We're here today with Doctor Jeff Linder, the chief of the division of General Internal Medicine at Northwestern University Feinberg School of Medicine.

Jeff, thank you for joining us today.

Thanks Jordan.

So for those who don't know, Northwestern medicine is a health system headquartered in Chicago, IL, with 2700 inpatient beds and 11,000 providers across 12 hospitals and other ancillary facilities.

Other ancillary facilities, there are many topics we're going to cover today from antibiotic stewardship.

Telehealth digital front doors Ehrs, but I like to start with antibiotic stewardship.

It's a topic you've published extensively on, and our known for.

I understand, Jeff, that you are on the Presidential Advisory Council on combating antibiotic resistant bacteria, is that right?

So I've I've presented to that group, so I was not on the on the Council itself, but if presented that group among other groups and on other advisory committees, it HEDIS and the Joint Commission and NCQA.

OK, great.

Excellent.

So what I'd like to to to ask you to kick off this conversation is how is Northwestern using technology platforms today to reduce overprescribing of antibiotics?

Yeah, I think the main thing is I'm using our information systems to generate better feedback.

So I've been working with behavioral scientists, social psychologists, and behavioral economists over the past.

It's getting towards 15 years now about how we change prescribers behavior and one of the first areas we did this was around antibiotic prescribing.

And so we are using our enterprise data warehouse and the EHR to generate kind of simpler reports about how individual clinicians and clinics antibiotic prescribing is and feeding that back to them.

Umm.

And so how I'd like, I think it'd be interesting to our listeners if you were to walk us through a particular use case where you saw maybe a a cohort of providers or an individual provider who was just potentially prescribing way more antibiotics than our clinically indicated as having been necessary.

Yeah.

And then kind of what the intervention was and then what the outcome was, if you wouldn't mind?

Yeah.

So we have a paper about antibiotic prescribing in our immediate care center.

So that's the northwestern medicine urgent care centers.

And like a lot of urgent care centers, the antibiotic prescribing rate was, to put it nicely, suboptimal.

Mm-hmm.

UM for respiratory infections, I mean, in their defense like 50% of the visits they see are for respiratory complaints.

Umm.

And so and they get scored and rated on patient satisfaction and throughput.

So it's challenging.

I don't wanna understate the challenges of.

You know doing well while you're doing right by the patients.

And so we developed a EDW report that we fed back to clinicians in our immediate care centers.

And the thing we were very focused on initially was clearly inappropriate antibiotic prescribing.

So we could and the generalizable message here is if you can.

Right target.

So you know this was antibiotic prescribing for colds, the flu, acute bronchitis where the patient kind of had nothing else going on.

And we knew that the top performers among our immediate care clinicians had an inappropriate antibiotic prescribed rate of 0%.

And then we compare how everybody else was doing relative to the top performing doctors.

And so this is how you're doing relative to the top performers in your clinic.

Umm.

And by giving people that report, we reduce the inappropriate antibiotic prescribing rates sort of in from the 30 to 40% range over the course of about a year and a half to two years to like 10%.

Well, do so.

And just to be clear, these were so the top performers, they had zero percent.

They were.

They were never prescribing antibiotics when it was not needed, but they were prescribing it when it was needed.

Right.

And then there were other providers who were prescribing it.

Many times when it was not needed and they were able to reduce the times when they inappropriately, inappropriately prescribed it. Correct.

Correct.

And you know, this gets, you know, it gets really complicated in a hurry.

And so it's like as a first pass, we're just trying to eliminate very clear inappropriate antibiotic prescribing.

But there's two things happening there.

There's a diagnosis selection, and then there's an antibiotic prescription.

And so you could easily, if you were.

I have another colleague, so Mark Friedberg, who's at Rand, who refers to if you were an evil doing.

Metric defeating clinician, you know it's not hard to figure out like, OK Now everybody has pneumonia and I never I never diagnose anybody with a nonspecific upper respiratory infection AKA a cold.

Uh-huh.

Umm.

Then you know, we've eradicated the diagnosis of the cold, but we've not changed the antibiotic prescriber and like, that's not victory.

And so you actually have to be clear about the target of your intervention.

And then expand the basket of diagnosis.

You're focused on a little bit to make sure you're not seeing that diagnosis shifting on the part of clinicians.

Did you?

Did you ever have under prescribing, meaning that it what they should have been prescribed, but we're not?

We did not see that and in in a number of studies we have not seen under prescribing and we've also done studies looking at do people in, in with those that narrow inappropriate diagnosis group.

OK.

You know, do they when we shut off antibiotic prescribing, that group, do we see more Edu visits, hospitalizations, follow-up clinic visits and we never do.

Mm-hmm.

So on the topic of changing provider behavior over the course of a year and a half, you said you can bear providers against top performers in their same clinic.

So was the solution merely printing out this report physically, booking 20 minutes of time to sit with them at a table and chairs?

And say, here's you.

Here's everybody else.

Here's you.

Here's everybody else or where their clinical decision support tools like a Best Practice advisory alert that would pop up.

I mean, was it a combination of all the above?

How did you actually go about changing that behavior?

Yeah, it was more the former.

So we actually had.

So Catherine Ritter, who's a A colleague who's is an urgent care doc.

And you need, you know, you need a champion who does the kind of care where you're trying to change the behavior, cuz if I show up, I'm a general internist, they say, well, you're a primary care doctor.

Umm. Mm-hmm.

You have no idea what it's like in all of those.

That's one of the defense mechanisms like these data don't apply to me, and I'm hearing about this from somebody who doesn't understand my life.

Umm.

Hmm.

Umm.

And so we had Catherine Ritter, who's a card carrying urgent care doc visit the different practices.

You know, we also have an ambulatory antibiotic stewardship team that would feedback.

Umm.

So in that respect, the actual intervention itself is much more social than technical.

Umm.

So we need the technical stuff to be able to get the data, but the loop is closed, sort of with the social aspect of it.

And to be clear, to put too fine a point on this, maybe I mentioned we're a lot of this was designed with behavioral scientists and social psychologists.

Umm.

You know the idea of showing you how you're doing relative to your peers and your top performing peers is key.

You know, a lot of times we think about putting more information in the EHR and I would argue we actually have too much information in the EHR and not enough good information.

But actually, what we nobody's prescribing antibiotics for colds because they don't know they shouldn't do that.

They're doing it because of other things, and so we have to other pressures, time pressure, patient satisfaction, pressure.

Umm.

Patient expectation pressure and so you have to meet that that perceived pressure with kind of the peer pressure of you know doing the right thing by patients and that this is an organizational imperative.

So I'm a doctor in an ambulatory clinic, and I've been prescribing at a rate 30% higher than his clinically indicated as being appropriate.

And I have my sit down with the doctor from the ER that you just said.

And she really convinces me that I've been doing the wrong thing.

Whoop.

Yeah.

OK.

OK, I'm on board now.

I'm gonna do the right thing, except hold on a second.

I still have 23 patients to see a day and patients are still coming in saying I'm sick.

Yeah.

I need antibiotics and I've gotta say, no, you don't, but how do I manage a time and the patient satisfaction, all the other pressures and the direct to consumer pharmaceutical marketing that says you know patients are coming in demanding these things.

How do I?

How do I handle these things now that I know what the right thing is?

Yeah.

And I'm I'm glad you asked, cause we also, you know we're we're not just UM coming at the clinicians with Shane, right.

Umm.

So we also try to give them tools, so communication tools and efficiency tools where we want people to be able to do this efficiently, leave the patient satisfied and do the right thing and make the case that you can do that.

So we did have you can look at our if you dig around our website, which is ASP, so antimicrobial stewardship program asp.m.org and God help you if you watch it, there's a video of me sort of demonstrating, you know, quick, highly rated communication skills with patients.

Umm.

Umm.

So you can do this quickly and.

An efficiently and leave the patient happy too.

And so and others have done work in this area too.

So Rita Mangione Smith and then another intervention we've used over the years is commitment posters.

Umm.

Umm.

Umm.

The visit and the the action from those posters is probably more in the clinicians mind than anywhere else, right?

So the clinician knows that the patient knows that the clinician has already pre committed to doing the right thing and so you're trying to short circuit that clinicians presumption that the patient is here to get their Z pack, yeah.

Got it.

Got it.

So now we we know what we need to do.

We know how to do it.

We're all ready to March forward.

Let's look a bit into the future.

We've now, you know, had a year or a few years of of of time has passed where we've been successfully reducing amount of inappropriate antibiotic prescription.

What's the outcome clinically?

I mean, obviously you're prescribing fewer, but you know, is it too small of a sample size to say, hey, we've had a reduced risk of mersa, you know, reduce hospital acquired or infections is, is there any kind of positive health outcome because obviously you're looking at at at at at a social at a societal level, you know, with antibiotics in the food stream and everything, you know, there's a lot of problems with the lack of efficacy of antibiotics.

Yes.

But just at Northwestern, can you evaluate outcomes?

Yeah, yeah, I think it's a couple things.

And so your for your listeners, you know, getting the HEDIS measures about avoiding inappropriate antibiotic prescribing for acute bronchitis and then actually the heat just measures have broadened in the past couple of years to reducing overall antibiotic prescribing.

So insofar as that is a quality target for your listeners, I would encourage them to look at HEDIS measures and then they can go back to payers and say, look, we're doing better at this.

Mm-hmm.

So that is a very concrete thing you can do, and I wouldn't discount the the satisfaction that clinicians get from being able to do this.

Like I've talked to a lot of people over the years where that have clinicians that have kind of done a 180 in their antibiotic prescribing and they actually kind of like feel better about it because they knew they were didn't sort of care.

And so there's a clinician satisfaction aspect of this as well.

Now on this topic, there's a few segues that we can go into.

One is, is there any telehealth or digital front door component to reducing overdiagnosis and overtreatment or is it mostly kind of when patients present in a physical clinic?

Yeah, great question.

A lot of and and I can take that a couple different directions.

Let me try to take it maybe 2, but 100% that you can make the argument that by the time the patient gets into the exam room with the doctor with a cold like too late, we've missed a huge opportunity in triage to say by all rights it sounds like you have a cold or you have a cough and you don't have any other comorbid illnesses that we're worried about.

And so it is A to a certain to be like a failure of triage.

And so building up better triage capabilities and and this is an imperative more in primary care than urgent care.

So urgent care.

We wanna get people in.

Who wanna be seen?

See them quickly.

Leave them happy.

Do the right thing.

Umm.

Primary care.

You know, we we have such a demand for seeing patients and and acute respiratory infections make up about 10% of all visits to primary care and most of those you could in some respects to look at that as waste and so doing better triage and keeping people at home with symptomatic treatments and kind of avoiding the visit in the 1st place is actually improving access in primary care.

So we're definitely doing that.

And then the 2nd place I wanted to take this was I actually just got funding along with a colleague, Julie Simsat, who's at University of Utah.

She's a sociologist.

Umm to study patients who make lots of these visits.

And so just to like pick off the patients who make four or more visits for inappropriate antibiotics over the course of like 18 to 24 months and actually go right to them and say because we always hear from doctors that oh, it's the patients that want the antibiotics and you really need to talk to the patients.

And so in this project, we kind of answered by saying, OK, we're going to go talk to those patients.

Huh.

And and that is that ongoing or do you have any results preliminary, OK?

We have just started.

We have just started, yeah.

Got it.

Let's see.

So we're talking about the effective telemedicine remote health monitoring, are there are, how are they functioning as a newest tools and preventive medicine.

We just mentioned how they may kind of alleviate kind of over the burden on seeing many different patients on providers and therefore improve access or there are any other, how else have telemedicine, remote health monitoring been assisting primary care and preventive medicine?

I mean the the biggest one that I have in mind and actually I've been, you know, in in reading about the the COVID pandemic, you know, during the COVID pandemic I ran our COVID monitoring program.

So this was like thousands of patients who had COVID and we kind of set up an automated daily questionnaire that they would fill out, but you could easily imagine generalizing that to respiratory complaints that.

So I sort of mentioned like a failure of triage but, and not that we've pulled this off, but imagine a world where somebody called into the practice and said, hey, I'm, you know, I need an antibiotic.

I have a runny nose and you say, OK, let's have you fill out these questions.

And if if it doesn't seem like there are any red flags, don't need to come in, you know we're gonna send you another questionnaire in in another day and you can sort of stay attached to the patient through the course of their illness.

And you know, never mind, with AI tools kind of potentially making this easier, but I think that's what's coming in the future.

Well, Jeff, we are approaching the end of this podcast episode and I'd like to kind of pose a final question to you.

You mentioned when we were just talking a moment ago about HEDIS measures for inappropriate antibiotic use and you said that as you see providers go more in line with the gold standard, you're seeing improved provider satisfaction.

I know that there's an issue with electronic health records and increasing complexity of medical practice.

You wrote a paper that said for providers never gets easier, you just go faster.

Right.

So on that topic, with so not topic, would provider burnout on the and on the topic of provider satisfaction where they're doing the right thing in accordance with the Hippocratic Oath to do no harm?

Greg LeMond quote. Yeah.

Yeah.

I'd like to ask you if you could reflect upon the positive externalities of reducing antibiotics over use.

I mean, I think that we touch on some of them.

So there's the the you know, the I don't.

Mm-hmm.

I'm not sure if it's an externality, but you know, maybe in the context of the patient doctor visit.

But yeah, reducing inappropriate antibiotic prescribing, reducing the prevalence of antibiotic resistant bacteria, fewer costs, maybe you can prevent these visits as I alluded to.

Mm-hmm.

But the biggest thing by far is adverse drug events.

So kind of that happened in a much kind of less severe level, but are much more common.

So somewhere between 15 to 25% of people who get an antibiotic are going to have some kind of adverse reaction to it.

If it's a rash diarrhea yeast infection for having gotten an antibiotic that they didn't need in the 1st place, and I think that is actually kind of the the quality imperative is avoiding adverse drug drug events from antibiotics.

Perfect.

Well, with that, I'd like to thank you for joining us today, Jeff, for a listeners.

This has been doctor Jeff Linder, the chief of the division of General Internal Medicine at the Northwestern University Feinberg School of Medicine.

Jeff, thank you very much for joining us today.

Thank you so much.