Examples Of Successful Interventions To Reduce Inappropriate Antibiotic

Several successful interventions to reduce inappropriate antibiotic use have been described in the literature. All used multiple simultaneous interventions targeting relevant groups to affect change among provider, patient, and organizational factors. Some included interventions specifically targeted at antibiotic use, and some focused on other utilization issues, such as self-care, symptom treatment, or day care policies.

Gonzales et al. published the results of their multidimensional intervention on the treatment of adult acute bronchitis in 1999 (39). This was a nonrandomized quasi-experimental study involving four primary care practices in Denver, Colorado that were part of a nonprofit group-model health maintenance organization.

The full intervention site received household- and office-based patient educational materials. Household materials were mailed to families and included magnets outlining preventive and self-care issues, what to expect for a visit for respiratory illness, a CDC pamphlet entitled "Your Child and Antibiotics," an industry-sponsored pamphlet regarding handwashing, and a letter from their practice's medical director about the importance of reducing unnecessary antibiotic use. Office-based materials, directed at patients and family medicine and internal medicine clinicians, included posters regarding: (i) the lack of effect of antibiotic treatment on duration of illness for "bronchitis or chest colds," (ii) a graphic showing the increased prevalence of invasive antibiotic-resistant S. pneumoniae in Colorado, and (iii) a graph showing risk of carriage of PRSP stratified by prior antibiotic use. The clinician intervention consisted of a 30-min education session about how to reduce unnecessary antibiotic use for bronchitis, and site-specific practice profiling about bronchitis treatment the previous winter season. The limited intervention site received only office-based educational materials, and two control sites provided usual care without added interventions. All outcomes were compared to baseline values. During the study period, there was a decrease in antibiotic prescription rates for bronchitis at the full intervention site (from 74% to 48%) but not at the control and limited intervention sites. There were no differences in changes in nonantibiotic prescription rates, and return visits did not differ between sites. This group has published several other quasi-experimental trials of similar interventions used for different patient groups in different settings (112-114).

Finkelstein et al. tested the impact of a family and physician educational outreach intervention on pediatric antibiotic use in Massachusetts and Washington State managed care practices. They randomized 12 practices to either intervention or control groups. The physician intervention consisted of two small-group practice meetings with a physician peer leader. At the first meeting, leaders reviewed six one-page CDC-endorsed summaries of prescribing guidelines, focusing on differentiating pediatric bacterial acute otitis media from chronic otitis with effusion, which does not require antibiotics. Four months later, leaders at the second meeting reinforced the recommendations, and presented practitioner- and practice-level feedback regarding antibiotic prescribing rates for the previous year. Parents in intervention practices were mailed the CDC pamphlet: "Your Child and Antibiotics," with a cover letter signed by their own pediatricians. CDC waiting room posters and pamphlets reinforced the same key messages. Antibiotic dispensing for children 3 to 36 months of age decreased by 18.6% in intervention practices compared with 11.5% in control practices. Among children 36 to < 72 months of age, antibiotic dispensing decreased by 15% in intervention practices and 9.8% in control practices. The intervention had an overall adjusted effect of 16% in the younger and 12% in the older age group (68).

Belongia et al. reported their Wisconsin nonrandomized controlled before-and-after intervention trial of parent and clinician education on pediatric antibiotic prescribing and PRSP carriage by children using child care facilities. The intervention region consisted of three adjacent countries in northern Wisconsin and their two adjacent cities. The control region was a geographically distinct area surrounding the city of Marshfield, Wisconsin. Children in licensed child care facilities were screened for nasopharyngeal carriage of PRSP. Intervention region clinicians received grand rounds presentations by a peer leader, followed by practice-based small-group meetings with peer educators, presenting five key educational messages regarding antibiotic use for pediatric respiratory illnesses. Clinicians received written practice guidelines for five types of pediatric upper respiratory illnesses developed by a local physician working group, CDC fact sheets for physicians on judicious antibiotic use for common respiratory illnesses and bacterial resistance, samples of parent education pamphlets and information sheets, a sample letter allowing a child to return to childcare with an acute upper respiratory infection, and an imitation "prescription pad" providing written recommendations for symptomatic treatment of upper respiratory infections. Intervention region community procedures included: presentations for child care providers, local public health agencies, parent groups, and community organizations; CDC pamphlets and posters distributed to clinics, pharmacies, child care facilities, and schools; and presentations by project nurses to primary care clinic medical assistants and office staff regarding appropriate antibiotic use. "Cold kits" were provided to intervention region offices for distribution to adolescents and adults. The solid antibiotic prescription rate per clinician declined by 19% in the intervention region compared with 8% in the control region. The liquid antibiotic prescribing rates declined by 11% in the intervention region and increased by 12% in the control region. Retail antibiotic sales declined in the intervention but not in the control region. For participating children attending child care facilities, neither antibiotic use nor nasopharyngeal PRSP carriage rates differed between the intervention and control regions (88).

Perz et al. used data from Tennessee's Medicaid Managed Care Program to study the impact of the Knox County Health Department multifaceted yearlong campaign to decrease pediatric unnecessary antibiotic use. Tennessee's three other large urban counties did not receive the intervention and served as controls. Knox County's intervention was directed at three audiences: the 250 key primary care providers in the county, parents of young children, and the general public. Physician education consisted of peer leader lectures by a CDC physician to 150 key providers, presentations at hospital staff meetings, grand rounds, continuing medical education and resident conferences, distribution of treatment guidelines for pediatric respiratory infections to all 250 providers, and published articles in the Knox County Health Department newsletter mailed to all 1500 Knox County physicians. Most parent education materials were developed by and available from the CDC and consisted of pamphlets mailed to 40,000 households with children in day care and grades K-3, patient education materials distributed to the 250 key providers, and pamphlets distributed to the parents of every newborn. Public education consisted of; 30,000 pamphlets distributed to hospitals, clinics, and dental offices; television, radio, and newspaper announcements; 38,000 pamphlets distributed to families receiving influenza vaccine; and 53,000 pamphlets distributed at pharmacies. Antibiotic prescription rates declined in both intervention and control counties, with an intervention-attributable decline of 11% (69).

Hennessy et al. surveyed 13 rural Alaskan villages annually for 2 years for S. pneumoniae carriage and resistance, and collected population-based data on outpatient antibiotic use. Antibiotic use and pneumococcal carriage were both followed after a medical provider and community education campaign was introduced in four villages and then expanded the following year to include the remaining nine villages. The intervention included workshops for community health aides and physicians and follow-up visits to community health aides to reinforce the issues. Community residents received information regarding appropriate antibiotic use and antibiotic resistance in village meetings, at community fairs, through health newsletters, and in high school classrooms. Antibiotic use decreased by 31% in the initial intervention villages and by 35% in the remaining villages when they were included. No decrease in carriage of penicillin-resistant pneumococci was demonstrated after the intervention (7).

Samore et al. reported their cluster randomized trial in 12 rural Idaho and Utah communities, testing the impact of a community intervention with and without a clinical decision support system (CDSS) on reducing inappropriate primary care and emergency department antibiotic prescribing for respiratory infections. The community intervention was introduced in two waves. The first wave included meetings with community leaders, print news releases, distribution of bilingual examination room posters and brochures about appropriate antibiotic use in physician offices and pharmacies, and a mailing of a "do not treat viral infections with antibiotics" information card and refrigerator magnet to parents of children under 6 years of age. The second community intervention wave centered on self-care for respiratory illnesses. A spiral bound self-care guide for respiratory tract infections was distributed at clinics, health fairs, special events, and through one-to-one interactions with community residents. Articles regarding self-care were sent to community newspapers. Decision support tools distributed to clinicians covered guidelines for the treatment of pharyngitis, otitis media, bronchitis, upper respiratory tract infection, sinusitis, pneumonia, croup, and influenza. Three different support tools were offered to clinicians. In one version, a paper form was filled out by the patient, answering questions about specific symptoms. The paper form served as an information resource for the provider. The second tool was a paper-based flowchart designed to lead the clinician to the most appropriate diagnosis and treatment decision. The third tool was a PDA that generated patient-specific diagnostic and treatment recommendations based on clinical data entered by the clinician. Clinician education regarding antibiotic resistance, appropriate antibiotic use, and the decision support tools were provided to clinicians through lectures, small-group meetings, and one-on-one interactions with the study team. The antibiotic prescribing rate decreased by 10% from baseline in the clinical decision support arm, and increased by 1% and 6%, respectively, in the community intervention alone and nonstudy communities. Antibiotic use for "never-indicated" indications and macrolide use decreased more in the clinical decision support arm compared with the other communities (95).

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