditures by medication, class, and healthcare setting in the United States, 2010–2015. Clin Infect Dis 2018;66:185190.CrossRefGoogle ScholarPubMed
Sanchez, GV, Fleming-Dutra, KE, Roberts, RM, et al. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65(6):112.CrossRefGoogle ScholarPubMed
Harris, AM, Hicks, LA, Qaseem, A. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016;164:425434.CrossRefGoogle ScholarPubMed
Chow, A, Benninger, M, Brook, I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72e112.CrossRefGoogle ScholarPubMed
Rosenfeld, RM, Piccirillo, JF, Chandrasekhar, SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015;152 suppl 2:S1S39.Google Scholar
Shulman, ST, Bisno, AL, Clegg, HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:e86e102.CrossRefGoogle Scholar
Corporate Data Warehouse (CDW). US Department of Veterans’ Affairs Health Services Research & Development website. Accessed November 19, 2021.Google Scholar
Avorn, J. Academic detailing: “marketing” the best evidence to clinicians. JAMA 2017;317:361362.CrossRefGoogle ScholarPubMed
Livorsi, DJ, Nair, R, Dysangco, A, et al. Using audit and feedback to improve antimicrobial prescribing in emergency departments: a multicenter quasi-experimental study in the Veterans’ Health Administration. Open Forum Infect Dis 2021;8:ofab186.CrossRefGoogle Scholar
Buehrle, DJ, Shively, NR, Wagener, MM, et al. Sustained reductions in overall and unnecessary antibiotic prescribing at primary care clinics in a Veterans’ Affairs Healthcare System following a multifaceted stewardship intervention. Clin Infect Dis 2020;71:e316e322.CrossRefGoogle Scholar
National Center for Healthcare Statistics. Veterans’ health statistics. Centers for Diseases Control and Prevention website. Accessed November 19, 2021.Google Scholar
Yoo, M, Madaras-Kelly, K, Nevers, M, et al. A Veterans’ Healthcare Administration (VHA) antibiotic stewardship intervention to improve outpatient antibiotic use for acute respiratory infections: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2021. doi: 10.1017/ice.2021.393.CrossRefGoogle Scholar
Gong, CL, Zangwill, KM, Hay, JW, et al. Behavioral economics interventions to improve outpatient antibiotic prescribing for acute respiratory infections: a cost-effectiveness analysis. J Gen Intern Med 2019;34:846854.CrossRefGoogle ScholarPubMed
Rognstad, S, Brekke, M, Gjelstad, S, et al. Potentially inappropriate prescribing to older patients: criteria, prevalence and an intervention to reduce it: the prescription peer academic detailing (Rx-PAD) study—a cluster-randomized, educational intervention in Norwegian general practice. Basic Clin Pharmacol Toxicol 2018;123:380391.CrossRefGoogle Scholar
King, LM, Lovegrove, MC, Shehab, N, et al. Trends in US outpatient antibiotic prescriptions during the coronavirus disease 2019 pandemic. Clin Infect Dis 2021;73:e652e660.CrossRefGoogle ScholarPubMed
Weiner, JP, Bandeian, S, Hatef, E, et al. In-person and telehealth ambulatory contacts and costs in a large US insured cohort before and during the COVID-19 pandemic. JAMA Netw Open 2021;4:e212618.CrossRefGoogle Scholar
Rubin, R. Influenza’s unprecedented low profile during COVID-19 pandemic leaves experts wondering what this flu season has in store. JAMA 2021;326:899900.CrossRefGoogle ScholarPubMed
Roth, S, Gonzales, R, Harding-Anderer, T, et al. Unintended consequences of a quality measure for acute bronchitis. Am J Manag Care 2012;18:e217e224.Google ScholarPubMed
HEDIS measures, antibiotic utilization for respiratory conditions. National Committee on Quality Assurance website. Published 2022. Accessed February 15, 2022.Google Scholar
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