Evaluating equity in antibiotic stewardship and disparities in appropriateness of antibiotic treatment - Project Summary Antibiotic overuse is a serious public health crisis. Antibiotics are one of the most commonly prescribed medications where 7 of every 10 Americans receive an antibiotic annually. This is concerning considering that it is estimated that ~30% of antibiotics prescribed in outpatient clinics are unnecessary. Whether appropriate or inappropriate, antibiotic use can result in adverse events including allergic reactions, Clostridioides difficile infection (CDI), and antibiotic resistance. Antibiotic stewardship (AS) is recommended to optimize antibiotic use and curb inappropriate antibiotic prescribing and encompasses strategies such as academic detailing, audit and feedback, and laboratory testing. AS strategies have been shown to improve prescribing, while decreasing costs, antibiotic resistance, and CDI. We have recently begun quality improvement activities to support the implementation of AS strategies described in the CDC Core Elements of Outpatient Antibiotic Stewardship in urgent care clinics and Federally Qualified Health Centers (FQHCs), which generally serve underserved and vulnerable patient populations in the Chicagoland area. A new accreditation standard was recently published by The Joint Commission (TJC) recommending that a focus on health equity and disparities be integrated within existing quality improvement activities like the Core Elements. This is significant because disparities in antibiotic prescribing have been identified, where Black patients are less likely to receive antibiotics than White patients, but more likely to receive inappropriate prescribing. In addition, several individual and provider characteristics have been found to be associated with unnecessary prescribing but are limited as these studies do not interrogate the drivers of these disparities such as structural determinants or the patient experience. Evaluating implementation of AS strategies through the lens of structural inequities and the intersection with other patient and provider characteristics are critical for informing and enhancing uptake of AS strategies and their impact on patient outcomes. We propose to conduct a mixed methods study using surveys to evaluate facility implementation of AS and equity standards; electronic health record (EHR) data from urgent care and FQHC clinics to evaluate disparities in antibiotic prescribing; and qualitative interviews with patients to interrogate the factors that shape variation in antibiotic prescribing and equity in prescribing. The expected outcomes of this study are to close the knowledge gap on understanding drivers of inequity and identify strategies to facilitate equitable antibiotic prescribing in resource-limited settings that treat vulnerable patients, such as FQHCs. This project is significant and innovative because using a mixed methodology to incorporate health equity evaluation with AS implementation represents a significant paradigm shift and has not been rigorously evaluated. Evaluating implementation of AS strategies and equity standards and their relationship with disparities in antibiotic prescribing (whether minimizing or exacerbating) will have impact by informing interventions to improve and ensure equitable antibiotic prescribing and reduce unnecessary antibiotic prescribing.
