How a Quality Improvement Project Increased the Appropriateness of Antibiotic Prescribing to 97%

Evidence-based guidelines and communication are key


By Mark Rood, MD


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A study, published in the journal Pediatrics, found that antibiotic prescribing was higher in direct-to-consumer (DTC) telemedicine visits compared to in-person urgent or primary care appointments. Antibiotics were prescribed in 52% of DTC telemedicine appointments, 42% of urgent care visits and 31% of primary care provider (PCP) visits.

Additionally, antibiotic management was not aligned with published guidelines. The study found only 59% of telemedicine visits and 68% of urgent care visits were concordant with guidelines, compared to 78% of PCP visits.

Data is quickly outdated in this industry

Over the last several years, several telemedicine platforms—Cleveland Clinic included—have focused on a similar goal: the development and implementation of evidence-based standards. As a result, the quality of care provided via many telemedicine platforms has improved. The recent article in Pediatrics did not reflect these improvements, however, as it analyzed data from visits generated by only one health plan and its contracted DTC telemedicine provider between 2015 and 2016, before any of these evidence-based standards were implemented. In the evolution in digital health, this is essentially a generation ago.

As a quality-driven institution, when Cleveland Clinic began offering virtual visits, we sought to develop a world-class model for this emerging care platform. Before we even saw patients online, we created Cleveland Clinic protocols for all relevant disease states.


Anecdotally, the most common use of antibiotics across Cleveland Clinic Express Care® Online is for the treatment of sinus infections. That said, we strictly follow the Infectious Diseases Society of America’s guidelines for prescribing on our platform for both adults and children.

Evidence-based guidelines developed by experts

Cleveland Clinic Express Care® Online offers virtual visits for pediatric patients experiencing symptoms that may be related to seasonal allergies, conjunctivitis, the common cold, influenza, minor burns or lacerations, rashes, sinus and upper respiratory infections. Other virtual visits are offered for adults only, including consults for asthma, back strains, bronchitis, urinary tract infections and yeast infections.

Our pediatric protocols were designed in 2015-2016 by Cleveland Clinic pediatricians and family medicine providers, and are based on the principle that patients should receive the same standard of care whether they see a provider in-person via video conference. These protocols are shared on an intranet for all Cleveland Clinic providers.

Cleveland Clinic recently completed a quality improvement project that focused on ensuring the appropriateness of visit-type, documentation and antibiotic prescriptions in an effort to ensure that Cleveland Clinic patients received the same quality of care online as they do in our medical offices. As part of the project, 100% of all virtual pediatric visits are reviewed each month. Initially, up to 67% of the visits were deemed inappropriate. Systemic barriers to communication and guideline adherence were addressed, and we developed advanced algorithms to prompt providers about antibiotic decision making. Within six months, the number of inappropriate visits declined by 66% to 1%. Additionally, the rate of appropriate antibiotic prescribing increased from 69% to 97% over the same time frame.


Communication is vital

At Cleveland Clinic, virtual visits are live, synchronous audiovisual connections, and conducted on the Express Care® Online platform. Though virtual visits can be scheduled, they are more commonly on-demand for “urgent care”-type complaints (e.g., flu, upper-respiratory illness, etc). As a basic rule, Cleveland Clinic does not offer virtual visits for patients under two years of age.

Whether a patient is within or outside of the Cleveland Clinic Health System, we make every effort to share the encounter notes with the patient’s primary care provider. We support and wish to maintain the medical home, while expanding access to quality providers.

Not every patient is a candidate for a telemedicine experience. With our providers, we emphasize the importance of assessing whether an in-person visit would be recommended before commencing a virtual visit. Clinicians use their best medical judgment to determine if the virtual visit is appropriate for a particular patient or situation, and may stop a visit at any time. If we feel that an in-person visit is warranted, we do our best to facilitate a “warm hand-off” with other care providers.

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