Abstract
BackgroundOveruse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians.MethodsClinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29).ResultsCompared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions—including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components’ effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy.ConclusionsFuture efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.
Highlights
Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem
At EMR-based practices, a similar algorithm was programmed into the health system’s electronic medical record and clinicians were provided with an “order set” that recommended selected tests and treatments based on the specific diagnosis resulting from application of the algorithm
Individual and community consequences of antibiotic overuse Overall, 97% of respondents from the intervention practices agreed that antibiotic resistance is a major public health problem, and 93% believed that over-prescribing of antibiotics is a major cause of antibiotic resistance (Table 1)
Summary
Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S, more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. A combination of patient and physician education has been shown to help reduce antibiotic overuse for a variety of acute respiratory tract infections, including acute bronchitis [4,5], but levels of improvement have been limited, on average, to less than 20% absolute reduction across the study populations of physicians [9,10,11,12]. Antibiotic prescribing for acute bronchitis has been more resistant to change than for other acute respiratory infections, and the large majority (up to 90%) of patients diagnosed with acute bronchitis continue to be prescribed antibiotics [17,18,19]
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