Elsevier

Annals of Emergency Medicine

Volume 50, Issue 3, September 2007, Pages 221-230
Annals of Emergency Medicine

Infectious disease/original research
Cluster-Randomized Trial to Improve Antibiotic Use for Adults With Acute Respiratory Infections Treated in Emergency Departments

Presented at the 29th annual meeting of the Society of General Internal Medicine, April 2006, Los Angeles, CA; and at the annual meeting of the Society for Academic Emergency Medicine, May 2006, San Francisco, CA.
https://doi.org/10.1016/j.annemergmed.2007.03.022Get rights and content

Study objective

We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections.

Methods

Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics.

Results

The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval −3% to 5%) and at intervention sites decreased by 10% (95% confidence interval −18% to −2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction.

Conclusion

Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Introduction

In recent years, there has been a growing concern about the emergence of antibiotic resistance among bacterial pathogens.1, 2 Because antibiotic resistance patterns are strongly correlated with antibiotic use patterns, multiple organizations have identified reductions in unnecessary outpatient antibiotic use as a critical component of efforts to combat antibiotic resistance.3 Targeting unnecessary antibiotic use is important because such use also confers unnecessary individual risk of adverse drug reactions, which are not uncommon with antibiotics.

At the center of campaigns to reduce unnecessary antibiotic use are efforts to understand and improve on management strategies for patients with acute respiratory tract infections.4, 5 Acute respiratory tract infections, which include nonspecific upper respiratory tract infections, acute bronchitis, sinusitis, pharyngitis, otitis media, and pneumonia, account for the majority of outpatient antibiotic use,6 even though available evidence strongly demonstrates that the majority of acute respiratory tract infections, specifically upper respiratory tract infections and acute bronchitis, are not bacterial in origin and, therefore, are unlikely to benefit from antibiotic treatment.5 To date, most interventions to reduce unnecessary antibiotic use for acute respiratory tract infections have focused on primary care settings7, 8, 9 and have demonstrated that combined patient and clinician educational strategies can successfully reduce the use of antibiotics for acute respiratory tract infections. In addition, recent time trend analyses have demonstrated that broader awareness of these issues has resulted in national downward trends in the use of antibiotics for acute respiratory tract infections in primary care settings.10, 11

Unfortunately, levels of antibiotic use for acute respiratory tract infections managed in the emergency department (ED) have not decreased to the same extent as that observed in primary care settings,12 and overall levels of antibiotic prescribing remain high.13 The ED setting is distinct from the primary care setting in a number of ways, having a greater acuity of illness, the need for rapid triage and treatment, and limited previous and subsequent contact with patients. As a result, established methods for reducing antibiotic overuse for acute respiratory tract infections in primary care settings may not readily translate into ED settings.

The Improving Antibiotic Use in Acute Care Treatment (IMPAACT) project is examining the impact of interventions on antibiotic use for acute respiratory tract infections among a national sample of Veterans Administration (VA) and non-VA hospitals. The specific aim of the present study was to test the impact of a multidimensional patient and clinician educational program on reducing unnecessary antibiotic use for acute respiratory tract infections. Our primary endpoint was the proportion of antibiotics prescribed for patients with upper respiratory tract infections and acute bronchitis evaluated in the ED. Our secondary endpoints included antibiotic prescribing for antibiotic-responsive acute respiratory tract infection diagnoses (including community-acquired pneumonia, sinusitis, and acute exacerbations of chronic bronchitis), the frequency of return ED visits and hospital admissions within 2 weeks of the index visit, and overall visit satisfaction. We evaluated the program in VA and non-VA hospital EDs to test whether distinct health care structures modified the impact of the program.

Section snippets

Study Design

The IMPAACT randomized controlled trial involves EDs at 8 VA medical centers and 8 non-VA academic medical centers. The trial was conducted as part of a joint Agency for Healthcare Research and Quality and VA Health Services Research and Development Service Award to compare the translation of research into practice across VA and non-VA settings. Details of the hospital sampling strategy have been previously described.14 In brief, we surveyed all 135 major VA medical centers and all US non-VA

Characteristics of Study Sites

We examined a total of 2,659 visits for acute respiratory tract infection diagnoses at control sites and 3,006 visits for acute respiratory tract infection diagnoses at intervention sites across the year 1 and year 2 winter periods. Table 1 summarizes the final specific acute respiratory tract infection discharge diagnoses documented in the medical record, comparing intervention and control sites during year 1 and year 2. Overall, nonspecific upper respiratory tract infection and acute

Limitations

Hawthorne effects are always of concern in trials intended to modify physician or patient behaviors. As such, clinician coding of diagnoses could be driven by treatment decisions such that physicians would be more likely to code for more antibiotic-responsive acute respiratory tract infections after deciding to prescribe an antibiotic. Indeed, we did observe a relative increase in the diagnosis of pharyngitis at intervention compared to control sites, which may have accounted for some of the

Discussion

We found that a multidimensional educational intervention targeting patients and clinicians appears to reduce antibiotic prescribing for patients diagnosed with upper respiratory tract infection or acute bronchitis in the ED, 2 common conditions for which antibiotics are frequently overprescribed.18 The reduction in antibiotic prescribing for upper respiratory tract infections or acute bronchitis was not associated with any apparent increase in the frequency of return visits or delayed

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    Supervising editor: Gregory J. Moran, MD

    Author contributions: JPM, CAC, TM, CM, and RG were responsible for study conception and design. JPM, JM, SKL, AK, and RG were responsible for acquisition of data and administrative, technical, or material support. JPM, CAC, TM, CM, JM, and RG conducted analysis and interpretation of data. JPM, CAC, CM, JM, and RG were responsible for drafting of the article and statistical analysis. JPM, CAC, TM, and RG obtaining funding. All authors provided critical revision of the manuscript. JPM and RG were responsible for study supervision. JPM and RG takes responsibility for the paper as a whole.

    Conflicts of interest: Dr. Metlay has served as a scientific consultant or received unrestricted educational funds from Aventis Pharmaceuticals and Roche Pharmaceuticals. Dr. Gonzales served as a consultant for Abbott Laboratories, Inc. to study C-reactive protein levels as a potential diagnostic test for outpatients with community-acquired pneumonia. Dr. Camargo has received financial support for participation in conferences, consulting, and medical research from the following industry sponsors with an interest in respiratory infections: Abbott, Aventis, Aventis Pasteur, GlaxoSmithKline, MedImmune, and Merck. None of the other authors have any conflicts of interest or financial disclosures.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that may create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was funded by the Translating Research into Practice initiative, jointly sponsored by the Agency for Healthcare Research and Quality (1 R01 HS013915) and the Health Services Research and Development Service of the Department of Veterans Affairs (AVA-03-239). The funding agencies had no role in the design and conduct of the study; collection management, analysis, and interpretation of the data; or preparation, review, or approval of the article.

    Available online May 23, 2007.

    Reprints not available from the authors.

    All members are listed in the Appendix.

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