Michael H. Kanter, MD

 An epidemic of opioid overuse has resulted in nationwide efforts to decrease prescribing, but there is concern that implementing these recommendations will cause patients who are accustomed to opioids for chronic pain to be dissatisfied with care.

 Retrospective cohort study of satisfaction scores for patients prescribed opioids for noncancer chronic pain for at least 6 consecutive months from 2009 to 2014.

 We used mixed effects regression to examine the association between opioid dose reduction and the frequency of unfavorable patient satisfaction scores. Subgroup analysis compared the effect of dose reduction on satisfaction scores for encounters between patients and their assigned primary care provider (PCP) versus encounters between patients and an unassigned provider.

 Included were 2492 encounters involving patients with high-dose chronic opioid use for noncancer pain. A reduction in opioid prescribing occurred in 29% of encounters, and most of these resulted in favorable satisfaction scores (86.4%). After adjustment, the odds of an unfavorable score in the dose reduction group were just marginally higher and not significant (odds ratio [OR], 1.31; 95% CI, 1.00-1.73). Stratified by different encounter types, opioid dose reduction was not associated with unfavorable scores for visits with an assigned PCP (OR, 1.16; 95% CI, 0.79-1.70), but the odds of an unfavorable score were higher for encounters with an unassigned provider (OR, 1.50; 95% CI, 1.01-2.23).

 Overall, reducing opioid use for chronic pain is not associated with lower patient satisfaction scores, but encounters with unassigned providers may be associated with slightly lower satisfaction when opioids are reduced.

Our retrospective study of 2492 encounters for patients accustomed to high-dose opioids for chronic pain compared patient satisfaction scores between those with a recommended decrease in opioids and those without a reduction. We found the following:

Most encounters resulting in an opioid reduction maintained favorable overall satisfaction (86.4%).

Reducing opioids for chronic pain is not associated with unfavorable patient satisfaction scores (

Any potential adverse effect on satisfaction from a reduction in opioids is ameliorated for encounters with an assigned primary care provider.

Prescriptions for opioid analgesics have recently risen dramatically,

 a purported low addiction potential, shortened office visits, increasing patient expectations, and regulatory pressure to ensure appropriate pain management.

 Opioid use, measured in morphine milligram equivalents (MME), has increased in the United States by 300%, from 180 MME per capita in 1997 to 710 MME per capita in 2010.

 Deaths due to overdose have paralleled this dramatic rise in prescriptions, with opioid-related deaths increasing 200% from 2000 to 2014.

Professional groups, patient advocates, and government agencies have responded by developing guidelines for safely prescribing opioids.

 In August 2016, then Surgeon General Vivek Murthy, MD, sent a letter to all US physicians petitioning them to decrease opioid prescribing.

 Prescribers have been asked to consult state-level prescription drug monitoring programs, avoid coprescribing opioids with other classes of sedating drugs, and reduce individual patients’ opioid consumption to less than 50 MME daily.

 Despite these efforts, the alarming increase in opioid prescribing has not slowed, much less reversed, nationwide.

 One reason physicians are reluctant to deny or reduce opioid prescriptions is fear of patient complaints or lower patient satisfaction scores.

 This may be particularly relevant when physicians treat patients with whom they do not have a long-term relationship.

Consequences for providers with poor patient satisfaction scores may include lower pay,

 reduced chances of promotion, and even loss of employment. Of particular concern are patients who have historically been prescribed opioids for chronic pain and are now being weaned in accordance with current recommendations.

This study investigated whether reducing opioid prescriptions for patients without cancer to safer levels is associated with low satisfaction scores among patients with high opioid use in a real-world managed care setting.

A retrospective cohort study was conducted using clinical encounters of patients prescribed opioids for chronic noncancer pain between 2009 and 2014 within Kaiser Permanente Southern California. Inclusion criteria included clinical encounters with patients who completed a patient satisfaction survey and had been prescribed 50 or more MME per day for at least 6 consecutive months prior to the encounter. Encounters with patients younger than 18 years and those with a known cancer diagnosis (

International Classification of Diseases, Ninth Revision

 codes 140-203) were excluded. The cohort was divided into a dose-reduction group, defined by encounters with patients whose daily opioid use dropped below 50 MME for at least 30 days following the encounter related to the satisfaction survey, and a nonreduction group (continued daily use ≥50 MME for at least 30 days after the encounter). Satisfaction surveys were sent to patients after randomly selected (approximately 15%) clinical encounters, per routine operations in our health system (

The primary outcome was defined as the proportion of encounters with unfavorable satisfaction scores. The score is derived from 10 questions related to patient satisfaction with the encounter, each response ranging from very dissatisfied (1) to very satisfied (10). We defined a favorable score as 9 or greater, in agreement with the health system’s use of this cut point value to help determine financial incentives, hospital credentialing, and eligibility for associate physicians to become partners.

We adjusted for patient age, patient gender, Elixhauser score,

 provider years of experience, assigned primary care provider (PCP) visit, and provider partner status to account for observable differences between groups. We analyzed factors associated with the predictive variables using a general linear mixed effects model for logistic regression, including a provider-level random intercept to account for unmeasured provider effects. We included an interaction term to examine the effect of dose reduction in subgroups of assigned versus unassigned providers. An assigned encounter was defined as a visit between a patient and their assigned PCP. All analyses were performed using SAS statistical software, version 9.3 (SAS Institute Inc; Cary, North Carolina).

The sample included 2492 encounters, 29% of which were followed by a reduction in opioid prescribing. Patients in the dose reduction group were more likely to be younger than 65 years and female and to have an Elixhauser comorbidity score of 3 or greater (

). Patients who experienced a reduction in opioids to below 50 MME daily had a median decrease of 80 (mean = 109) MME.

Overall, most satisfaction scores were favorable for patient encounters with (86.4%) or without (89.9%) a dose reduction (Table 1). Adjusted odds of an encounter resulting in an unfavorable score were not statistically different for encounters resulting in an opioid dose reduction (odds ratio [OR], 1.31; 95% CI, 1.00-1.73; 

We did not find evidence to support an interaction between an opioid reduction and a PCP satisfaction score (

 = .358). Unadjusted favorable satisfaction scores were statistically less common after opioid reduction for both unestablished provider encounters (82.8% vs 88.0%; 

 <.001) and encounters with an assigned PCP (90.8% vs 89.5%; 

 ≤.001), but the small absolute difference in each group is of questionable clinical relevance. Adjusted odds of an unfavorable score following dose reduction were higher after an encounter with an unassigned PCP (OR, 1.50; 95% CI, 1.01-2.23) but not with an assigned PCP (OR, 1.16; 95% CI, 0.79-1.70).

In this study, we found that overall satisfaction was very high among patients with chronic use of high doses of opioids and that low patient satisfaction scores were not associated with a substantial reduction in their opioid dose. Prior research has demonstrated that opioid prescribing is not associated with patient satisfaction in emergency department settings.

 Our study of a chronic pain population had similar findings and highlights the benefits of an assigned PCP managing chronic pain, as low satisfaction had a slight association with reductions in opioid dosing for encounters with an unestablished provider.

Daily use of 50 or more MME is generally thought to significantly increase the risk of accidental overdose and death while conferring minimal advantage in terms of pain control.

 Consequently, the CDC and other professional organizations have recommended that physicians attempt to reduce opioid prescribing whenever possible.

 Countering these recommendations are numerous barriers, including the fear of dissatisfied patients, particularly if financial remuneration or job security is tied to patient satisfaction scores.

 At a minimum, our findings should reassure PCPs, because reducing opioid prescribing for patients with chronic noncancer pain in our study cohort was not associated with unfavorable satisfaction scores.

Although patient satisfaction was generally high, unfavorable satisfaction scores appear to be slightly more likely when opioids are reduced during an encounter with someone other than an assigned PCP. However, this small increased risk of an unfavorable satisfaction score does not justify risky opioid prescribing, and failing to lower opioid doses to safe levels for 20 patients in hopes of possibly improving patient satisfaction for 1 encounter is not reasonable. Future studies should attempt to understand why this occurs and determine which strategies can maintain high patient satisfaction after opioid dose reduction for encounters with unassigned PCPs.

Retrospective quasi-experimental study designs have several limitations. Although we adjusted for observable differences between groups, unmeasured confounders may be present. For example, we cannot determine the motivating factors associated with opioid dose reduction, and this may have confounded the results. In addition, our health system’s survey response rate of approximately 18% potentially introduced a response bias. However, patients who are unhappy about dose reductions are more likely to respond and report adverse scores, biasing the results in favor of a positive association between dose reduction and unfavorable scores. Further, we believe that our results are indicative of the actual satisfaction scores that are currently reported for comparisons of hospitals, health plans, and physicians and therefore representative of how satisfaction surveys are used in practice, as opposed to research settings.

Overall, there is no association between decreasing opioids and an unfavorable patient satisfaction score among encounters with patients with chronic noncancer pain. Satisfaction remains favorable in most cases following opioid dose reduction. However, there may be an association with lower satisfaction scores for unestablished providers reducing opioid prescribing for those accustomed to high opioid doses.&ensp;

Internal funding for the KPSC Care Improvement Research Team supported this project.

Department of Research and Evaluation (ALS, ES, YLW, AW, MKG), and Medical Director of Quality and Clinical Analysis (MHK), Kaiser Permanente Southern California, Pasadena, CA; Department of Emergency Medicine, Los Angeles Medical Center, Kaiser Permanente Southern California (ALS), Los Angeles, CA; Department of Emergency Medicine, University of Southern California, Los Angeles (MM), Los Angeles, CA; The Permanente Federation (MHK), Oakland, CA.

 Internal funding for the KPSC Care Improvement Research Team supported this project.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (ALS, ES, MHK, MKG); acquisition of data (YLW, MHK); analysis and interpretation of data (ALS, ES, YLW, AW, MM, MHK, MKG); drafting of the manuscript (ALS, ES, MM, MHK); critical revision of the manuscript for important intellectual content (ALS, ES, AW, MM, MHK, MKG); statistical analysis (YLW, AW); and supervision (ALS, ES).

 Adam L. Sharp, MD, MS, Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Fl, Pasadena, CA 91101. Email: adam.l.sharp@kp.org.

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Articles

There is no significant association between unfavorable patient satisfaction and opioid reductions for chronic pain, but encounters with unestablished providers may slightly impair satisfaction when reducing opioids.

Satisfaction With Care After Reducing Opioids for Chronic Pain

 Antibiotic stewardship is key to optimizing patient outcomes and affordable care. The study objective was to examine the effect of provider education and clinical decision support (CDS) on antibiotic prescribing for acute sinusitis among providers of varying experience.

A stepped-wedge cluster randomized intervention to evaluate antibiotic use for acute sinusitis encounters at 126 Kaiser Permanente Southern California clinics between September 2014 and April 2015.

 The primary outcome was receipt of an antibiotic prescription. Multivariate analysis adjusted for patient, provider, and medical center characteristics. Secondary analyses described sinusitis and other common upper respiratory infection (URI) diagnoses and antibiotic use during the study period compared with prior years. Chart review of a random sample reported the proportion of encounters receiving guideline-concordant antibiotics. 

Analysis of 21,949 encounters (10,491 pre- and 11,458 post intervention) showed CDS reduced the use of antibiotics (adjusted odds ratio [AOR], 0.78; 95% CI, 0.71-0.87), although the pre-post absolute difference was small (85.9% vs 83.9%, respectively). Education had a large initial effect (AOR, 0.51; 95% CI, 0.46-0.57), which did not persist. Increasing years of provider experience raised the rates of antibiotic prescribing, but did not have a significant interaction with CDS (

= .19). The effect of CDS varied by medical center (

<.001). In addition, sinusitis diagnoses decreased post intervention, with no overall increase in antibiotic prescribing for URI diagnoses. Lastly, guideline-concordant antibiotic use increased by 14%. 

Provider education and CDS improved antibiotic stewardship and changed diagnosis patterns. The benefits of education were brief, and CDS effectiveness varied by medical center. 

It is vital to understand the effectiveness of interventions designed to improve patient care in order to disseminate and replicate successful initiatives and avoid fruitless care improvement efforts. Our study of provider education and clinical decision support (CDS) on antibiotic prescribing for acute sinusitis offers the following to inform health systems and future research: 

CDS integrated in an electronic health record can discourage inappropriate antibiotic prescribing and will likely change diagnostic patterns. 

Provider education is unlikely to have a sustained effect on antibiotic prescribing.

The effectiveness of education and CDS will vary based on inherent differences among locations.

Antimicrobial stewardship is key to optimizing patient outcomes and minimizing the emergence of drug-resistant bacterial organisms.

 Unfortunately, the goal of reducing inappropriate antibiotic prescribing has remained elusive.

 This is true despite the existence of a variety of strategies to improve antibiotic stewardship, such as pay-for-performance incentives, documentation change strategies, provider education, and social “nudges.”

 We currently do not understand why these approaches have variable results across different settings. Research is needed to describe the effect of such interventions in general community practice and to understand variations in effect due to patient, provider, or medical center characteristics in order to inform current efforts to improve care. 

Acute sinusitis is a condition that affects 31 million annually

 The preponderance of evidence suggests antibiotics are not only ubiquitously overused for acute sinusitis treatment,

 but the correct antibiotic is often not chosen.

 Despite agreement regarding overuse, there is no universal recommendation regarding the precise group of patients with acute sinusitis who may benefit from antibiotics.

 We used the recommendations from our health system, patterned after the Infectious Diseases Society of America (IDSA)’s guideline,

 to report the effects of a 2-component intervention designed to improve antibiotic stewardship for acute sinusitis encounters. The components were computerized clinical decision support (CDS) within an electronic health record (EHR)

Clinical leaders and policy makers need to understand the variable effectiveness of multifaceted interventions, as well as the importance that individual provider characteristics may have on expected results. Our aim was to enhance the understanding of the effects of clinician education and CDS in a real-life clinical setting and, specifically, to assess any differences in effectiveness on providers with varying years of experience or among medical centers. 

We performed a pragmatic stepped-wedge cluster randomized study of provider education and CDS for acute sinusitis encounters. The study was performed in outpatient clinics (105 primary care, 21 urgent care) between September 2014 and April 2015 within Kaiser Permanente Southern California (KPSC), a large integrated health system. This system provides healthcare to more than 4 million members representative of the population diversity found in southern California. We used information from the EHR collected during routine care. This study was approved by the KPSC Institutional Review Board.

Each participating primary care and urgent care clinic is clustered within 1 of 6 medical service areas. Each service area was randomly assigned to receive the CDS intervention as part of a staged implementation over the course of 6 months. The total study period was 8 months, allowing for 1 month of pre-data for all areas prior to CDS implementation. CDS was turned on in 1 of the 6 areas each month until all were receiving CDS, then 1 month of post data was collected after all had received the intervention (

). This staggered implementation allowed for a stepped-wedge analysis.

 This design controls for confounders due to secular trends and strong champion effects. 

CDS was based on qualitative interviews with practicing clinicians

 and designed using features shown to be effective in previous trials.

 Automated in the EHR, CDS was initiated at the time of antibiotic prescribing for patients with an acute sinusitis diagnosis. Once triggered, it offered a clear recommendation based on current evidence.

 The alert informed providers that antibiotics were not generally recommended for patients with symptoms of less than 10 days’ duration. Additionally, CDS included options to justify use of antibiotics in the case of prolonged symptoms, “double worsening” of symptoms, or abnormal physical exam findings. CDS could be bypassed by providers, but required a response or cancellation to proceed with the order. In addition, CDS directed providers to an order set to facilitate the prescribing of amoxicillin or amoxicillin clavulanate if they had ordered a nonrecommended antibiotic for acute sinusitis. 

Provider education included a recorded online presentation and 2 webinars delivered in the middle of the staggered rollout (December). The intervention was created after previous research showed the need for improved stewardship and no temporal trends in improvement in the years leading up to our study period.

International Classification of Diseases, Ninth Revision, Clinical Modification

] code 461.x) taking place in primary care settings were included. We excluded encounters with specialists, follow-up visits, and patients with chronic diseases compromising their immune response (chronic liver disease, 

 codes 140-165, 170-176, 179-209, and 235-239; and common rheumatologic disorders, 

 codes 714, 710, 555.9, and 556). To ensure completeness of data, we limited our sample to Kaiser health plan members. 

The primary outcome was prescription of an antibiotic, classified by the generic product identifier. Secondary outcomes included prescription of an antibiotic for diagnoses with similar symptoms as acute sinusitis (acute nasopharyngitis, 

 code 465; acute upper respiratory tract infections of other multiple sites, 

 code 465.8; acute upper respiratory tract infections not otherwise specified, 

 code 466; influenza with respiratory manifestations, 

 code 487.1; and bronchitis not specified as acute or chronic, 

Concordance estimates were done based on structured chart review from a random sample of 50 charts with some from each of the 6 medical service areas. The structured chart review was performed by a trained member of the research team who followed a standardized protocol to limit bias.

 This random sample was selected from encounters in which antibiotics were prescribed post intervention. We used a standardized data abstraction form and manual previously developed to identify guideline-concordant antibiotic use for similar acute sinusitis encounters, which is proven to have high interrater reliability (93% agreement, kappa = .86).

 This previous research provided estimates of concordance rates (32%) for acute sinusitis encounters receiving antibiotics for comparison purposes. We used results from our chart review and applied the sampling fraction to estimate the variance of the proportion of encounters receiving antibiotics concordant with recommendations post intervention. This estimate was calculated via standard formulas routinely used for survey sampling research,

 then applied to the entire sample to construct 95% confidence limits. 

We used multiple logistic regression analyses to examine the main effect of CDS on antibiotic prescribing. To account for the staggered implementation of CDS, a dichotomous variable was created to indicate whether the encounter was pre- or post CDS. Another indicator variable was included to assess the impact of education amidst the rollout of CDS. A facility variable was included to identify differences in effect among the service areas. The analysis adjusted for variables that were statistically associated (

The final model used the provider as a random intercept, the education indicator as a fixed effect, and indicator variables modeled as fixed effects to assess the separate effects of CDS and provider education. 

Secondary analyses examined the interaction between CDS and provider groups of varying years of experience. We categorized the years of provider experience into 4 groups (<3 years, 3-9 years, 10-20 years, and >20 years), using the largest group of providers (10-20 years) as the reference for comparison. We similarly examined the interaction between CDS and each of the medical service areas. Within these groups of providers and service areas we also compared the odds of receiving antibiotics pre- and post intervention. 

We performed additional analyses to understand changes in sinusitis encounter diagnoses compared with similar upper respiratory infections (URIs) and to evaluate if these encounters resulted in changes to antibiotic prescribing. We report the number of acute sinusitis encounters and other similar URIs, as well as the proportion resulting in antibiotics during the study period (September 2014-April 2015) compared with the same months in the 2 prior years, 2012 to 2013 and 2013 to 2014. Similarly, we report these diagnoses and the percent receiving antibiotics stratified pre-post CDA implementation and pre-post provider education during the study period, as well as the type of antibiotic used pre-post CDS for acute sinusitis encounters. 

The study sample included 21,949 initial acute sinusitis encounters for adults (Figure 1). A similar number of encounters were included before and after the implementation of CDS (10,491 pre- and 11,458 post intervention), and more patients were seen at primary care clinics (76%) than in urgent care settings (

The CDS intervention significantly reduced antibiotic use for acute sinusitis encounters (adjusted odds ratio [AOR], 0.78; 95% CI, 0.71-0.87) (

), although it demonstrated only a 2% absolute reduction. Provider education, assessed as a time effect during December, showed significant decreases in antibiotic prescribing (aOR, 0.51; 95% CI, 0.46-0.57) (Table 2), but these effects were not sustained over the study period (

The odds of receiving antibiotics increased with additional years of provider experience (Table 2), although there was not a statistically significant interaction between years of provider experience and CDS (

). There were significant differences in the effect of CDS and antibiotic prescribing based on the interaction with each medical service area (

The overall number of encounters with acute sinusitis diagnoses decreased compared with the same temporal period in the 2 prior years and represented a smaller proportion of acute URI diagnoses (8.1% vs 11.7% and 11.3%). The proportion of acute sinusitis encounters, compared with all similar URI diagnoses, decreased in the posteducation (7.5% vs 9.3%) and the post-CDS (7.1% vs 9.2%) periods compared with pre-intervention. The overall proportion of acute URI encounters receiving antibiotics decreased during the study period (27.1%) compared with prior years (31.2% and 30.7%), but this does not appear to be attributable to the intervention. Pre-post stratification showed there may have been some diagnosis shifting where antibiotics were still prescribed, as CDS (3.3% increase) and education (2% increase) showed a small increase in antibiotic prescribing for other URIs before and after implementation during the study period (

]). The types of antibiotics used pre-post intervention did not differ significantly (

Lastly, a structured review of acute sinusitis encounters for patients who received antibiotics found that 46% (95% CI, 32%-60%) were guideline concordant. This was a 14% absolute improvement from a structured review of acute sinusitis encounters from the same primary care clinics in the pre-implementation period (32%; 95% CI, 19%-45%).

We performed an effectiveness study of the ability of CDS and provider education to decrease the use of antibiotics for acute sinusitis encounters. Adjusted comparisons showed a 22% improvement in the odds of prescribing antibiotics after the intervention, but the absolute reduction was small (2%). After CDS and education, the number of encounters with an acute sinusitis diagnosis decreased substantially. Lastly, we found that CDS had variable effectiveness based on the medical service area.

This study makes several important contributions to the existing body of literature describing the effectiveness of CDS. First, we confirmed that CDS is effective in real-world clinical settings, but showed that the magnitude of benefit may be less than that observed in highly controlled studies of efficacy.

Second, we observed a pattern of diagnosis-shifting as a result of education and CDS implementation. This may be an example of documented CDS “workarounds,” and future studies and quality-improvement efforts should account for changes in diagnosis patterns.

 It is possible that providers substituted a diagnosis other than acute sinusitis once they were made aware that antibiotics were not indicated for most patients with sinusitis. Understanding how CDS modifies diagnosis patterns warrants future investigation, although, based on our results, these changes did 

 result in an overall increase in the use of antibiotics for all URI diagnoses. 

Third, we observed increasing odds of antibiotic prescribing correlated with increasing years of provider experience, but this did not result in varying CDS impact. CDS did vary in effectiveness, however, based on the medical service area of the encounter. This may be a result of the culture and context within particular settings that promotes success. This finding supports other reports that have shown these less tangible factors to be an important aspect of the success of interventions.

 What is clear is that clinical leaders, policy makers, and researchers should account for the variable effectiveness of CDS depending on the local medical center characteristics. 

Despite overall results demonstrating improvements in antibiotic stewardship and guideline-concordant prescribing, we observed a diminution in effect over time. Much of the overall effectiveness of the 2-component intervention may be attributed to the acute drop in prescribing in December associated with provider education, rather than the CDS intervention. This temporal improvement was not sustained, and by the end of the study period rebounded to near the prior baseline. This reinforces that sustained improvement in clinical practice is difficult to achieve. 

Our study confirms results from recent efficacy trials showing the benefit of “accountable justification”

 with automated CDS during outpatient encounters, although in a slightly different approach. The limited effectiveness of our results may be partially due to limited “accountability,” as our CDS required a clicked response, but did not require the provider to document in the medical record the reason for use of antibiotics. Additionally, we looked only at acute sinusitis encounters, a condition for which antibiotics are generally not indicated, except under special circumstances, instead of viral diagnoses for which antibiotics are always contraindicated. Based on our relatively large aOR and comparatively small absolute effect of CDS, we hypothesize that patients with shorter symptoms or less severe symptoms were those changed to a different diagnosis and not given antibiotics. This is also based on our chart review, which showed improvements in guideline-concordant use of antibiotics. This may explain the increase in other similar URI diagnoses without a rise in antibiotics for those conditions. Therefore, it is reasonable to predict that the effect of our intervention on overall use of antibiotics may be underestimated by the absolute 2% decrease in the proportion of encounters receiving antibiotics for acute sinusitis.

Provider education and integrated CDS reduced antibiotic use for acute sinusitis encounters and substantially changed patterns of diagnosis for acute URIs. The benefits of education were brief and did not persist through the study period, and CDS effectiveness varied by medical center.

The authors thank Ellen J. Rippberger and Lorena Perez-Reynoso for their administrative assistance and organization throughout this study. They also recognize Jason Doctor, PhD, and Daniella Meeker, PhD, for reviewing and providing feedback about the manuscript. 

 Department of Research and Evaluation, Kaiser Permanente Southern California (ALS, YRH, ES, MKG), Pasadena, CA; Department of Emergency Medicine, Los Angeles Medical Center, Kaiser Permanente Southern California (ALS), Los Angeles, CA; Department of Emergency Medicine, San Diego Medical Center, Kaiser Permanente Southern California (RC), San Diego, CA; Department of Emergency Medicine, Kaiser Permanente Northwest (RPR), Portland, OR; Medical Director of Quality and Clinical Analysis, Kaiser Permanente Southern California (MHK), Pasadena, CA.

 Internal funding from the KPSC Care Improvement Research Team (CIRT) supported this project.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

 Concept and design (ALS, ES, RC, MHK); acquisition of data (YRH); analysis and interpretation of data (ALS, YRH, ES, RC, RPR, MHK, MKG); drafting of the manuscript (ALS, ES, RPR); critical revision of the manuscript for important intellectual content (ALS, ES, RPR, MHK, MKG); statistical analysis (YRH, ES); administrative, technical, or logistic support (RC); and supervision (ALS).

 Adam L. Sharp, MD, MS, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Fl, Pasadena, CA 91101. E-mail: adam.l.sharp@kp.org. 

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2. Fishman N. Antimicrobial stewardship. 

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3. Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. 

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4. Carlet J, Collignon P, Goldmann D, et al. Society’s failure to protect a precious resource: antibiotics. 

. 2011;378(9788):369-371. doi: 10.1016/S0140-6736(11)60401-7.

The authors assessed the effect of provider education and clinical decision support (CDS) on antibiotic prescribing for acute sinusitis. Education and CDS improved antibiotic stewardship and changed diagnosis patterns.

Improving Antibiotic Stewardship: A Stepped-Wedge Cluster Randomized Trial

Patient-centered healthcare is a high priority and is commonly measured and incentivized through patient satisfaction surveys. There is a need to further understand if increasing satisfaction has the unintended consequence of encouraging low-value care. This study assessed the association of low-value antibiotic prescribing with patient satisfaction scores, and it evaluated patient and provider characteristics that may impact the association. 

 Retrospective, observational study of acute sinusitis (AS) encounters for adult members of a large integrated delivery system from 2010 to 2013.

 Bivariate and multivariate analyses evaluating the use of antibiotics, patient attributes, and provider characteristics associated with favorable patient satisfaction scores. 

 Among 5169 encounters for AS, 79.5% of encounters in which antibiotics were prescribed had favorable satisfaction scores versus 75.4% of encounters in which they were not. Independent predictors of favorable satisfaction scores included: receipt of antibiotics (adjusted odds ratio [aOR], 1.24; 95% CI, 1.00-1.55), 45 years or older (aOR, 1.45; 95% CI, 1.24-1.69), Elixhauser Comorbidity Index score 2 or greater (aOR, 1.21; 95% CI, 1.05-1.40), provider business partner status (aOR, 1.38; 95% CI, 1.20-1.58), and a bonded encounter between a patient and their assigned primary care physician (aOR, 2.06; 95% CI, 1.75-2.44).

 Patient satisfaction scores are slightly lower when antibiotics are 

prescribed for AS, but 75% of those encounters still received favorable satisfaction scores. Factors such as older patient age, more comorbidities, and an established patient—provider relationship had stronger associations with high patient satisfaction.

We assessed the effect of low-value antibiotic prescribing on patient satisfaction scores, as well as the impact of patient and provider characteristics on favorable scores. 

Patient satisfaction is slightly higher when low-value antibiotics are prescribed.

A total of 75.4% of encounters not resulting in prescriptions of low-value antibiotics still received favorable satisfaction scores.

Encounter factors such as an established patient-provider relationship, older patient age, and more chronic conditions each favorably influence patient satisfaction scores.

Future research and policies should account for these influential variables when studying or comparing patient satisfaction.

In recent years, patient satisfaction has been recognized as a key measure of the quality of healthcare delivery in the United States. In an effort to encourage a greater focus on patient satisfaction, hospitals and providers have been given financial incentives to measure and improve these scores, especially relative to their peers.

 Although some reports have shown a favorable relationship between high satisfaction scores and other dimensions of quality,

 others suggest that the emphasis on higher scores may promote job dissatisfaction among providers

 or increase potentially harmful low-value care.

 This conflicting evidence makes it difficult to know if efforts to improve patient satisfaction scores facilitate or hinder a health system’s ability to provide high-quality healthcare in other respects.

Another important, and seemingly unrelated issue, is antibiotic stewardship. Prescribing antibiotics for common viral illnesses is widely prevalent but unnecessary, costly, and potentially harmful.

Acute sinusitis (AS), which affects 30 million Americans annually,

 is an example of a common condition for which low-value antibiotics are too often prescribed. US and European studies have all reported high rates (81%-85%) of antibiotic use for AS,

 and in the participating study sites for the current study, the reported prescription rates were as high as 90%. With the majority of these prescriptions being contrary to current recommendations,

 these prescriptions are likely to cause more harm than benefit.

 This low-value prescribing for AS has become such a concern that it is targeted by 5 national provider organizations as part of the Choosing Wisely campaign.

Patient satisfaction is one reason for prescribing low-value antibiotics. Some providers believe that their patients expect to receive prescriptions for antibiotics

 and, in addition, that high patient satisfaction scores depend upon the receipt of such prescriptions.

 Although there has been some research on the relationship between the receipt of antibiotics and patient satisfaction scores, there is insufficient information to draw conclusions about the impact.

 Understanding the patient and provider characteristics that influence the relationship between low-value care and patient satisfaction will inform interventions and policies to promote high-quality care. 

The primary aim of this study was to assess the effect of low-value antibiotic prescribing on patient satisfaction scores. The secondary aims were to evaluate patient and provider characteristics that may confound or modify the association between receipt of low-value care and satisfaction scores. 

This is a retrospective, observational study of AS encounters (

International Classification of Diseases, Ninth Revision, Clinical Modification 

] code 461.x) from 2010 to 2013 within Kaiser Permanente Southern California, a large integrated delivery system that provides care for approximately 4 million members of a prepaid health plan.

The primary inclusion criterion was adults diagnosed with AS. To limit our sample to those with uncomplicated AS, who are least likely to warrant antibiotics, we excluded encounters resulting in hospital admission, follow-up encounters, and encounters for immunocompromised patients. A follow-up AS encounter was defined as a visit for a patient who had already had a visit for AS in the 30 days before the index visit. Follow-up visits were excluded as they are more likely to warrant an antibiotic prescription based on current recommendations.

 “Immunocompromised” was defined as the presence of a diagnostic code for any of the following in the 12 months prior to the encounter: chronic liver disease (

 codes 140-165, 170-176, 179-209, and 235-239), and common rheumatologic disorders frequently treated with immune-suppressing medications (

 codes 714, 710, 555.9, and 556), as described in prior studies.

 The sample for analysis included eligible patients with uncomplicated AS who completed a patient satisfaction survey.

Antibiotics are not required to achieve high patient satisfaction. Patient age, chronic conditions, and an established patient–provider relationship influence satisfaction with acute care.

Michael H. Kanter, MD

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