Mary Lee Barron, PhD, APRN, FNP-BC, FAANP

Acute bronchitis is one of the most common diagnoses in ambulatory care.

Approximately 5% of American adults will encounter at least one episode per year, with at least 90% of those patients seeking additional treatment.

Even though acute bronchitis is mostly viral in etiology, unnecessary antibiotic prescribing for the indication is persistent and widespread.

Uncomplicated acute bronchitis, or the occurrence of bronchitis in adults without a comorbidity or disease, can also present a challenge for health care providers regarding appropriate antibiotic prescribing.

Although efforts have been made to reduce inappropriate antibiotic prescribing for acute respiratory infections, the overuse of antibiotics, specifically for uncomplicated acute bronchitis, is actually worsening, not decreasing. One study’s results showed that inappropriate antibiotic prescribing for uncomplicated acute bronchitis remains high at over 70%.

Another study’s results revealed that unnecessary antibiotic prescribing for uncomplicated acute bronchitis has been more difficult to change than it has been for other conditions, with up to 90% of patients with acute bronchitis still receiving antibiotics inappropriately.

Reasons for inappropriate antibiotic prescribing include provider uncertainty, patient expectations, and the desire for expedient clinical resolution

Other influential factors include provider socio-demographics, practice setting, and health care plan restrictions. Lack of clarity about context in clinical presentation is another potential cause for inappropriate antibiotic prescribing.

In the retail clinic setting, quality scores reflecting antibiotic prescribing when managing uncomplicated acute bronchitis can rank higher than national benchmarks, although some variation does exist among retail clinicians.

One method for evaluating provider adherence to guideline recommendations is through the use of the Healthcare Effectiveness Data Information Set (HEDIS).

Developed and maintained by the National Committee for Quality Assurance, HEDIS is used to monitor antibiotic prescribing practices and optimize care delivery.

Study results have revealed that educational interventions can improve provider prescribing practices.

One type of educational intervention frequently utilized in the retail clinic setting is the webinar. Cost-effective and practical, webinars provide retail clinicians with access to current, convenient, economical, and evidence-based education.

To test whether webinar training can contribute to improvements in appropriate antibiotic prescribing in the retail clinic setting, one national retail clinic chain conducted an hour long webinar providing up-to-date information regarding the identification and management of uncomplicated acute bronchitis and pneumonia to 40 retail clinician attendees. More specifically, the aim was to answer 2 key questions:

Do webinar participants prescribe fewer antibiotics for the management of uncomplicated acute bronchitis after webinar training?

Do changes in antibiotic prescribing for uncomplicated acute bronchitis differ between providers who attended the webinar training compared with those who did not?

A systematic review of related literature conducted prior to the webinar uncovered that educational  interventions can improve antibiotic prescribing practices. In a quasi-experimental, pre-post study evaluating the combination of academic detailing with patient-provider education materials, antibiotic prescribing decreased from 43% to 33% following the implementation of the program.

Similarly, a large, randomized clinical trial found that clinical pathways, or algorithms, successfully helped reduce unnecessary antibiotic prescribing in 8 commonly encountered diagnoses, with acute bronchitis antibiotic prescriptions decreasing from a baseline of 60.5% to 54.9%.

However, no studies addressed the overuse of antibiotics when managing uncomplicated acute bronchitis within the retail clinic setting. Similarly, no studies used HEDIS scores as a tool to assess the effectiveness of an educational intervention such as a webinar upon antibiotic prescribing practice.

The chain’s management information system, which analyzes diagnostic coding and billing data, was used to obtain HEDIS scores for webinar participants and nonparticipants. Management uses this system routinely to calculate HEDIS scores for uncomplicated acute bronchitis and other quality indicators. HEDIS scores were obtained on providers for 3 months before the webinar and 3 months after. The primary outcome measure was the HEDIS measure, “Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis,” that measures the percent- age of adults 18 to 64 years old with a diagnosis of acute bronchitis who were not prescribed an antibiotic.

A statistically significant improvement in HEDIS scores of 9 percentage points (from 80% pre-webinar to 89% to post webinar) was observed among the 40 webinar participants. Subsequent analyses sought to determine whether this high-level finding held up under specific requirements. Although statistical significance was not observed in those analyses, improvements were consistently larger for webinar participants than for nonparticipants. For in- stance, a 17 percentage point improvement in HEDIS scores was observed among 10 health care providers who were performing below the group average during the pre-webinar period, which is notably about 2 times greater than the 8 percentage point increase observed among nonparticipants.

Because of the small number of participants, the results do not provide compelling data to support the webinar as an intervention for quality improvement. Subsequently, no inference regarding the association between HE- DIS scores and the webinar could be established based on statistical testing. However, the data do demonstrate that webinars have merit and are worthy of further investigation, particularly observational studies in the retail clinic setting. Further studies are needed regarding the effect of an educational intervention, such as the webinar, on provider coding in the retail clinic setting. Additional longitudinal studies to assess the length of practice change following the webinar may also provide insight regarding best education- al practices in the retail clinic setting.

Although they seek to maintain excellence in practice, training programs, including webinars, are principally designed to improve performance by providing information and skills that can be applied to elevate performance. Overall, the webinar is a cost-effective, convenient approach to reducing un- necessary antibiotic prescribing to patients with uncomplicated acute bronchitis, as demonstrated by the observed improvement of HEDIS scores. On a broader scale, the results not only showed that webinars convey evidence-based knowledge, but they also demonstrated that retail clinics are providing optimal patient care, achieving HEDIS scores far above the national average.

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Mary Lee Barron, PhD, APRN, FNP-BC, FAANP

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Implementing Webinar Training to Improve Appropriate Antibiotic Prescribing