Results of an Outpatient Antibiotic Stewardship Survey in Missouri

Abstract

Objective

To understand the perceptions, knowledge, and opportunities to improve antibiotic prescribing practices among outpatient providers.

Methodology

We disseminated a survey to a convenience sample of primary care and internal medicine physicians and mid-level providers practicing in the state of Missouri.

Results

Sixty-seven providers completed the survey. Most (64%) providers reported reviewing best practice guidelines and educational materials on a regular basis. Providers were most interested in patient-facing educational materials that would help support best practices. However, substantial variability existed in responses about antibiotic prescribing; some (15%) respondents stated that they rarely review guidelines or use antibiotic stewardship resources. Providers felt that any feedback about antibiotic prescribing practices should be provided via email and should focus on reducing antibiotic use for viral conditions.

Conclusion

Missouri survey respondents generally support appropriate antibiotic use to address antibiotic resistance. However, findings also suggest that delivering resources to targeted populations of over-prescribers may be beneficial. Future interventions should include physician-endorsed education to support safe antibiotic use and explore electronic feedback for viral conditions.

Introduction

Supporting antibiotic stewardship is a public health priority to help reduce antibiotic resistance and improve patient safety. Public health officials have been working to improve antibiotic use in outpatient settings. However, outpatient antibiotic prescribing trends have remained largely unchanged.¹

Several state health departments have started using large datasets to evaluate outpatient prescribing practices to identify areas for improvement. This process has included examining individual physician prescribing patterns, assessing variability between prescribers, identifying high and low outpatient prescribers of antibiotics, and assessing antibiotic appropriateness for common conditions to identify ways to improve antibiotic use on a state and national level.^2,3

The purpose of this study was to determine how outpatient physicians and other healthcare providers in Missouri prescribe antibiotics, what resources they use, and how they would like to receive feedback on antibiotic prescribing if statewide antibiotic stewardship interventions are performed in the future.

Methods

We created an online REDCap survey with items from similar studies in other settings⁵ (see https://collaborativecare.wustl.edu/items/2023-2024-patient-caregiver-and-clinician-perceptions-of-guidelines-about-antibiotic-stewardship-for-asymptomatic-bacteriuria/). Providers were recruited via email, newsletters, and presentations through the following sources: American College of Physicians – Missouri Chapter, St. Louis Area Business Health Coalition, Mercy, BJC Healthcare, The University of Missouri, and the Missouri Primary Care Association Annual Conference. Providers were eligible if they practiced medicine and could prescribe antibiotics in Missouri. At the end of the survey, they could opt to receive an electronic gift card as an incentive. The protocol was reviewed and approved as exempt research by the Washington University Human Rights Protection Office (IRB# 202401039).

Results

Participant Characteristics

Sixty-seven individuals completed the survey. Most had been in practice for one to five years, saw 15 or more patients a day, and specialized in Internal Medicine. About 34% (n=23) of providers worked in outpatient-only practices, closely followed by community-based practices, and university-based practices. Regions of practice was mostly concentrated to metropolitan areas (63%; n=42) (Table 1).

Table 1.

Demographic information of survey respondents.

Demographics
Years in Practice
Years	N	%
1 to 5	20	30
6 to 10	13	19
11 to 20	17	25
21 or more	13	19
Did not specify	4	6
Provider Specialties
Type	N	%
Internal Medicine	31	46
Family Medicine	23	34
Pediatrics	3	4
Infectious Diseases	5	7
Other*	9	10
Did not specify	2	3
Average number of patients seen per day
Patients	N	%
1 to 5	4	6
6 to 10	13	19
11 to 15	14	21
15 or more	39	58
Did not specify	4	6
Place of Practice
Location	N	%
University hospital	16	24
Non-university teaching hospital	1	1
Community hospital	17	25
Outpatient only	23	34
Federally Qualified Health Center	4	6
Long-term Care	1	1
Veterans Affairs	1	1
Did not specify	4	6
Practice Location
Location	N	%
Rural	2	3
Small town	10	15
Large town	9	13
Metropolitan	42	63
Did not specify	4	6
Gender Identity
Gender Type	N	%
Male	28	42%
Female	33	49%
Prefer not to say	2	3%
Did not specify	4	6%
Race
Race Type	N	%
Asian	7	10%
Black or African American	2	3%
White	53	79%
Prefer not to answer	1	1%
Did not specify	4	6%
Ethnicity	N	%
Ethnicity Type
Hispanic	1	1%
Non-Hispanic	61	91%
Did not specify	5	7%
Has used PCR-Based Testing
Yes	59	88%
No	4	6%
Did not specify	4	6%

^*other: convenient care, acute care, emergency medicine, wound care, and urgent care

Sixty-four percent (n=43) of Missouri physicians and mid-level providers who responded to the survey reported receiving training on prescribing antibiotics in the last 12 months. Virtual or web-based lectures (i.e. non-interactive, self-timed presentation) were the most common source of antibiotic prescribing education (Figure 1). Most (58%; n=39) of providers indicated that they typically review antibiotic prescribing guidelines at least two times a year.

Figure 1.

How Missouri antibiotic prescribers obtain educational information about antibiotic use.

Respondents also addressed potential antibiotic use in the setting of diagnostic uncertainty. Most (N=49, 73%) providers indicated that they would request more clinical tests to support their decision-making process, followed by patient education (N=45, 67%), and using a watch-and-wait approach (N=37, 55%) to see if symptoms resolve or worsen before prescribing an antibiotic.

Respondents felt that interventions combatting antibiotic resistance would be most effective at the prescriber level (N=55, 82%; see https://collaborativecare.wustl.edu/files/2025/07/Neyet.-al-MO-Med-2025-Supplemental-only.pdf ), through patient and family education (N=51; 76%), and at a regional or national level (N=38, 57%). However, opinions varied regarding how this data should be shared. Fifty-eight percent (n=39) of practitioners indicated that they would want to receive the data blinded, meaning the data would not be linked to specific providers and/or locations. Another 24% (n=16) of providers indicated they would like to receive the data with practitioner names and locations, limiting access only to providers who are prescribing antibiotics. Regarding receiving data that provides feedback related to prescribing practices, providers indicated that they would most want to receive antibiotic prescribing rates for viral conditions (n=32, 48%).

Optional open-ended comments at the end of the survey found that some providers recommended utilizing hospital-based antibiotic stewardship program approaches in outpatient settings. Other providers commented on struggles and frustrations with patients wanting antibiotics without being further assessed or commented on treating patients who have received multiple antibiotics for a variety of reasons in a short amount of time.

Discussion

Missouri physicians and mid-level providers reported regularly accessing educational materials and routinely reviewing best practice guidelines about antibiotics at least annually. Similarly, most respondents also provided expert-endorsed responses on to how they handle diagnostic uncertainty with antibiotic prescribing in their practices. However, substantial variability existed in responses, and some respondents stated that they rarely review guidelines or use antibiotic stewardship resources. To our knowledge, this is the first survey in Missouri asking how physicians would want their antibiotic prescribing practices to be shared. Respondents felt that feedback to high antibiotic prescribers should target viral conditions, be blinded to peers, and should be shared via email.

Figure 2.

Missouri prescribers self-reporting rates of reviewing antibiotic guidelines.

These findings provide insights on how the Missouri Department of Health and Senior Services should utilize limited resources to address antibiotic overuse. As most physicians reported that they have adequate access to resources and regularly review guidelines, additional resources could be spent on developing materials to assist physicians who are focused on prescribing antibiotics responsibly. This may include patient handouts and educational materials that will help reinforce physician messaging about appropriate antibiotic prescribing. Several of these resources exist in government and research settings but have not yet penetrated into routine practice. Some resources helping clinicians address viral conditions without antibiotics include prescription pads for patients provide information for symptom relief,⁷ a shared decision tool for diagnosing and prescribing antibiotics for UTIs,⁸ and self-guided communication skills training to help clinicians maintain patient satisfaction while avoiding unnecessary antibiotic prescriptions.⁹

The high degree of variability in survey responses suggest that there are likely some outliers in antibiotic prescribing that would benefit from additional feedback. Indeed, a recent study suggests that 9.3% of prescribers are responsible for 50% of antibiotic prescribing in some regions—which suggests that targeted interventions towards individual high-volume antibiotic prescribers should be considered.² A recent narrative review found that outpatient antimicrobial stewardship strategies focusing on provider and patient education, support systems for clinicians, and policy changes had the most impact on reducing antimicrobial resistance rates and improved appropriate antibiotic prescribing.⁶ These interventions should also be explored in Missouri.

Several state governments have started to look for antibiotic over prescribers using national data—with the goal of providing feedback about antibiotic use compared to peers. The current interventions, to our knowledge, have focused on sending letters in the mail and reviewing the total number of antibiotic prescriptions written by a single prescriber. The results of this survey suggest that Missouri physicians want more convenient information delivery (via email) and more specific feedback metrics (antibiotic prescription rates for viral conditions). Future interventions should take prescriber preferences into consideration both in Missouri and other states. Outpatient antibiotic appropriateness metrics is increasingly headed in this direction. The National Committee for Quality Assurance has developed a new Healthcare Effectiveness Data and Information Set (HEDIS) measure called the Antibiotic Utilization for Respiratory Conditions as a way to more closely assess how often people are prescribing antibiotics for viral upper respiratory tract infections.⁴

There were limitations to this study. The population of prescribers that responded skewed towards urban-practicing and younger physicians. Our survey did not ask participants to include their geographic location in Missouri, so some regions may be under represented, despite our efforts to contact and disseminate the survey statewide. Respondents may have also been more responsible antibiotic prescribers than non-respondents. We do not know how many people viewed the survey request, thus could not calculate an overall response rate. In addition, sampling was not random, making this study a convenience sampling approach. These may have limited the generalizability of our findings. The small number of participants limited our capacity to perform more robust statistical analyses.

Conclusion

Missouri antibiotic prescribers who responded to our study reported regularly accessing guidelines and utilizing evidence-based educational materials about antibiotic use. They also reported regularly using best practices to improve antibiotic use. Future interventions to improve antibiotic use should focus on patient educational materials and high-volume antibiotic prescribers for viral conditions, with outliers receiving blinded data via email.