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.
