Impact of a 16-Community Trial to Promote Judicious Antibiotic Use in Massachusetts

Abstract

OBJECTIVES. Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children. METHODS. We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to <72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid. RESULTS. The data include 223135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to <24, 24 to <48, and 48 to <72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to <24 months but was responsible for a 4.2% decrease among those aged 24 to <48 months and a 6.7% decrease among those aged 48 to <72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents. CONCLUSIONS. A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.

Antibiotic Prescribing During Pediatric Ambulatory Care Visits for Asthma

“…Physician education combined with a broader community-wide program was successful in improving antibiotic prescribing rates. 35 Provider feedback and patient education also was successful in decreasing the rate of increase of inappropriate antibiotic prescribing. 48 Although the interventions described did not focus specifically on antibiotic prescription during asthma visits, they suggest successful approaches that might be applied.…”

“…This finding is consistent with others that have demonstrated a relationship between education and more judicious use of antibiotics for pediatric upper respiratory illnesses. [34][35][36] Patient asthma education is increasingly being viewed as an important marker of quality of care in the ambulatory care setting. 37 The results from this finding suggest other potential benefits for asthma education, as it seems to be associated with more judicious use of antibiotics by providers.…”

Exploring the evidence base for national and regional policy interventions to combat resistance

“…Stewardship campaigns focusing on ambulatory and primary care prescribing behaviour have shown modest success on prescription rates. [19][20][21][22] Most campaigns show around 10% reductions in prescriptions and appear effective only in the short-run. 23,24 Multi-faceted campaigns that target both prescribers and consumers appear to yield better results than more narrowly designed interventions.…”

“…These have been shown to be effective in reducing antibiotic use, without increasing morbidity or affecting patient outcomes. 18,22,26,27 Hospital-based stewardship policies appear to have been better evaluated than those at community or national levels. The development and implementation of clinical antibiotic prescribing guidelines in secondary care provides the most compelling evidence of effectiveness with studies showing drops in prescribing of up to 80% for certain drug classes.…”

Reducing inappropriate antibiotics prescribing: The role of online commentary on physical examination findings

“…Nearly one-third of patients diagnosed with the common cold receive an antibiotic prescription, and prescribing for bronchitis and other viral illnesses are estimated to be higher than 50% [2,3]. While a number of recent studies indicate that inappropriate antibiotic prescribing may have peaked in the 1990s [4][5][6][7][8][9][10][11], there is evidence to suggest that declining prescribing rates are primarily driven by decreased rates of office visits for respiratory tract infections [8,12]. For patients presenting with URIs, physicians' rates of prescribing show a relatively modest and uneven decrease [8,12], together with increased reliance on broad-spectrum agents [1,4,10].…”