A multifaceted urgent care stewardship program was associated with substantially lower systemic glucocorticoid prescribing for acute respiratory infections, with mean clinician-level prescribing rates declining from 20.4 to 8.8 prescriptions per 100 stewardship-eligible visits over 14 months, according to findings.
In the quality improvement study, researchers evaluated 14,530 stewardship-eligible visits among 10,808 adult patients seen by 96 clinicians at two urgent care centers within the Northwestern Medicine health system between January 2023 and April 2025. The prestewardship period ran from January 2023 to January 2024, and the intervention period ran from February 2024 to April 2025. The two study sites were selected because they had higher glucocorticoid prescribing rates than other urgent care centers within the health system — well above prior national estimates of approximately 11% for outpatient respiratory infection visits, a rate that has remained largely unchanged since 2007.
The intervention combined clinician education, patient-facing educational materials, standardized after-visit summary language, and emailed peer comparison feedback informed by behavioral science principles. Feedback reports showed clinicians their own prescribing rate over the prior 12 months, the 10% median prescribing rate among all Northwestern Medicine urgent care clinicians, and the 4% prescribing rate among the lowest-prescribing 20% of clinicians.
The acute respiratory infection stewardship measure included adult urgent care visits involving diagnoses such as nonspecific upper respiratory tract infection, sinusitis, pharyngitis, acute bronchitis, influenza, and pneumonia. Visits were excluded when patients had conditions in which glucocorticoids may be clinically appropriate, including asthma, chronic obstructive pulmonary disease, malignant neoplasm, urticaria, systemic vasculitis, systemic lupus, and rheumatoid arthritis.
Prior to stewardship implementation, systemic glucocorticoids were prescribed at 1,815 of 7,130 eligible visits. During the intervention period, glucocorticoids were prescribed at 779 of 7,400 eligible visits.
Interrupted time series analysis showed no immediate step change in prescribing when the program began, suggesting the intervention was associated with a gradual behavioral shift rather than an acute response to program launch. During the stewardship period, prescribing declined by approximately 6% per month relative to the prestewardship period, corresponding to a 58% relative reduction across the 14-month intervention period.
Patients had a mean age of 58 years, and 64% were female. Among clinicians, 81% were female; 40% were physicians, 33% were advanced practice nurses, and 27% were physician assistants. The most common diagnoses were nonspecific upper respiratory infection, acute pharyngitis, and acute bronchitis.
In a February 2024 survey distributed to 204 urgent care clinicians across the health system, 60 clinicians responded. Among respondents, 55% reported that too many systemic glucocorticoid prescriptions were being issued for viral acute respiratory infections (ARIs), while 45% considered current prescribing practices appropriate. The most commonly cited reasons for prescribing included symptom relief and perceived patient expectations.
The researchers emphasized that no treatment guidelines recommend routine systemic glucocorticoid use for ARIs and that evidence supporting benefit remains limited. They also highlighted potential harms associated with even short courses of systemic glucocorticoids, including neuropsychiatric symptoms, hyperglycemia, sepsis, venous thromboembolism, fracture, gastrointestinal bleeding, and heart failure.
The study was not randomized and did not include a control group, limiting causal interpretation. The researchers also noted that changes in clinician coding practices could have artificially reduced the denominator of stewardship-eligible visits, potentially overstating the improvement in prescribing rates.
In addition, the study did not systematically assess unintended consequences of reduced glucocorticoid prescribing, including return visits, worsening clinical outcomes, patient satisfaction, or clinician distress and burnout.
"Further study is needed to determine whether the benefits of these interventions are generalizable more broadly, are effective in other ambulatory settings, or would help to reduce use of other overprescribed medications where potential harms may outweigh benefits," wrote Dharmesh Patel, MBA, of Northwestern Medical Group Quality and Patient Safety, and colleagues.
Disclosures can be found in the published study.
Source: JAMA Network Open