Reducing Antibiotic Prescribing in

Primary Care for Respiratory Illness

Matthew P. Kronman, MD, MSCE,a,b Jeffrey S. Gerber, MD, PhD,c Robert W. Grundmeier, MD,c Chuan Zhou, PhD,a,b
Jeffrey D. Robinson, PhD,d John Heritage, PhD,e James Stout, MD,a Dennis Burges, BA,a Benjamin Hedrick, BA,a
Louise Warren, MPH,a Madeleine Shalowitz, MD, MBA,f Laura P. Shone, DrPH, MSW,g Jennifer Steffes, MSW,g
Margaret Wright, PhD,g Alexander G. Fiks, MD, MSCE,c,g Rita Mangione-Smith, MD, MPHh

BACKGROUND: One-thirdof outpatient antibiotic prescriptions for pediatric acute respiratory tract abstract
infections (ARTIs) are inappropriate. We evaluated a distance learning program’s
effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.
METHODS:In this stepped-wedge clinical trial run from November 2015 to June 2018, we
randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings
Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media,
bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to
,11 years old without recent antibiotic use were included. Clinicians received the
intervention as 3 program modules containing online tutorials and webinars on evidence-
based communication strategies and antibiotic prescribing, booster video vignettes, and
individualized antibiotic prescribing feedback reports over 11 months. The primary outcome
was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression
compared prescribing rates during each program module and a postintervention period to
a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for
interpretability.
RESULTS:Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed
a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the
baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90–0.96).
Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI,
0.50–0.87) and sinusitis (aRR 0.59; 95% CI, 0.44–0.77) but not for acute otitis media (aRR
0.93; 95% CI, 0.83–1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95%
CI, 0.51–0.70).
CONCLUSIONS: This
program reduced antibiotic prescribing during outpatient ARTI visits; broader
dissemination may be beneficial.

a WHAT’S KNOWN ON THIS SUBJECT: Behavioral interventions including

Department of Pediatrics, University of Washington, Seattle, Washington; bSeattle Children’s Research Institute, individualized clinician prescribing feedback can reduce inappropriate antibiotic
Seattle, Washington; cDepartment of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; prescribing in ambulatory settings. These interventions have not been previously
d
Department of Communication, College of Liberal Arts and Sciences, Portland State University, Portland, Oregon; paired with communication training and evidence-based education on antibiotic
e
Department of Sociology, University of California, Los Angeles, Los Angeles, California; fNorthShore University prescribing for childhood acute respiratory tract infections.
HealthSystem, Evanston, Illinois; gPrimary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
h WHAT THIS STUDY ADDS: In this multisite stepped-wedge cluster-randomized trial,
Kaiser Permanente Washington Health Research Institute, Seattle, Washington
the Dialogue Around Respiratory Illness Treatment intervention combined
communication training, evidence-based antibiotic prescribing education, and
individualized prescribing feedback, producing a 7% sustained reduction in the
probability of antibiotic prescribing for acute respiratory infection visits.

To cite: Kronman MP, Gerber JS, Grundmeier RW, et al.

Reducing Antibiotic Prescribing in Primary Care for
Respiratory Illness. Pediatrics. 2020;146(3):e20200038

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PEDIATRICS Volume 146, number 3, September 2020:e20200038 ARTICLE
Antibiotic prescribing for childhood scale intervention combining best assignment. Enrolled clinicians
acute respiratory tract infections practices in antibiotic prescribing received intervention modules
(ARTIs) occurs at an estimated feedback, behavioral interventions, according to their practice-assigned
annual rate of 421 prescriptions per and communication techniques used wedge. Two NorthShore clinicians
1000 population, accounting for to reduce inappropriate antibiotic saw patients at 2 study sites
.70% of all antibiotics prescribed prescribing for pediatric ARTIs is randomly assigned to different
to ambulatory children.1,2 lacking. wedges. For both clinicians, all visits
Approximately one-third of all at either study site after their earliest
We developed the Dialogue Around
antibiotic prescriptions for childhood intervention exposure were
Respiratory Illness Treatment (DART)
ARTIs are likely inappropriate, considered postintervention visits.
quality improvement (QI) program,
accounting for .10 million
hypothesizing that pairing Internet-
potentially preventable antibiotic Study Visit Inclusion and Exclusion
based communication skills training Criteria
prescriptions for US children
with individualized antibiotic
annually.2,3 Although recent data Visits by children aged 6 months
prescribing audit and feedback would
revealed that oral antibiotic
reduce overall antibiotic prescribing to ,11 years of age with an
prescriptions for all pediatric
for ARTI. International Classification of
conditions decreased 13% from 2011 Diseases, 10th Revision (ICD-10)
to 2016, the 2015 US Government diagnosis code (Supplemental
action plan targets a 50% reduction METHODS Table 5) for AOM, bronchitis,
in inappropriate outpatient antibiotic pharyngitis, sinusitis, or upper
use by 2020.4,5 Study Design, Participants, and
respiratory infection (URI) were
Setting
included. Only oral antibiotics
The American Academy of Pediatrics We implemented the DART QI prescribed on the clinic visit date
(AAP) and Infectious Diseases Society program using a cluster-randomized were included in prescribing
of America have published treatment stepped-wedge clinical trial to measures for each ARTI. ARTI visits
guidelines outlining first- and second- maximize statistical power and allow were excluded from prescribing
line treatments for the following each practice to receive the measures if there were any
bacterial ARTIs: acute otitis media intervention through staggered concomitant non-ARTI bacterial
(AOM), sinusitis, and group A implementation across diagnoses (Supplemental Table 5) or
streptococcal pharyngitis.6–8 Audit of 19 community-based primary care antibiotic prescriptions during the
primary care provider antibiotic pediatric practices. Study data were 30 days preceding the index visit
prescribing for ARTIs paired with collected from November 2015 (which might necessitate second-line
individualized feedback reports through June 2018. All practices were prescribing). Visits by children with
previously reduced inappropriate recruited from 2 practice-based penicillin or cephalosporin antibiotic
antibiotic prescribing for bacterial research networks: the AAP Pediatric allergies were excluded from second-
ARTIs, although the reduction Research in Office Settings (PROS) line prescribing measures.
disappeared after feedback (n = 11 practices from 9 states) and
discontinuation.9,10 Behavioral the NorthShore University Intervention
interventions similarly reduced HealthSystem (n = 8 practices in the
The DART QI program (1) was
antibiotic treatment of adult viral Chicago, IL, metropolitan area).
received by clinicians; (2) contained
ARTIs, but the effect waned within Included practices used a common
evidence-based online tutorials,
12 months of the study electronic health record (EHR) within
webinars, booster video vignette
conclusion.11,12 Internet-based their network. The practice was the
sessions, and individualized antibiotic
communication skills training has unit of randomization. The
prescribing feedback reports; and (3)
reduced inappropriate antibiotic NorthShore practices were allocated
was received in 3 modules over an
prescribing in adult health care by random permutation (by C.Z.) to
11-month period (Fig 1). All DART QI
settings.13,14 In previous work, each of 4 wedges (2 practices each;
program educational materials are
authors using the methods of Fig 1). The PROS practices were
available online.19
conversation analysis have also enrolled later and were similarly
elucidated the provider randomly allocated to wedges In module 1, clinicians viewed 25-
communication best practices that 2 to 4 (3–4 practices each). Written minute online tutorials about best
are associated with decreased informed consent was obtained from practices for both parent-clinician
inappropriate antibiotic prescribing pediatricians and pediatric nurse communication practices and
during pediatric ARTI visits.15–18 practitioners (“clinicians”; n = 57; antibiotic prescribing, participated in
However, a comprehensive, large- 1–6 per practice) before random live or recorded 40-minute webinars

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2 KRONMAN et al
FIGURE 1
Study intervention and timing.

on those topics, and received an outcome) and for 5 secondary components by determining if
individualized feedback report outcomes (described below). Rates clinicians opened each online tutorial
presenting antibiotic prescribing were compared to a goal rate derived and completed embedded quiz
rates during ARTI visits in the from the 20% of enrolled clinicians questions at a passing rate of 80%. All
baseline control period (see with the lowest antibiotic prescribing enrolled pediatricians were offered
Outcomes section below). The theory rates for those conditions, a form of American Board of Pediatrics
of planned behavior20 underpinned peer-comparison feedback. Outlier Maintenance of Certification Part 4
development of the evidence-based feedback report results were credit for completing the DART QI
communication tutorial, which aims investigated, and targeted validation program.
to modify how providers frame was performed at providers’ requests.
treatment recommendations and
In module 2, clinicians received two Data Collection
follow-up plans for patients with
5-minute online booster video
ARTIs.15–17 We implemented 2 main EHR data were used to collect
vignettes recapping communication
strategies: (1) building subjective patient-level covariates, assess
best practices and the second
norms, self-awareness, and changing visit-level ARTI antibiotic
antibiotic prescribing feedback
attitudes among the clinicians prescribing rates, and generate
report, presenting prescribing rates
supporting the targeted the DART QI program antibiotic
during the module 1 participation
communication and prescribing prescribing feedback reports,
period. In module 3, clinicians
behaviors and (2) developing the primary, and secondary outcome
received 1 communication booster
skills to achieve these goals through measures. Enrolled clinicians
video vignette and the third and
modeling, practice, feedback, provided usual care during the
fourth antibiotic prescribing feedback
reinforcement, and building self- baseline control period until their
reports, presenting prescribing rates
confidence. The evidence-based wedge started the intervention
during modules 2 and 3, respectively.
antibiotic prescribing tutorials were (Fig 1). Ongoing data collection
based on published guidelines for the All enrolled clinicians received links until June 2018 provided
diagnosis and management of each to the Web-based tutorials, webinars, a planned additional 2- to 8-month
ARTI, including delayed prescribing booster video vignettes, and postintervention sustainability
techniques.6–8,21 Each individualized individualized antibiotic prescribing period, during which practices
feedback report (Supplemental Fig 3) feedback reports via e-mail. Study no longer actively received the
contained antibiotic prescribing rates staff tracked clinician participation in intervention nor were aware of
for all ARTI combined (primary the Web-based intervention data collection.

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PEDIATRICS Volume 146, number 3, September 2020 3
Outcomes Statistical Analysis Power and sample size calculations
The primary outcome was the visit- The primary intention-to-treat (ITT) were based on preliminary studies
level (as opposed to patient-level) analysis included all study clinicians outlining national ARTI antibiotic
antibiotic prescribing rate for all and used multivariable mixed-effects prescribing rates and the effect of
ARTIs during each study module, for logistic regression clustered by previous feedback interventions on
which the denominator was all both the clinician and practice to improving antibiotic prescribing.3,9
included ARTI visits during that Those calculations assumed 4 wedges
determine the effect of exposure to
module, and the numerator was of 5 practices each, a small 20.1%
each DART module on the binary
ARTI visits during which antibiotic temporal effect, a practice random-
outcome of whether an antibiotic was
prescribing occurred. Because effect SD of 5% and within-clinician
prescribed during each ARTI visit,
antibiotic appropriateness measures random-effect SD of 10%, and that
adjusted a priori for child age, sex,
require symptom data difficult to clinician ARTI antibiotic prescribing
and race and/or ethnicity (factors
extract from an EHR (eg, presence of would follow a binomial distribution.
previously associated with antibiotic
severe otalgia during AOM), we Using linear mixed-effects regression
prescribing).22,23 Each practice used
selected antibiotic prescribing rather on clinician-level prescribing rates,
standard approaches to collect race
than appropriateness as the primary we estimated that 4 wedges, 4
and/or ethnicity data, typically at the
outcome. The 5 secondary outcomes practices per wedge, and 3 clinicians
time of registration. Analysis was also
included (1) visit-level antibiotic per practice would provide ∼93%
adjusted for influenza season
prescribing rates for viral ARTI, power to detect an absolute decrease
(November through March) and in antibiotic prescribing for all ARTI
(2) visit-level prescribing rates for patient level of medical complexity by
pharyngitis (streptococcal and visits from 55% to 45% and an
using the previously validated absolute decrease in second-line
nonstreptococcal combined), and Pediatric Medical Complexity
second-line antibiotic prescribing prescribing for bacterial ARTI from
Algorithm version 3.0.24,25 In 27% to 17%.
rates for (3) AOM, (4) streptococcal reporting the results, we converted
pharyngitis, and (5) sinusitis. the logistic regression odds ratios This study was reviewed and
Bronchitis, nonstreptococcal into adjusted rate ratios (aRRs) to approved by the Western, AAP,
pharyngitis, and URI were considered facilitate interpretation and describe NorthShore University Health System,
viral ARTIs for which antibiotics are these results as increases or and Children’s Hospital of
inappropriate. Bacterial ARTIs decreases in the likelihoods of Philadelphia Institutional Review
included AOM, streptococcal antibiotic prescribing during ARTI Boards. All analyses were conducted
pharyngitis, and sinusitis. On the visits.26,27 On the basis of the cluster- in R version 3.6.0.28
basis of published national randomized design, all
guidelines,6–8 the goal for first-line preintervention ARTI visits serve as
prescribing for each bacterial ARTI controls. An additional model RESULTS
was amoxicillin for AOM (except including a time period indicator Overall, 57 clinicians (50
when diagnosed concurrently with used a likelihood ratio test to pediatricians and 7 nurse
conjunctivitis, for which amoxicillin- determine if changes in antibiotic practitioners) from 19 practices
clavulanate was also considered as prescribing over time were driven by agreed to participate and were
first line to treat Haemophilus secular trends. included in the analysis (Fig 2). The
influenzae otitis-conjunctivitis number of clinicians at each practice
syndrome), penicillin or amoxicillin We planned a priori to evaluate the
ranged from 1 to 6 (median of 3).
for streptococcal pharyngitis, and primary and secondary outcomes
amoxicillin or amoxicillin-clavulanate among the subgroup of clinicians who Over the study period, 29 762
for sinusitis. When multiple actively participated in the entire individual children (Table 1)
diagnoses were present, antibiotics intervention (ie, they watched all experienced 72 723 total ARTI visits,
were attributed in a hierarchical available tutorials, webinars, and with 13 764 (46.2%) children having
fashion first to sinusitis, then to AOM, boosters and received feedback 1 ARTI visit, 6387 (21.5%) having 2,
and then to pharyngitis. Visits were reports) and those who did not (ie, and 9611 (32.3%) having $3 (range
only described as viral ARTI if no only received feedback reports but of 3–29). Among all 72 723 ARTI
competing bacterial diagnoses were did not engage fully with remaining visits, 28 758 (39.5%) received
present. All systemic antibiotic intervention components). All antibiotics. A total of 447 children
prescriptions that did not meet the analyses began after completion of were excluded because of antibiotic
definition of first line were the postintervention period in use in the previous 30 days, and 1590
considered second line. June 2018. children were excluded because of

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4 KRONMAN et al
FIGURE 2
Study flow diagram.

concomitant bacterial infections 4% (95% confidence interval [CI], prescribing was significantly lower
during their ARTI visit. 1%–7%) in module 1, 16% (95% CI, during each module and during the
12%–19%) in module 2, 11% (95% postintervention period. Additional
Engagement With the Intervention CI, 8%–14%) in module 3, and 7% models including a time period
All clinicians received feedback (95% CI, 4%–10%) during the indicator revealed unchanged results
reports. There were 41 (72%) postintervention period. Unadjusted for both the primary and secondary
clinicians at 17 practices who antibiotic prescribing rates are outcomes and demonstrated no
engaged actively with the reported in Supplemental Table 6. significant secular trend in antibiotic
intervention by viewing all online prescribing rates.
communication and prescribing Secondary Outcomes
tutorials and webinars, whereas 16 The probability of prescribing Subgroup Analyses
(28%) clinicians at 8 practices did not antibiotics for viral ARTI was Subgroup analyses revealed similar
engage in all aspects of the significantly lower during each results to those of the ITT analyses
intervention (14 clinicians viewed DART module and during the for both engaged and less-engaged
none of the online training materials, postintervention period compared to clinicians regarding the probability of
whereas 2 clinicians viewed at least 1 the baseline control period (Table 2). antibiotic prescribing for all ARTIs,
but not all online modules). The probability of prescribing viral ARTI, and pharyngitis during all
antibiotics for pharyngitis was study periods compared to baseline
Primary Outcome significantly lower during modules 2 (Tables 3 and 4). However, for
In the adjusted ITT analysis, the and 3 but not during module 1 or second-line antibiotic prescribing,
probability of antibiotic prescribing during the postintervention period. although results for engaged
for all ARTI visits was lower during The probability of prescribing clinicians were similar to the ITT
each module and during the 2- to 8- second-line antibiotics for AOM was results, those for the less-engaged
month postintervention period only lower during module 2 clinicians revealed a significantly
compared to the baseline control compared to the baseline control increased probability of prescribing
period (Table 2, Supplemental Fig 4). period. However, for streptococcal second-line antibiotics for AOM
The probability of antibiotic pharyngitis and sinusitis, the during the postintervention period
prescribing for all ARTIs decreased probability of second-line antibiotic compared to the baseline (increased

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PEDIATRICS Volume 146, number 3, September 2020 5
TABLE 1 ARTI Patient Demographics and Diagnoses by Study Time Period improvements reversed immediately
Demographics Baseline Module 1 Module 2 Module 3 Postintervention after the study conclusion, and study
No. patients 21 401 1936 2132 2211 2082
pediatricians later reported ignoring
Age, y, median 4.24 (1.86–6.84) 3.83 (1.32–6.69) 3.08 3.41 (1.08–6.42) 2.80 (0.95–6.07) or distrusting their feedback
(IQR) (1.02–6.07) reports.10,29
Female 10 538 (49.2) 959 (49.5) 1038 (48.7) 1069 (48.3) 1028 (49.4)
Race Other randomized trials in adults
White 13 438 (62.8) 1045 (54.0) 1331 (62.4) 1264 (57.2) 1089 (52.3) have revealed that behavioral and
Black or 470 (2.2) 56 (2.9) 45 (2.1) 52 (2.4) 52 (2.5) communication intervention
African strategies can improve ambulatory
American
Asian American 797 (3.7) 83 (4.3) 98 (4.6) 85 (3.8) 120 (5.8)
antibiotic prescribing. The Stemming
or Pacific the Tide of Antibiotic Resistance
Islander educational program involved topics
Native 169 (0.8) 6 (0.3) 23 (1.1) 17 (0.8) 3 (0.1) such as provision of guidelines and
American video communication skills training
Mixed race 292 (1.4) 20 (1.0) 28 (1.3) 29 (1.3) 15 (0.7)
Not available 6235 (29.1) 726 (37.5) 607 (28.5) 764 (34.6) 803 (38.6)
and led to significant reductions in
Hispanic 4760 (22.2) 372 (19.2) 424 (19.9) 436 (19.7) 385 (18.5) antibiotic prescribing for all
ethnicity diagnoses during the year after
PMCA intervention exposure.13 A separate
Nonchronic 14 630 (68.4) 1365 (70.5) 1595 (74.8) 1650 (74.6) 1561 (75.0) study including 246 practices from 8
Noncomplex 4862 (22.7) 410 (21.2) 389 (18.2) 423 (19.1) 394 (18.9)
chronic
European practice-based research
Complex 1909 (8.9) 161 (8.3) 148 (6.9) 138 (6.2) 127 (6.1) networks revealed that Internet-
chronic based communication skills training
Diagnoses alone reduced antibiotic prescribing
All ARTI, n 42 191 6287 7319 8166 8760 rates for adults with ARTIs by
Viral ARTI 19 438 (46.1) 2764 (44.0) 3633 (49.6) 4265 (52.2) 4224 (48.2)
All pharyngitis 12 190 (28.9) 2146 (34.1) 2023 (27.6) 1765 (21.6) 2340 (26.7)
9%.14 Similar to the DART QI
AOM 7461 (17.7) 1006 (16.0) 1131 (15.5) 1530 (18.7) 1684 (19.2) program, these interventions
Streptococcal 4300 (10.2) 781 (12.4) 618 (8.4) 567 (6.9) 840 (9.6) allowed clinicians to access
pharyngitis online components and practice
Sinusitis 3102 (7.4) 371 (5.9) 532 (7.3) 606 (7.4) 512 (5.8) communication skills at convenient
Data are presented as No. (%) unless otherwise specified. Module 1 contained online communication and antibiotic times, a critical flexibility for busy
prescribing tutorials and webinars and an individualized antibiotic prescribing feedback report. Module 2 contained 2
online communication booster video vignettes and an antibiotic prescribing feedback report. Module 3 contained 1
primary care clinicians.
communication booster video vignette and 2 antibiotic prescribing feedback reports. IQR, interquartile range.
The DART QI intervention combines
professionally produced, evidence-
27% [7%–47%]; Table 4) and no during streptococcal pharyngitis
based educational modules that can
change in the probability of and sinusitis visits. However, the
be viewed asynchronously at
prescribing second-line antibiotics for intervention did not result in
clinicians’ discretion with individual
streptococcal pharyngitis or sinusitis sustained reductions in antibiotic
feedback reports that also contain
across study periods (Table 4). prescribing during all pharyngitis
a peer comparison element. The
visits nor in reduced second-line
DART training videos remain freely
antibiotic prescribing for AOM.
available online to interested
DISCUSSION With this study, we build off work clinicians (including study
In this stepped-wedge, cluster- demonstrating that educational participants for intervention
randomized clinical trial including interventions combined with sustainability), although study
.70 000 ARTI visits in practices quarterly individualized antibiotic clinicians no longer receive feedback
across 9 states, the DART QI program prescribing feedback could reduce reports.20 The 7% reduction in
decreased the overall rate of broad-spectrum antibiotic antibiotic prescribing for all ARTIs, if
antibiotic prescribing among all ARTI prescribing for patients with extrapolated to all ambulatory ARTI
visits, and this effect was sustained in pneumonia and sinusitis.9 However, visits to pediatricians nationally,
the 2- to 8-month postintervention that intervention did not reduce would represent .1.5 million fewer
period. The DART QI program broad-spectrum antibiotic antibiotic prescriptions for children
resulted in sustained reductions in prescribing for pharyngitis or any with ARTI annually.3 The DART QI
antibiotic prescribing during viral antibiotic prescribing for viral ARTIs. intervention also resulted in lasting
ARTI visits and sustained decreases Additionally, follow-up data revealed improvements in antibiotic
in second-line antibiotic prescribing that antibiotic prescribing prescribing for viral ARTI,

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6 KRONMAN et al
TABLE 2 Rate Ratios of Antibiotic Prescribing During All ITT Analysis Visits for ARTI Overall and by Condition (by Study Time Period)
Condition Measure Baseline Module 1 Module 2 Module 3 Postintervention
aRR (95% CI)
ARTI overall Any prescribing Reference 0.96 (0.93–0.99) 0.84 (0.81–0.88) 0.89 (0.86–0.92) 0.93 (0.90–0.96)
Viral ARTI Any prescribing Reference 0.63 (0.52–0.76) 0.65 (0.55–0.78) 0.64 (0.54–0.75) 0.60 (0.51–0.70)
All pharyngitis Any prescribing Reference 1.06 (1.01–1.12) 0.90 (0.84–0.95) 0.85 (0.80–0.91) 0.96 (0.91–1.02)
AOM Second-line Reference 1.01 (0.88–1.15) 0.69 (0.60–0.80) 0.96 (0.86–1.07) 0.93 (0.83–1.03)
prescribing
Streptococcal pharyngitis Second-line Reference 0.71 (0.53–0.94) 0.61 (0.46–0.82) 0.46 (0.32–0.66) 0.66 (0.50–0.87)
prescribing
Sinusitis Second-line Reference 0.75 (0.55–0.99) 0.51 (0.38–0.68) 0.66 (0.52–0.85) 0.59 (0.44–0.77)
prescribing
Module 1 contained online communication and antibiotic prescribing tutorials and webinars and an individualized antibiotic prescribing feedback report. Module 2 contained 2 online
communication booster video vignettes and an antibiotic prescribing feedback report. Module 3 contained 1 communication booster video vignette and 2 antibiotic prescribing feedback
reports.

streptococcal pharyngitis, and Clinicians could also have altered include this as part of our
sinusitis. When examining only those their antibiotic prescribing habits streptococcal pharyngitis visit
visits to clinicians engaged in all because of a Hawthorne effect after definition. Our inclusion criteria
intervention components, the DART study commencement, but our use of would miss children who received
QI intervention appears to improve a prolonged baseline antibiotic antibiotics within 30 days before at
antibiotic prescribing for AOM as prescribing period helped mitigate outside clinics (eg, urgent care
well, suggesting that the addition of this issue. Because this study centers); however, those children
evidence-based communication and generated antibiotic prescribing would generally receive second-line
antibiotic prescribing education may feedback reports on the basis of ICD- antibiotics for ARTI, thereby
be important to improving 10 diagnosis codes, clinicians could decreasing the apparent intervention
prescribing for this condition. alter their choice of diagnosis codes effect. Likewise, the intervention
over time (eg, coding a visit as effect on antibiotic prescriptions
There are several important
sinusitis rather than as URI to justify provided outside ARTI clinic visits,
limitations to this study. First, 2 study
antibiotic prescribing), but the and the changes in the antibiotic
clinicians each practiced at multiple
proportion of bacterial ARTI prescribing rate for AOM were not
practices that were randomized to
diagnoses did not increase in evaluated. In this study, we only
different wedges. In the analysis, we
a consistent or clinically meaningful
assigned all visits after their first evaluated the effect of the DART QI
way to suggest that such code-shifting intervention on primary care
intervention as postintervention
occurred (Table 1). Practices may be pediatricians and nurse practitioners,
visits, biasing the results comparing
unable to generate their own but it is unknown whether these
pre- and postintervention visits
feedback reports, limiting
toward the null. Because most of the results can be generalized to
generalizability of and the ability
intervention was received others who provide care for
to disseminate this intervention.
individually, the possibility of these 2 children with ARTIs (eg, family
clinicians contaminating the Because rapid streptococcal antigen practice, emergency department,
intervention in their later- testing was not routinely captured in or urgent care clinicians). Lastly,
randomized practice is unlikely. the EHR of all practices, we could not the 2- to 8-month postintervention

TABLE 3 Rate Ratios of Antibiotic Prescribing During Visits to Fully Engaged Clinicians for ARTI Overall and by Condition (by Study Time Period)
Condition Measure Baseline Module 1 Module 2 Module 3 Postintervention
aRR (95% CI)
ARTI overall Any prescribing Reference 0.97 (0.93–1.01) 0.84 (0.80–0.87) 0.89 (0.86–0.93) 0.92 (0.89–0.96)
Viral ARTI Any prescribing Reference 0.73 (0.59–0.90) 0.57 (0.46–0.72) 0.61 (0.50–0.74) 0.62 (0.52–0.74)
All pharyngitis Any prescribing Reference 1.06 (0.99–1.12) 0.87 (0.81–0.93) 0.84 (0.78–0.91) 0.96 (0.90–1.02)
AOM Second-line Reference 1.02 (0.87–1.19) 0.69 (0.58–0.81) 0.87 (0.75–0.99) 0.78 (0.67–0.90)
prescribing
Streptococcal pharyngitis Second-line Reference 0.74 (0.53–1.00) 0.62 (0.45–0.84) 0.37 (0.24–0.56) 0.63 (0.46–0.87)
prescribing
Sinusitis Second-line Reference 0.64 (0.45–0.91) 0.47 (0.34–0.66) 0.60 (0.45–0.80) 0.49 (0.35–0.69)
prescribing
Fully engaged clinicians watched all available tutorials, webinars, and boosters and received feedback reports.

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PEDIATRICS Volume 146, number 3, September 2020 7
TABLE 4 Rate Ratios of Antibiotic Prescribing During Visits to Less-Engaged Clinicians for ARTI Overall and by Condition (by Study Time Period)
Condition Measure Baseline Module 1 Module 2 Module 3 Postintervention
aRR (95% CI)
ARTI overall Any prescribing Reference 0.96 (0.89–1.03) 0.88 (0.81–0.95) 0.87 (0.82–0.93) 0.93 (0.87–0.99)
Viral ARTI Any prescribing Reference 0.40 (0.26–0.61) 0.85 (0.62–1.15) 0.70 (0.53–0.93) 0.53 (0.39–0.72)
All pharyngitis Any prescribing Reference 1.09 (0.97–1.21) 1.02 (0.89–1.16) 0.87 (0.75–1.00) 0.98 (0.87–1.09)
AOM Second-line Reference 0.99 (0.77–1.24) 0.70 (0.52–0.92) 1.17 (0.99–1.38) 1.27 (1.07–1.47)
prescribing
Streptococcal pharyngitis Second-line Reference 0.58 (0.29–1.12) 0.65 (0.31–1.33) 0.98 (0.51–1.83) 0.72 (0.40–1.27)
prescribing
Sinusitis Second-line Reference 1.13 (0.65–1.83) 0.63 (0.34–1.11) 0.90 (0.54–1.42) 0.96 (0.57–1.54)
prescribing
Less-engaged clinicians only received feedback reports but did not engage fully with remaining intervention components. Module 1 contained online communication and antibiotic
prescribing tutorials and webinars and an individualized antibiotic prescribing feedback report. Module 2 contained 2 online communication booster video vignettes and an antibiotic
prescribing feedback report. Module 3 contained 1 communication booster video vignette and 2 antibiotic prescribing feedback reports.

period may not represent the participated in the DART study. Pediatric Partners of the Southwest
true long-term intervention The NorthShore practices (Durango, CO); Plateau Pediatrics
durability. were as follows (alphabetical order, (Crossville, TN).
listed with permission): Deerfield,
CONCLUSIONS Illinois; Evanston, Illinois (Central);
Evanston, Illinois (Davis);
The DART QI program reduced ABBREVIATIONS
Glenview, Illinois; Gurnee, Illinois;
overall antibiotic prescribing during
Lincolnwood, Niles, Old Orchard, AAP: American Academy of
childhood ARTI visits, and this
Illinois; Plaza Del Lago, Illinois; Pediatrics
antibiotic prescribing reduction was
Vernon Hills, Illinois. The PROS AOM: acute otitis media
sustained during the postintervention
period. Providing online practices were as follows aRR: adjusted rate ratio
communication training and (alphabetical order, listed with ARTI: acute respiratory tract
evidence-based antibiotic permission): Advanced infection
prescribing education in combination Preventive Care Pediatrics CI: confidence interval
with individualized antibiotic (Bradenton, FL); All Star Pediatrics DART: Dialogue Around Respiratory
prescribing feedback reports (Countryside, IL); A to Z Pediatric and Illness Treatment
may help achieve national Youth Healthcare (Addison, IL); EHR: electronic health record
goals of reducing unnecessary Cornerstone Pediatrics (Seguin, TX); ICD-10: International Classification
outpatient antibiotic prescribing for East End Pediatrics, PC (East of Diseases, 10th Revision
children. Hampton, NY); Eureka ITT: intention-to-treat
Pediatrics (Eureka, CA); Hampton PROS: Pediatric Research in Office
Pediatrics, PLLC (Southampton, NY); Settings
ACKNOWLEDGMENTS Paragould Pediatrics, PLLC QI: quality improvement
We thank the practices, pediatricians, (Paragould, AR); Pediatric Medicine URI: upper respiratory infection
and nurse practitioners that of Wallingford, LLP (Wallingford, CT);

Deidentified data limited to visit-based prescribing rates, patient characteristics, and dummy variables for clinic site will be shared. No protected health
information for study participants will be shared. Data will be provided as a comma-separated values file with a data dictionary defining all variables included in
the file and will be transferred by using a secure file transfer protocol. Additional tools will not be made available. The data will be made available after publication
of the primary studies to researchers who provide a detailed methodologically sound proposal and data use agreement. Proposals should be submitted to Dr
Mangione-Smith ([email protected]).
Dr Mangione-Smith conceptualized and designed the study, obtained funding, assisted with study execution, analyzed and interpreted the data, drafted the initial
manuscript, and provided study supervision; Dr Kronman assisted with study design and execution and data analysis and interpretation and drafted the initial
manuscript; Dr Zhou assisted with study design, performed statistical analysis of the data, and drafted the initial manuscript; Drs Gerber, Grundmeier, Heritage,
and Robinson assisted with study design and execution, interpreted the data, and critically revised the manuscript; Dr Fiks, assisted with study design and
execution, data acquisition, and data interpretation and critically revised the manuscript; Drs Shalowitz, Stout, Shone, and Wright and Ms Steffes assisted with
study design and execution and data acquisition, critically revised the manuscript, and provided administrative, technical, and material support; Mr Burges, Mr
Hedrick, and Ms Warren critically revised the manuscript and provided administrative, technical, and material support; and all authors approved the final

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8 KRONMAN et al
manuscript as submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www.clinicaltrials.gov (identifier NCT02943551).
DOI: https://doi.org/10.1542/peds.2020-0038
Accepted for publication May 15, 2020
Address correspondence to Matthew P. Kronman, MD, MSCE, Seattle Children’s Hospital, 4800 Sand Point Way NE, M/S MA.7.226, Seattle, WA 98115.
E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the National Institutes of Health R01 HD084547-01 to Dr Mangione-Smith (principal investigator). Additional infrastructure funding was
provided by the American Academy of Pediatrics and the Health Resources and Services Administration of the US Department of Health and Human Services under
UA6MC15585, National Research Network to Improve Child Health. The information, content, and/or conclusions are those of the authors and should not be
construed as the official position or policy of, nor should any endorsements be inferred by the Health Resources and Services Administration, Department of Health
and Human Services, or US Government. Additionally, the funders and/or sponsors had no role in the design and conduct of the study; collection, management,
analysis, and interpretation of the data; preparation, review, or approval of the article; or decision to submit the article for publication. Funded by the National
Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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10 KRONMAN et al
 Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness
Matthew P. Kronman, Jeffrey S. Gerber, Robert W. Grundmeier, Chuan Zhou, Jeffrey
D. Robinson, John Heritage, James Stout, Dennis Burges, Benjamin Hedrick, Louise
Warren, Madeleine Shalowitz, Laura P. Shone, Jennifer Steffes, Margaret Wright,
Alexander G. Fiks and Rita Mangione-Smith
Pediatrics 2020;146;
DOI: 10.1542/peds.2020-0038 originally published online August 3, 2020;

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Services http://pediatrics.aappublications.org/content/146/3/e20200038
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http://pediatrics.aappublications.org/content/146/3/e20200038#BIBL
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 Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness
Matthew P. Kronman, Jeffrey S. Gerber, Robert W. Grundmeier, Chuan Zhou, Jeffrey
D. Robinson, John Heritage, James Stout, Dennis Burges, Benjamin Hedrick, Louise
Warren, Madeleine Shalowitz, Laura P. Shone, Jennifer Steffes, Margaret Wright,
Alexander G. Fiks and Rita Mangione-Smith
Pediatrics 2020;146;
DOI: 10.1542/peds.2020-0038 originally published online August 3, 2020;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/146/3/e20200038

Data Supplement at:

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