Holly Frost, MD, senior director for the Center for Health Systems Research at Denver Health and associate professor of pediatrics at the University of Colorado School of Medicine, has dedicated much of her time to improving the way antibiotics are prescribed to patients. As part of her antibiotic stewardship work, Frost helped develop a first-of-its-kind, open-source tool—the Outpatient Automated Stewardship Information System (OASIS), created with support from The Pew Charitable Trusts—to help health systems and clinicians improve their prescribing practices. OASIS harnesses data from electronic health records and other health care data systems to assess antibiotic use; by streamlining the tracking and reporting of antibiotic use, OASIS can help ensure the appropriate distribution of these critical drugs.
This interview has been edited for clarity and length.
Q: How did you first become interested in antibiotic stewardship?
As a practicing pediatrician, I saw a lot of kids get prescribed antibiotics when they probably didn’t need them, and then come back into the office with side effects from the antibiotics such as diarrhea. Through these experiences, I recognized the huge burden that unnecessary antibiotic use was placing on patients and that there’s a clinical and public health need for improving antibiotic stewardship practices.
My background is also in infectious disease research, so during that time we could see the increase in resistance among bacteria, including for very common infections we treat in kids such as ear and sinus infections.
Q: What have you found most rewarding about your antibiotic stewardship work?
A: The great collaborations between patients, clinicians, health care administrations, policymakers, and stakeholders in the field that have allowed us to make big changes over time. Throughout the past five to 10 years, we’ve been able to make sure that the stewardship interventions we’re developing are meeting the needs of patients and families.
Q: And this relationship between antibiotic stewardship and patient care is critical, right?
A: Our goal is to improve care and quality of life for patients; we want to ensure that we’re doing the best that we can for them. We know that a lot of patients experience adverse drug events, such as upset stomach and rash, when they’re prescribed antibiotics. Antibiotics also put patients at risk for infections like Clostridioides difficile, formerly known as Clostridium difficile—a severe form of diarrhea that we’ve seen increase over time, largely as a result of unnecessary antibiotic use.
We also know that bacterial resistance has been increasing because of the overuse of antibiotics, which means that infections become more difficult to treat—and, in some cases, can mean that there are no effective antibiotics to treat certain infections at all.
Q: When did you first have the idea to develop the Outpatient Automated Stewardship Information System, or OASIS?
A: It goes back to before the pandemic, when I was working on a project with the American Academy of Pediatrics and the Centers for Disease Control and Prevention. We know that giving feedback to clinicians on their prescribing is one way to effectively reduce unnecessary antibiotic use. So we rolled out an antibiotic stewardship intervention program across pediatric practices in Colorado and Virginia that gave feedback to clinicians about their prescribing practices compared with those of their peers. But we found that the participating practices took between four and 20 hours a month to generate the reports, which wasn’t sustainable long term.
So we looked for an alternative approach, one that wouldn’t take clinicians 20 hours a month to generate reports. I began to work with a wonderful data analyst to automate the process, so that whenever we needed the reports, the system would automatically pull the data, create a report, and email it out to providers.
Q: And that became OASIS. Can you say more about how it works to reduce the overprescribing of antibiotics?
A: OASIS is a free, open-access tool that pulls data from electronic health records, analyzes it, and sends clinicians feedback reports that help them recognize their prescribing habits. Tracking and reporting of antibiotic prescribing is a core element of outpatient stewardship with the potential to significantly improve prescribing practices.
Q: Can you give an example?
A: In a previous study at Denver Health, using OASIS to audit and provide feedback to clinicians improved how often children with ear infections received the correct duration of antibiotics; a 26% improvement in less than 60 days.
OASIS has now also been implemented for additional measures, including first-line treatment for ear infections and antibiotic prescribing for respiratory conditions, at Denver Health and Children’s Hospital Colorado.
Q: How does this use compare with your original goals for OASIS?
A: When we first came up with OASIS, our plan was to use it internally. I don’t think we ever anticipated that it would take off like it has and be used so broadly. Our goal now is to expand uptake of OASIS within different health care organizations to help keep the stewardship community from having to reinvent the wheel when implementing their own antibiotic prescribing feedback program.
One of the big challenges that we face as a community is that we have a good sense of what works in terms of stewardship, and we can make projects work in certain health care systems or in certain research studies, but we haven’t effectively scaled those interventions on a national level. OASIS could really drive the field forward by rapidly scaling effective stewardship programs and implementing them across health care systems.
Q: How would that happen? In other words, how can other health care providers start to use OASIS?
A: Clinicians interested in using OASIS can sign up for a free membership on the OASIS website, where they can find information and videos about the tool. The website also features projects that are available to download and can be modified for clinicians’ own health care systems.
Q: More broadly, how do you hope that automated tools like OASIS will affect health care?
A: I hope that, with OASIS, stewards, health care systems, and public health entities can begin to work together and collaborate more frequently on their stewardship efforts. For example, while our team at Denver Health has created tracking and reporting metrics for acute otitis media and respiratory conditions, our goal is for other clinicians in the stewardship community to create their own metrics and share their projects and the associated analytic codes with other OASIS users.