Cluster-Randomized Trial to Improve Antibiotic Use for Adults With Acute Respiratory Infections Treated in Emergency Departments
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.
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Supervising editor: Gregory J. Moran, MDAuthor 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.
PII: S0196-0644(07)00383-6
doi:10.1016/j.annemergmed.2007.03.022
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
