Can an education and outreach program reduce unnecessary antibiotic prescribing among young children visiting physicians and HMO clinics?

An education and outreach intervention, directed at physicians and parents of young children visiting practices affiliated with two managed health care plans, reduced antibiotic dispensing beyond an independent trend toward lower antibiotic use in control group practices. The intervention involved peer-led physician education and performance feedback combined with educational materials mailed to parents and displayed in clinic waiting rooms.

Why is this important?

To curb the spread of antibiotic-resistant pathogens, unnecessary use of antibiotics must be reduced. This goal may be especially important among young children, who have a higher rate of infection with antibiotic-resistant pathogens than other age groups (Whitney et al. 2000).

Although physicians have reduced antibiotic prescribing over the past decade (McCaig et al. 2002), further progress is needed. Many physicians say that parents pressure them to prescribe antibiotics for a sick child when antibiotics are not clinically indicated (Bauchner et al. 1999). A multifaceted intervention to educate patients and physicians was successful in reducing unnecessary antibiotic use among adults (Gonzales et al. 2001).

Interventions

To test the effects of a one-year targeted educational intervention aimed at reducing unnecessary antibiotic prescriptions for children, 12 urban and suburban group practices and multispecialty clinics affiliated with two geographically unique managed health care plans were randomized by matched pairs to intervention and control groups (Finkelstein et al. 2001).

• Parents of enrolled children receiving care at intervention practices were mailed a pamphlet on appropriate antibiotic use that was developed by the Centers for Disease Control and Prevention (CDC), with a cover letter signed by their physician. Additional CDC pamphlets and posters were displayed in intervention clinic waiting rooms.
• A CDC-trained pediatric peer leader conducted small-group educational sessions with physicians in the intervention practices at the start of the intervention and again four months later, with the follow-up presentation including feedback on group and individual physician antibiotic prescribing performance.

Findings

Antibiotic dispensing decreased by 10 percent to 12 percent from the baseline to the intervention year among young children visiting control group practices, probably because of national public health initiatives. Antibiotic dispensing decreased significantly more, by 15 percent to 19 percent, in the intervention clinics (Finkelstein et al. 2001).

Among children who visited in both the baseline and intervention years, there was a "relative intervention effect" of 12 percent to 16 percent fewer antibiotics dispensed in the intervention practices, beyond the change in antibiotic use in the control practices after adjusting for baseline use of antibiotics (data not shown).

Implications

A multifaceted educational intervention directed at both physicians and parents was successful in boosting the reduction in antibiotic prescribing beyond the preexisting trend toward lower antibiotic use.

Improvement Ideas and Resources

The Centers for Disease Control and Prevention provides educational resources on reducing antibiotic resistance through appropriate antibiotic use.

Measure:

In this cluster-randomized controlled trial, 12 clinical practices affiliated with two managed care organizations were stratified by size and randomly assigned (by pairs based on similar ranked baseline antibiotic prescribing rates) to intervention or control groups. Computerized claims data were analyzed for enrolled children ages 3 months up to 72 months if they had pharmacy benefits for at least three months during the study period and had a record of ambulatory visits and antimicrobial prescribing during the study period. There were 14,468 and 13,460 patients in the baseline and intervention years, respectively. Observation time in person-years was determined for each child as the period of membership in the age subgroup (based on age at the start of the intervention year) during the baseline and intervention years. Baseline antibiotic use was significantly lower in the intervention sites. The change in unadjusted dispensing rates (shown in the chart) was significantly greater for intervention versus control sites. In a comparison of rates for 8,815 children enrolled during both years of observation (not shown), a significant intervention effect was confirmed after adjusting for each patient's antibiotic use in the baseline year, their age, and correlation between prescription rates for children in each practice site. This effect was confirmed in separate practice-level analyses, which found that the improvement was not attributable to extreme results at any one practice site (Finkelstein et al. 2001).

Limitations:

The study did not separately assess rates of antibiotic prescribing for appropriate and inappropriate reasons.

Source:

The study used computerized claims data and was conducted by researchers at the Harvard Medical School and Harvard Pilgrim Health Care, Boston; the University of Washington, Seattle; Group Health Cooperative, Seattle; the Centers for Disease Control and Prevention, Atlanta; the Veterans Administration Medical Center, Philadelphia; Tufts University, Medford, Mass.; and Vasca, Inc., Tewksbury, Mass. (Finkelstein et al. 2001).

References:

* Indicates source of data used in the chart(s).

Bauchner, H., S. I. Pelton, and J. O. Klein. 1999. Parents, Physicians, and Antibiotic Use. Pediatrics 103 (2): 395–401.

* Finkelstein, J. A., R. L. Davis, S. F. Dowell et al. 2001. Reducing Antibiotic Use in Children: A Randomized Trial in 12 Practices. Pediatrics 108 (1): 1–7.

Gonzales, R., J. F. Steiner, J. Maselli et al. 2001. Impact of Reducing Antibiotic Prescribing for Acute Bronchitis on Patient Satisfaction. Effective Clinical Practice 4 (3): 105–11.

McCaig, L. F., R. E. Besser, and J. M. Hughes. 2002. Trends in Antimicrobial Prescribing Rates for Children and Adolescents. Journal of the American Medical Association 287 (23): 3096–102.

Whitney, C. G., M. M. Farley, J. Hadler et al. 2000. Increasing Prevalence of Multidrug-Resistant Streptococcus Pneumoniae in the United States. New England Journal of Medicine 343 (26): 1917–24.