Improving the prescribing of antibiotics for urinary tract infection. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. Reducing antibiotic use in children: a randomized trial in 12 practices. Prescribing--a suitable case for treatment. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. Physician behavior modification using claims data: tetracycline for upper respiratory infection. Experimental evaluation of the effects of drug information on antibiotic prescribing: a study in outpatient care in an area of Sri lanka. Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae: A controlled intervention trial in rural Alaska. A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care. Randomised controlled trial of effect of feedback on general practitioners' prescribing in Australia. Randomized, controlled trial of prescribing training in a South African province. A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. Modification of general practitioner prescribing of antibiotics by use of a therapeutics adviser (academic detailer). Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study. Improving drug use through continuing education: a randomized controlled trial in Zambia. Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. Confidential prescriber feedback and education to improve antibiotic use in primary care: a controlled trial. Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study. Small group intervention vs formal seminar for improving appropriate drug use. Impact of a limited fluoroquinolone reimbursement policy on antimicrobial prescription claims. Improving physician prescribing patterns to treat rhinopharyngitis. Intervention strategies in two health systems of Mexico. Influencing prescribing for urinary tract infection and asthma in primary care in Sweden: a randomized controlled trial of an interactive educational intervention. An evaluation of statewide strategies to reduce antibiotic overuse. Effect of an explicit decision-support tool on decisions to prescribe antibiotics for sore throat. Pilot study for appropriate anti-infective community therapy. Effect of a guideline-based strategy to optimize use of antibiotics. Can drug treatment be improved by feedback on prescribing profiles combined with therapeutic recommendations? A prospective, controlled trial in general practice. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. Improving antibiotic prescribing in office practice. A controlled trial of three educational methods. Persistence of improvement in antibiotic prescribing in office practice. Primary care workshops can reduce and rationalize antibiotic prescribing. A community intervention trial to promote judicious antibiotic use and reduce penicillin-resistant Streptococcus pneumoniae carriage in children. Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trial of patient information leaflet. Changes in antibiotic prescribing for children after a community-wide campaign.
In recent years there have been changes in the recommended antibiotic treatment for urinary tract infections (UTIs). In particular, the use of amoxycillin or co-trimoxazole is now discouraged, with amoxycillin-potassium clavulanate, cephalexin and trimethoprim becoming first-line agents for uncomplicated lower UTIs.
                To examine whether academic detailing, performed by a pharmacist, could modify prescribing practices for antibiotics used in the treatment of UTI in the community setting.
                The intervention was conducted in Southern Tasmania, using the remainder of the State as a control area. The target group of general practitioners was sent educational material designed to assist in the appropriate prescribing of antibiotics in the treatment of UTI. A pharmacist then visited each general practitioner and discussed the rational use of antibiotics for UTIs directly with him/her. Outcomes were measured using evaluation feedback from the general practitioners and pharmacoepidemiological data, which were not linked to diagnosis. The key variable examined was the total defined daily doses (DDDs) dispensed for the recommended first-line agents (amoxycillin-potassium clavulanate, cephalexin and trimethoprim) compared with amoxycillin (3 g single-dose form) and co-trimoxazole.
                The educational programme was very well received by the general practitioners. Changes in the prescribing of antibiotics commonly used for UTIs were evident in both study regions over the course of the study, but the improvements were significantly greater in the intervention area.
                Educational programmes utilizing academic detailing by pharmacists can modify prescribing practices within the community setting. The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due, in part, to the excessive use of antibiotics for acute respiratory tract infections.
                To decrease total antibiotic use for uncomplicated acute bronchitis in adults.
                Prospective, nonrandomized controlled trial, including baseline (November 1996-February 1997) and study (November 1997-February 1998) periods.
                Four selected primary care practices belonging to a group-model health maintenance organization in the Denver, Colo, metropolitan area.
                Consecutive adults diagnosed as having uncomplicated acute bronchitis. A total of 2462 adults were included at baseline and 2027 adults were included in the study. Clinicians included 56 physicians, 28 physician assistants or nurse practitioners, and 9 registered nurses.
                The full intervention site received household and office-based patient educational materials, as well as a clinician intervention consisting of education, practice-profiling, and academic detailing. A limited intervention site received only office-based educational materials, and control sites provided usual care.
                Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods.
                Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period. During the study period, there was a substantial decline in antibiotic prescription rates at the full intervention site (from 74% to 48% [P = .003]), but not at the control and limited intervention sites (78% to 76% [P = .81] and 82% to 77% [P = .68], respectively). Compared with control sites, changes in nonantibiotic prescriptions (inhaled bronchodilators, cough suppressants, and analgesics) were not significantly different for intervention sites. Return office visits (within 30 days of the incident visit) for bronchitis or pneumonia did not change significantly for any of the sites.
                Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions. To test whether an educational outreach intervention for families and physicians, based on the Centers for Disease Control and Prevention (CDC) principles of judicious antibiotic use, decreases antimicrobial drug prescribing for children younger than 6 years old. Setting. Twelve practices affiliated with 2 managed care organizations (MCOs) in eastern Massachusetts and northwest Washington State. Patients. All enrolled children younger than 6 years old.
                Practices stratified by MCO and size were randomized to intervention or control groups. The intervention included 2 meetings of the practice with a physician peer leader, using CDC-endorsed summaries of judicious prescribing recommendations; feedback on previous prescribing rates were also provided. Parents were mailed a CDC brochure on antibiotic use, and supporting materials were displayed in waiting rooms. Automated enrollment, ambulatory visit, and pharmacy claims were used to determine rates of antibiotic courses dispensed (antibiotics/person-year) during baseline (1996-1997) and intervention (1997-1998) years. The primary analysis (for children 3 to <36 months and 36 to <72 months) assessed the impact of the intervention among children during the intervention year, controlling for covariates including patient age and baseline prescription rate. Confirmatory analyses at the practice level were also performed.
                The practices cared for 14 468 and 13 460 children in the 2 study years, respectively; 8815 children contributed data in both years. Sixty-two percent of antibiotic courses were dispensed for otitis media, 6.5% for pharyngitis, 6.3% for sinusitis, and 9.2% for colds and bronchitis. Antibiotic dispensing for children 3 to <36 months old decreased 0.41 antibiotics per person-year (18.6%) in intervention compared with 0.33 (11.5%) in control practices. Among children 36 to <72 months old, the rate decreased by 0.21 antibiotics per person-year (15%) in intervention and 0.17 (9.8%) in control practices. Multivariate analysis showed an adjusted intervention effect of 16% in the younger and 12% in the older age groups. The direction and approximate magnitude of effect were confirmed in practice-level analyses.
                A limited simultaneous educational outreach intervention for parents and providers reduced antibiotic use among children in primary care practices, even in the setting of substantial secular trends toward decreased prescribing. Future efforts to promote judicious prescribing should continue to build on growing public awareness of antibiotic overuse. nan To compare immediate with delayed prescribing of antibiotics for acute otitis media.
                Open randomised controlled trial. Setting: General practices in south west England.
                315 children aged between 6 months and 10 years presenting with acute otitis media.
                Two treatment strategies, supported by standardised advice sheets-immediate antibiotics or delayed antibiotics (antibiotic prescription to be collected at parents' discretion after 72 hours if child still not improving).
                Symptom resolution, absence from school or nursery, paracetamol consumption.
                On average, symptoms resolved after 3 days. Children prescribed antibiotics immediately had shorter illness (-1.1 days (95% confidence interval -0.54 to -1.48)), fewer nights disturbed (-0.72 (-0.30 to -1.13)), and slightly less paracetamol consumption (-0.52 spoons/day (-0.26 to -0.79)). There was no difference in school absence or pain or distress scores since benefits of antibiotics occurred mainly after the first 24 hours-when distress was less severe. Parents of 36/150 of the children given delayed prescriptions used antibiotics, and 77% were very satisfied. Fewer children in the delayed group had diarrhoea (14/150 (9%) v 25/135 (19%), chi(2)=5.2, P=0.02). Fewer parents in the delayed group believed in the effectiveness of antibiotics and in the need to see the doctor with future episodes.
                Immediate antibiotic prescription provided symptomatic benefit mainly after first 24 hours, when symptoms were already resolving. For children who are not very unwell systemically, a wait and see approach seems feasible and acceptable to parents and should substantially reduce the use of antibiotics for acute otitis media. Professional Standards Review Organization claims data were used in defining, planning, implementing and evaluating an approach to an ambulatory medical care problem utilizing educational intervention. Modification of physicians' tetracycline prescribing behavior was achieved in an actual practice setting by personal visits from peer physicians. The intervention level of epidemiology is useful for studying effects in health systems research. Due to practical and ethical reasons, it is often difficult to apply experimental methods such as classical randomized clinical trials in the field. However with alternative approaches such as 'randomization by group' some of these problems can be overcome. Drug information has since long been considered as an instrument to influence physicians, however evaluation of its effects is a new field of research. In the present study the impact of drug information on prescribing behaviour was evaluated in an outpatient setting in Sri Lanka. The study included 15 state health institutions (45 prescribers) with a common drug formulary. Groups of prescribers were randomized into two interventions; newsletters and newsletters reinforced by a group seminar, and one control group. The target topic was 'rational prescribing of antibiotics'. Some 18,766 randomly selected outpatient drug prescriptions were studied. Antibiotics (and sulphonamides) were prescribed to 33.2% of the patients. An overall trend towards a decrease in proportion of patients prescribed antibiotics in the two intervention groups was seen, although the difference was not significant (p greater than 0.05) compared to the control group. This is similar to the effect of written information on prescribing in other studies. A mean difference of -7.4% in written, -7.3% in written + seminar and -0.4% in the control group was shown. The general antibiotic prescribing pattern did not change in any of the three groups. Penicillin was the most commonly prescribed antibiotic and tetracycline was only rarely prescribed to children. This experiment indicates the feasibility of drug information intervention studies in developing countries.(ABSTRACT TRUNCATED AT 250 WORDS) From 1998 to 2000, 13 rural Alaskan villages (population, 3326) were surveyed annually by nasopharyngeal cultures for Streptococcus pneumoniae carriage. Data regarding antibiotic use for the entire population was abstracted from clinic records. In 1999, education of medical providers and the community about appropriate antibiotic use began in 4 villages; this program was expanded to include all villages in 2000. Antibiotic courses per person decreased by 31% in the initial intervention villages and by 35% in the remaining villages after education (P<.01 for each). Samples were obtained for culture from a mean of 31% of the population each year; 31% carried pneumococcus. No sustained decrease in carriage of penicillin-nonsusceptible strains was observed. When linear regression was used, serotype accounted for 81% of the variance in pneumococcal minimum inhibitory concentrations after the intervention, compared with 7% for antibiotic use. This suggests that reducing the carriage of serotypes associated with antibiotic resistance by use of pneumococcal conjugate vaccines may have a greater short-term impact than does decreasing antibiotic use. Despite evidence that uncomplicated lower respiratory tract infection (cough) does not respond appreciably to antibiotics and that bacterial resistance is increasing, general practitioners (GPs) still prescribe frequently.
                To assess delayed antibiotic prescribing as a strategy for reducing the unnecessary use of antibiotics for cough in primary care.
                Open randomised controlled trial of delayed versus immediate prescribing of antibiotics.
                One hundred and ninety-one adult patients with uncomplicated cough in 22 Scottish practices who would have received antibiotics under the GP's usual practice were randomised to receive either an immediate prescription (92 patients) or a delayed prescription (99 patients).
                Delayed subjects were asked to wait a week before deciding whether to collect their prescription. Outcome measures included symptom duration, prescription uptake, patient satisfaction, patient enablement, and subsequent consultation rates. The 48 GPs who recruited patients were surveyed six months after the trial to see whether they used delayed prescribing as a part of their normal practice.
                Study and control groups were similar at baseline. Of the subjects in the delayed arm, 55% did not pick up their prescription. Although most patients were satisfied, more patients in the immediate arm were very satisfied with the treatment (P = 0.001) and the consultation (P = 0.03). The patients in the immediate arm were also more enabled (3.3 versus 2.4; P = 0.04), although more of them intended to consult for similar complaints in the future (85% versus 69%, P = 0.02). We were unable to detect any difference in actual consulting behaviour in the follow-up period (mean = 15 months [SD = 5 months]). Subsequently, 68% of GPs used delayed prescribing at least monthly; all gave the prescription to the patient.
                Delayed prescribing is effective at reducing the use of antibiotics for self-limiting cough; however, patients are less satisfied and enabled as a result. Patients may be deterred from consulting rather than becoming enabled. To evaluate the effect on general practitioners' prescribing of feedback on their levels of prescribing.
                Randomised controlled trial.
                General practice in rural Australia.
                2440 full time recognised general practitioners practising in non-urban areas.
                Two sets of graphical displays (6 months apart) of their prescribing rates for 2 years, relative to those of their peers, were posted to participants. Data were provided for five main drug groups and were accompanied by educational newsletters. The control group received no information on their prescribing.
                Prescribing rates in the intervention and control groups for the five main drug groups, total prescribing and potential substitute prescribing and ordering before and after the interventions.
                The intervention and control groups had similar baseline characteristics (age, sex, patient mix, practices). Median prescribing rates for the two groups were almost identical before and after the interventions. Any changes in prescribing observed in the intervention group were also seen in the control group. There was no evidence that feedback reduced the variability in prescribing nor did it differentially affect the very high or very low prescribers.
                The form of feedback evaluated here-mailed, unsolicited, centralised, government sponsored, and based on aggregate data-had no impact on the prescribing levels of general practitioners. Prescribing practices impact greatly on drug use and expenditure. The situation in developing countries is often compounded by a limited health budget. Furthermore, because of role substitution in these countries, prescribers are often not formally trained in rational prescribing. The study described in this paper assesses the effect of a prescribing training intervention for primary health care nurses.
                A generic training-of-trainers course and a 4-day effective prescribing course were presented to 24 provincial trainers. These trainers then conducted effective prescribing workshops for 20 primary health care nurses per workshop. In 1997, 457 prescribers were trained by this method in South Africa's Northern Province. The study investigated the impact of the training on prescribing practices for two target conditions, in a control and a study group of 11 clinics each, 1 month after and 3 months after the intervention.
                Primary health care clinics in the Lowveld Region of the Northern Province of South Africa.
                Prescribing practices for the two conditions examined were significantly improved by the training. Changed behaviour was not only seen in prescribing for upper respiratory tract infections, used as an example condition, but also for diarrhoea and/or vomiting, a common condition in the region, which was not included in the training programme. These results show that prescribers not only retained the knowledge gained, but were also able to apply their new skills to other conditions (transfer effect). The change in the study group was maintained for 3 months after training, while there were no significant improvements in prescribing in the control group.
                The training intervention had a beneficial effect on prescribing practices. Prescribing practices for otitis media are not consistent with current evidence-based recommendations.
                To determine whether point-of-care evidence delivery regarding the use and duration of antibiotics for otitis media decreases the duration of therapy from 10 days and decreases the frequency of prescriptions written.
                Randomized, controlled trial.
                Primary care pediatric clinic affiliated with university training program. Intervention. A point-of-care evidence-based message system presenting real time evidence to providers based on their prescribing practice for otitis media.
                Proportion of prescriptions for otitis media that were for <10 days and frequency with which antibiotics were prescribed.
                Intervention providers had a 34% greater reduction in the proportion of time they prescribed antibiotics for <10 days. Intervention providers were less likely to prescribe antibiotics than were control providers.
                A point-of-care information system integrated into outpatient pediatric care can significantly influence provider behavior for a common condition. This was a pilot study of the use of a clinical pharmacist as a therapeutics adviser (academic detailer) to modify antibiotic prescribing by general practitioners.
                Following a visit by the adviser (March-May), 112 general practitioners were recruited and randomised to control or active groups. A panel of experts prepared a best practice chart of recommended drugs for upper and lower respiratory tract infections, otitis media and urinary tract infections. The adviser made a 10-15 min visit to each prescriber in the active group (June-July), gave them the chart and discussed its recommendations briefly. Doctors in the control group were not visited nor given the chart. Prescription numbers for all prescribers were obtained from the Commonwealth Health Insurance Commission for the pre(March-May) and postdetailing (August-September) periods using a three month lag time for data collection. Data for total numbers of prescriptions and for selected individual antibiotics used in these two periods were analysed using nonparametric statistics.
                Prescribing patterns were similar for the control and active groups in the predetailing period. For both groups, there were significant (P<0.03) increases (45% for control and 40% for active) in total number of antibiotic prescriptions in the post compared with the predetailing period. This trend was anticipated on the basis of the winter seasonal increase in respiratory infections. In line with the chart recommendations for first-line treatment, doctors in the active group prescribed significantly more amoxycillin (P<0.02) and doxycycline (P<0.001) in the post vs predetailing periods. By contrast, doctors in the control group prescribed significantly more cefaclor (P<0.03) and roxithromycin (P<0.03), drugs that were not recommended. The total cost of antibiotics prescribed by doctors in the control group increased by 48% ($37 150) from the preto postdetailing periods. In the same time period, the costs for the active group increased by only 35% ($21 020).
                We conclude that the academic detailing process was successful in modifying prescribing patterns and that it also decreased prescription numbers and costs. Application of the scheme on a nationwide basis could not only improve prescriber choice of the most appropriate antibiotic but also result in a significant saving of health care dollars. Infections with group A streptococcus (GAS) occur in 10% to 20% of patients with sore throats, whereas antibiotics are prescribed 50% of the time. Clinical scoring rules can more accurately predict the likelihood of GAS infection, but whether family physicians will adopt such approaches is unclear. This study sought to determine whether repeated clinical prompts to use a scoring approach could help family physicians lower antibiotic use in patients with a sore throat.
                Randomized trial in which physicians were assigned to use either (1) chart stickers that prompted them to calculate a score based on clinical findings and provided management recommendations linked to score totals or (2) a clinical checklist.
                Ninety-seven family physicians in Ontario, Canada, assessed 621 children and adults with sore throat and obtained a throat swab for culture.
                (1) Unnecessary antibiotic prescriptions given to patients with a negative throat culture and (2) overall antibiotic use.
                There were no differences between the control and intervention group in unnecessary antibiotic prescriptions (16.1% vs 20.4%, respectively, P =.29) or overall antibiotic use (27.9% vs 28.1%, P =.97). However, a number of physicians dropped out of the study; as a result, the characteristics of the physicians in the 2 groups were dissimilar in factors related to prescribing. After adjusting for these differences and patient clustering by physician, the odds ratio for the effect of the intervention on unnecessary antibiotic prescriptions was 0.76 (95% confidence interval [CI] = 0.42, 1.40) and 0.57 for overall antibiotic use (95% CI = 0.27, 1.17).
                Chart prompts during clinical encounters to use a clinical score in the assessment of patients with a sore throat did not reduce unnecessary antibiotic prescribing by family physicians. The problems encountered in conducting this community-based intervention trial are discussed in relation to the negative result. The objective of this study was to evaluate the impact of three continuing education seminars (within a period of 4 months) on the quality of patient management and rational drug use. The study was designed as a randomized controlled trial. Prescribers in 16 general health centers were allocated to an intervention (eight health centers) or a control (eight health centers) group. A total of 5,685 patient cards was analyzed for quality of case management and rational drug use. In the intervention health centers the average number of drugs per patient decreased from 2.3 to 1.9 (p = 0.005) and the proportion of patients managed with nonpharmacological treatment increased from 1 to 13.2%. Recorded history taking, examination, and diagnosis improved in the intervention health centers. More drugs were correctly chosen in the intervention health centers compared to control health centers (p = 0.03). The proportion of patients prescribed antibiotics decreased and the proportion of patients adequately managed increased in the intervention health centers. Our conclusion is that continuing education in the form of repeated seminars is effective in influencing prescribers and in promoting rational drug use in primary care. To test the use of a delayed prescription compared with instructions to take antibiotics immediately in patients presenting to family physicians with upper respiratory tract infections (common colds).
                Randomized controlled single-blind study.
                Subjects were 129 patients presenting with the common cold who requested antibiotics or whose physicians thought they wanted them. All patients were in a family practice in Auckland, New Zealand, consisting of 15 physicians (9 male, 6 female) who had completed medical school between 1973 and 1992.
                Outcomes were antibiotic use (taking at least 1 dose of the antibiotic), symptom scores, and responses to the satisfaction questions asked at the end of the study.
                Patients in the delayed-prescription group were less likely to use antibiotics (48%, 95% CI, 35%-60%) than were those instructed to take antibiotics immediately (89%, 95% CI, 76%-94%). Daily body temperature was higher in the immediate-prescription group. The lack of difference in the symptom score between the 2 groups suggests that there is no danger in delaying antibiotic prescriptions for the common cold.
                Delayed prescriptions are a safe and effective means of reducing antibiotic consumption in patients with the common cold. Clarification of patient expectations for antibiotics may result in a lower prescription rate. When the patient demands a prescription, delaying its delivery has the potential to provide gentle education. In the early 1990s there was an increase in erythromycin resistance among group A streptococci in Finland. In response, policies regarding outpatient antibiotic therapy were changed, and nationwide recommendations were issued that called for reductions in the use of macrolide antibiotics for respiratory and skin infections in outpatients. We studied the effect of this policy on the pattern of erythromycin resistance throughout Finland.
                From 1991 through 1996, a total of 39,247 group A streptococcal isolates from throat swabs (82 percent of the isolates) and pus samples (18 percent) and 290 isolates from blood cultures were studied in regional microbiology laboratories. The susceptibility of the isolates to erythromycin was tested by the disk-diffusion or the screening-plate method.
                Consumption of macrolide antibiotics decreased from 2.40 defined daily doses per 1000 inhabitants per day in 1991 to 1.38 in 1992 (P=0.007) and remained near the lower level during the study period. The change in consumption was followed by a steady decrease in the frequency of erythromycin resistance among group A streptococcal isolates from throat swabs and pus samples, from 16.5 percent in 1992 to 8.6 percent in 1996 (odds ratio for 1996 as compared with 1992, 0.5; 95 percent confidence interval, 0.4 to 0.5).
                In Finland, after nationwide reductions in the use of macrolide antibiotics for outpatient therapy, there was a significant decline in the frequency of erythromycin resistance among group A streptococci isolated from throat swabs and pus samples. Antibiotics are a medication class for which inappropriate prescribing is frequently described. We sought to assess the effectiveness of a mailed intervention combining confidential prescribing feedback with targeted educational bulletins in increasing the use of less expensive, first-line antibiotics by practising physicians.
                The participants were 251 randomly selected primary care physicians from southern Ontario who consented to participate (135 in the feedback group and 116 in the control group). Prescribing data were obtained from the claims database of the Ontario Drug Benefit program, which covers all Ontarians over age 65 years for drugs selected from a minimally restrictive formulary. Confidentially prepared profiles of antibiotic prescriptions coupled with guidelines-based educational bulletins were mailed to the intervention group every 2 months for 6 months. The control group received no intervention until after completion of the study. The main outcome measures were change from baseline in physician's median antibiotic cost and proportion of episodes of care in which a prespecified first-line antibiotic was used first.
                The median prescription cost of about $11 remained constant in the feedback group but rose in the control group (change of $0.05 v. $3.37, p < 0.002). First-line drug use increased in the feedback group but decreased in the control group (change of 2.6% v. -1.7%, p < 0.01). In a mailed survey of 100 feedback recipients (response rate 76%), 82% indicated that they would participate readily in another, similar program.
                A simple program of confidential feedback and educational materials blunted cost increases, increased the use of first-line antibiotics and was highly acceptable to Ontario primary care physicians. It is difficult to put research findings into clinical practice by either guidelines or prescription feedback.
                To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups.
                199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments.
                Difference in the prescribing behaviour between the year before and the year after the intervention.
                Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group; this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group.
                Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care. In an attempt to evaluate the efficacy of different methods of interventions to improve the appropriate use of drugs for acute diarrhoea, a controlled study has been carried out in 6 districts in Yogyakarta and Central Java provinces, Indonesia. This study was designed to investigate the impacts of two different methods of educational intervention, i.e. a small group face-to-face intervention and a formal seminar for prescribers, on prescribing practice in acute diarrhoea. The districts were randomly assigned into 3 groups and 15 health centers were selected from each district. Prescribers in Group 1 underwent a small group face-to-face intervention conducted in the respective health center. Those in Group 2 attended a formal seminar conducted at the district level. Prescribers in Group 3 served as the control group. Both interventions were given on a single occasion without follow-up supervision or monitoring. Written information materials on the appropriate management of acute diarrhoea were developed and were provided to all prescribers in the intervention groups. Focus group discussions (FGDs) involving prescribers and consumers in the 6 districts were carried out to identify various underlying motivations of drug use in acute diarrhoea. The findings of the FGDs were used as part of the intervention materials. To evaluate the impacts of these interventions on prescribing practice, a prescribing survey for patients under five years old with acute diarrhoea was carried out in health centers covering 3-month periods before and after the intervention. The results showed that both interventions were equally effective in improving the levels of knowledge of prescribers about the appropriate management of acute diarrhoea. They were also partially effective in improving the appropriate use of drugs, reducing the use of non-rehydration medications. There was a highly significant reduction of antimicrobial usage either after small-group face-to-face intervention (77.4 +/- 2.7% to 60.4 +/- 2.9%; P < 0.001) or formal seminar (82.3 +/- 3.0% to 72.3 +/- 3.6%; P < 0.001), and the former caused significantly (P < 0.001) greater reduction than the latter. There was also a significant (P < 0.01) reduction in the usage of antidiarrhoeals after both interventions, i.e. from 20.3 +/- 3.7% to 12.5 +/- 3.3% (P < 0.01) after face-to-face intervention and from 48.5 +/- 4.1% to 27.0 +/- 4.3% (P < 0.01) after seminar. However, the formal seminar had a significantly (P < 0.01) greater impact than the small group face-to-face intervention. There was also a trend toward increased oral rehydration solution (ORS) usage after both interventions, but this did not achieve the level of statistical significance (P > 0.05). No changes were observed in the control group. Although the small group face-to-face intervention did not appear to offer greater impacts over large seminars in improving the appropriate use of drugs in acute diarrhoea, since the unit cost of training is far less costly than the seminar, it might be feasibly implemented in the existing supervisory structure of the health system. To examine the influence on administrative pharmacy claims of a policy that limited the reimbursement of the fluoroquinolones and other antimicrobials in the senior population within Nova Scotia, Canada.
                The administrative claims database of the Nova Scotia Seniors' Pharmacare Program was used to identify all prescription claims for orally administered antibiotics and urinary antiinfectives. The number of beneficiaries receiving antimicrobials and the number, duration, and cost of prescriptions for antimicrobials were measured monthly. Descriptive time-series plots were used to compare antimicrobial use for two 12-month periods before the institution of the policy (December 1, 1994-November 30, 1995, and December 1, 1995-November 30, 1996) and the 12 months after the policy took effect (January 1, 1997-December 31, 1997).
                Following the implementation of the fluoroquinolone reimbursement policy, the number of patients using antimicrobials decreased by 2.2% and the number of prescriptions for antimicrobials decreased by 3.4%. Fluoroquinolone prescriptions decreased by 80.2%; prescriptions for sulfonamides and trimethoprim increased by 34.9%, cephalosporins by 17.0%, and macrolides and lincosamides by 16.5%. The only prescription duration to change was the fluoroquinolones, which increased by 25%. The average cost per antimicrobial user/year decreased from $35.24 during prepolicy period 2 to $27.51 during the postpolicy period.
                Prescription claims for fluoroquinolones in seniors decreased following the introduction of the policy. Total antimicrobial use also decreased, although this may be related to other factors. The effect of this policy change on patient outcomes requires further study. To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide. Our aim was to evaluate effects on prescribing for urinary tract infection (UTI) and asthma, of an education with messages based on national guidelines, aimed at improving prescribing in primary care in Sweden. The study is part of the European Drug Education Project. A randomized controlled trial, with groups of general practitioners (GPs) allocated to education on UTI (18 groups, 104 GPs) or asthma (18 groups, 100 GPs), the two parallel intervention arms being controls for each other. Feedback was provided on the GP's judgments of simulated cases and prescribing. Prescribing indicators were developed and measured before and after the intervention. Analysis was performed by multi-level technique. Prescribing of first choice UTI drugs increased in the intervention arm from 52% to 70% and remained constant in the control arm (P < 0.001). The proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms. The educational model can be used to improve prescribing. Further studies are needed to define when the model is effective. The rapid increase of antibiotic resistance poses a significant threat to human health. Overuse of antibiotics has been linked to rates of antibiotic resistance. This study assessed the utility of two common interventions--1) practice profiling and feedback and 2) patient education materials--implemented to decrease antibiotic prescribing for pediatric upper respiratory infections (URIs).
                Based on Medicaid regions in Kentucky, primary care physicians managing pediatric respiratory infections in Medicaid were randomized into four groups. Groups received either 1) performance feedback only, 2) patient education materials only, 3) both feedback and education materials, or 4) no intervention. Participating physicians had their antibiotic prescribing assessed for the period of July 1, 1996, to November 30, 1997, with an intervention in June 1997. The study included 216 physicians and 124,092 episodes of care.
                All groups increased in proportion of episodes with antibiotics between the pre-intervention and post-intervention periods. Prescribing in the patient education group and the patient education and feedback group increased at a significantly lower rate than in the control group. Physicians did not change their coding of illness to justify antibiotics after the intervention, and there was no significant generalization of effect of the pediatric intervention on prescribing for adult URIs.
                These interventions demonstrate little if any impact on promoting appropriate antibiotic prescribing. Antibiotic prescribing for viral respiratory infections continues to increase, suggesting concomitant increases in antibiotic resistance. Studies of scoring rules for sore throat have failed to show that they lower antibiotic prescription rates. The authors studied the effect of an explicit decision-support tool, incorporating a modified score, on antibiotic-prescription decisions. Four hundred and fifty family physicians received an information package, a score card, and a recording form to use during one sore-throat encounter. The physicians randomly received either a control form or an intervention form that required them to interact with the score during the clinical recording process. There was a trend towards a reduction in antibiotic prescriptions (21%, p=0.09) in the physicians using the intervention form. A greater reduction (45%, p=0.06) was observed for patients whose probabilities of infection with group A streptococcus were low. Sore-throat-scoring rules may reduce unnecessary antibiotic prescriptions if physicians are specifically cued to use them during clinical encounters and appropriate management responses are linked to score estimates for the likelihood of group A streptococcus infection. To determine whether a community-wide, multi-intervention educational strategy (CoMPLI model) could enhance adoption of clinical guidelines and improve the use of antibiotics.
                Before-after trial using baseline and study periods with a control group.
                A small community in central Ontario.
                Health professionals, the general public, and the pharmaceutical industry.
                The educational strategy (CoMPLI), carried out during 6 winter months, consisted of continuing medical education sessions for health professionals and pharmaceutical representatives and a parallel public education campaign that included town hall meetings and pamphlets distributed by local pharmacists. The two main messages were: do not use antibiotics for viral respiratory infections, and use drugs recommended in the publication, Anti-infective Guidelines for Community-Acquired Infections.
                Total number of antibiotic claims and adjusted odds ratios (OR) were used to measure the likelihood of physicians prescribing first- or second-line agents compared with the previous year and compared with control physicians.
                Claims in the study community decreased by nearly 10% during the 6-month study period compared with the baseline period from the previous year. Study physicians were 29% less likely (OR-1 = 0.71, range 0.67 to 0.76) to prescribe second-line antibiotics during the study period than physicians in the rest of the province.
                Physicians participating in the pilot study were more likely to follow drug recommendations outlined in published guidelines. We have carried out a prospective, controlled trial to ascertain whether mailed feedback on general practitioners' (GPs) own prescribing combined with relevant recommendations on drug treatment, can improve the prescribing. The GPs in the Norwegian county of Møre and Romsdal recorded all their contacts with patients and prescriptions during two periods. After the first period the GPs in Romsdal only (intervention group) received a mailed report giving their prescribing profiles as well as treatment recommendations for insomnia and acute cystitis. The total number of contacts with patients was 68,625 in which 55,747 items were prescribed. The GPs in the intervention group changed their prescribing in accordance with the intervention: they prescribed significantly less sleeping-pills for each patient, preferred short- to long-acting benzodiazepine hypnotics and tranquilizers, and they chose trimethoprim as a first line treatment for acute cystitis. We conclude that it is possible to improve the GPs' prescribing through mailed feedback. To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat.
                Unblinded, cluster randomised pretest-post-test trial.
                142 general practices in Norway.
                72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection.
                Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants.
                Changes in rates of use of antibiotics, laboratory tests, and telephone consultations. Results: Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practices in the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures.
                Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice. We conducted a statewide controlled trial of three methods to improve antibiotic prescribing in office practice: a mailed brochure, a drug educator visit, and a physician visit. Educational topics were three antibiotics contraindicated for office practice and oral cephalosporins. Medicaid prescribing data were used to select donors who needed education. The effect of the methods was evaluated by comparing the change in prescribing (the year before the intervention v the year after the intervention) for the doctors receiving education with the prescribing of comparable doctors chosen as controls. The mailed brochure had no detectable effect, and the drug educator had only a modest effect. The physician visits produced strong attributable reductions in prescribing of both drug classes. For the contraindicated antibiotics, the reductions were 18% in number of doctors prescribing, 44% in number of patients per doctor receiving these drugs, and 54% in number of prescriptions written per doctor. For the oral cephalosporins, both number of patients and number of prescriptions per doctor were reduced by 21%. Doctors responded equally well to recommendations designed to improve the quality of care and to reduce the cost of care. We evaluated persistence of the prescribing improvement seen in a previous statewide controlled trial, which measured improvement in the prescribing of contraindicated antibiotics and oral cephalosporins in the year after an educational intervention. Doctors visited by physician-counselors substantially improved their prescribing of both classes of drugs. The beneficial effect of the physician-counselors persisted throughout year 2, with attributable reductions in prescribing of 30% and savings of $950 for each doctor visited. The marked and lasting improvement in prescribing produced by the physician-counselors suggests using this model to develop ongoing programs to improve prescribing. We describe a controlled study comparing the effects on primary care prescribing in west Gloucestershire, UK, where antibiotic workshops were offered, with those in east Gloucestershire, where microbiology tutorials were given. The year-on-year changes in quantity and costs of antibiotics dispensed following general practice prescriptions were measured. There was no significant difference in the number of antibiotic items prescribed across the county, but the number of prescriptions for broad-spectrum agents (quinolones, cephalosporins and co-amoxiclav) declined by 15.4% in west Gloucestershire, compared with a 6.5% increase in east Gloucestershire (P: = 0.002). Use of narrow-spectrum antibiotics (penicillin V, trimethoprim and nitrofurantoin), whose use was encouraged, did not change in west Gloucestershire practices, but decreased by 12% in east Gloucestershire practices (P: = 0.003). There was increased use of clarithromycin and azithromycin in both groups of practices. Antibiotic workshops held in the primary care setting can rationalize antibiotic prescribing. This can reduce prescribing costs and selection pressure by broad-spectrum antimicrobial agents and, perhaps, go some way to reducing the development of resistance. Inappropriate use of antibiotics is common in primary care, and effective interventions are needed to promote judicious antibiotic use and reduce antibiotic resistance. The objective of this study was to assess the impact of parent and clinician education on pediatric antibiotic prescribing and carriage of penicillin-nonsusceptible Streptococcus pneumoniae in child care facilities.
                A nonrandomized, controlled, community intervention trial was conducted in northern Wisconsin Clinicians. Clinic staff received educational materials and small-group presentations; materials were distributed to parents through clinics, child care facilities, and community organizations. Prescribing data were analyzed for 151 clinicians who provided primary pediatric care; nasopharyngeal carriage of penicillin-nonsusceptible S pneumoniae was assessed for 664 children in the baseline period (January-June 1997) and for 472 children in the postintervention period (January-June 1998).
                The median number of solid antibiotic prescriptions per clinician declined 19% in the intervention region and 8% in the control region. The median number of liquid antibiotic prescriptions per clinician declined 11% in the intervention region, compared with an increase of 12% in the control region. Retail antibiotic sales declined in the intervention region but not in the control region. Among participating children in child care facilities, there were no significant differences in antibiotic use or penicillin-nonsusceptible S pneumoniae colonization between the intervention and control regions.
                A multifaceted educational program for clinicians and parents led to community-wide reductions in antibiotic prescribing, but in child care facilities, there was no apparent impact on judicious antibiotic use or colonization with drug-resistant S pneumoniae. Longer follow-up time or greater reductions in antibiotic use may be required to identify changes in the pneumococcal susceptibility. To assess whether sharing the uncertainty of the value of antibiotics for acute bronchitis in the form of written and verbal advice affects the likelihood of patients taking antibiotics.
                Nested, single blind, randomised controlled trial.
                Three suburban general practices in Nottingham Participants: 259 previously well adults presenting with acute bronchitis.
                In group A, 212 patients were judged by their general practitioner not to need antibiotics that day but were given a prescription to use if they got worse and standard verbal reassurance. Half of them (106) were also given an information leaflet. All patients in group B (47) were judged to need antibiotics and were given a prescription and encouraged to use it.
                Antibiotic use in the next two weeks. Reconsultation for the same symptoms in the next month.
                In group A fewer patients who received the information leaflet took antibiotics compared with those who did not receive the leaflet (49 v 63, risk ratio 0.76, 95% confidence interval 0.59 to 0.97, P=0.04). Numbers reconsulting were similar (11 v 14). In group B, 44 patients took the antibiotics.
                Most previously well adults with acute bronchitis were judged not to need antibiotics. Reassuring these patients and sharing the uncertainty about prescribing in a information leaflet supported by verbal advice is a safe strategy and reduces antibiotic use. Overuse of antibiotics has contributed to microbial resistance, compromising the treatment of bacterial infections. Very high levels (>50%) of antibiotic resistance among invasive Streptococcus pneumoniae have been documented in Knox County, Tennessee.
                To determine the effectiveness of a community-wide intervention aimed at reducing inappropriate antibiotic use among children.
                The Knox County Health Department led a multifaceted year-long campaign (May 1997 through April 1998) aimed at decreasing unnecessary antibiotic use among children. Tennessee's 3 other major urban counties (Shelby, Hamilton, and Davidson) did not conduct similar campaigns and served as controls. Evaluation included white and black children (aged <15 years) enrolled in Tennessee's Medicaid Managed Care Program in the 4 study counties, representing 36% of the study counties' children (464 200 person-years observed).
                Educational efforts were directed toward health care practitioners (primarily via peer leader presentations) and to the parents of young children and the public (primarily via printed materials).
                The intervention-attributable effect on antibiotic use, defined as the excess percentage change in oral antibiotic prescription rates in Knox County between the 12-month preintervention and postintervention periods, relative to that of control counties.
                Antibiotic prescription rates declined 19% and 8% among Knox County and control county children, respectively, yielding an 11% intervention-attributable decline (95% confidence interval, 8%-14%; P<.001). The intervention-attributable decrease in prescription rates was greatest among children aged 1 to less than 5 years (among white children, 8% [P<.001]; among black children, 18% [P<.001]).
                A community-wide educational intervention reduced antibiotic prescription levels among children in Knox County.
The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.