Urgent Care Stewardship for Glucocorticoid Overuse in Acute Respiratory Infections

Importance: Systemic glucocorticoids have little or no demonstrated efficacy for acute respiratory infections (ARIs) and have known adverse effects. Clinicians in urgent care centers vary widely in their use of glucocorticoids for patients seen for ARIs. Objective: To develop and test a multifaceted urgent care stewardship program to reduce the use of glucocorticoids for ARIs. Design, Setting, and Participants: This quality improvement study included clinicians seeing patients from January 2023 through April 2025 presenting with ARIs at 2 urgent care centers within an academic health system. Interventions: Beginning in February 2024, clinicians were emailed a survey about steroid stewardship, received brief virtual clinician education, and were provided with educational pamphlets to distribute to patients. In May and December 2024, they received email feedback using peer comparison with descriptive and injunctive norms. Main Outcomes and Measures: Segmented Poisson regression with clinician-level random effects was used to analyze monthly clinician-level rates of ARI urgent care visits where a systemic glucocorticoid was prescribed (steroid stewardship-eligible visits) before (January 2023 to January 2024) and after (February 2024 to April 2025) steroid stewardship. Visits were excluded for patients with conditions where glucocorticoid treatment may be clinically appropriate. Retrospective interrupted time series modeling of glucocorticoid prescriptions was performed before and after stewardship program implementation. Results: From January 2023 to April 2025, 10 808 patients (mean [SD] age, 58 [24] years; 6879 [64%] female; 3929 [36%] male) were seen for ARI by 96 clinicians (78 [81%] females; 18 [19%] male; 32 [33%] advance practice nurses; 38 [40%] physicians; 26 [27%] physician assistants) presenting with ARIs at 2 urgent care centers within an academic health system. Participating clinicians attended 14 530 steroid stewardship-eligible visits (7130 before and 7400 during stewardship). The most common diagnoses were nonspecific upper respiratory infection (17%), acute pharyngitis (15%), and acute bronchitis (7%). The mean (SD) clinician-level observed rate per 100 stewardship-eligible visits of systemic glucocorticoid prescriptions decreased from 20.4 (17.8) in the period before stewardship to 8.8 (14.5) during the stewardship period (P <.001). During the stewardship period, the relative rate of glucocorticoid prescribing decreased by 0.94 (95% CI, 0.92 to 0.96; P <.001) per month compared with the period before stewardship. Conclusions and Relevance: In this quality improvement study of a multi-faceted, behavioral science-informed intervention to promote glucocorticoid stewardship for ARIs in urgent care settings, implementation was associated with reductions in glucocorticoid prescribing.