Physician Responses to a Community-Level Trial Promoting Judicious Antibiotic Use

Christopher J. Stille; Sheryl L. Rifas-Shiman; Ken Kleinman; Jamie B. Kotch; Jonathan A. Finkelstein

doi:10.1370/afm.839

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Table 1.

Demographic Characteristics of Respondents

Characteristic	Total	Intervention	Control	P Value
Note: Numbers and percentages vary between items due to differing numbers of missing values.
^a Fisher’s exact test.
Number responding	168	98	70
Specialty, No. (%)				.05^a
Pediatrics	123 (74)	66 (67)	57 (81)
Family medicine	41 (25)	30 (31)	11 (16)
Other	2 (1)	1 (1)	1 (1)
Male	106 (63)	68 (69)	38 (55)	.06
Direct patient care, hours per week (≥25), No. (%)	151 (92)	87 (91)	64 (93)	.63
Percentage of patients ensured by Medicaid, No. (%)				.93^a
0%–20%	71 (43)	44 (46)	27 (40)
21%–40%	68 (41)	37 (39)	31 (46)
41%–60%	19 (12)	11 (11)	8 (12)
61%–80%	3 (2)	2 (2)	1 (1)
81%–100%	3 (2)	2 (2)	1 (1)
Years in practice, mean (SD)	18 (10)	18 (11)	17 (10)	.60

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Table 2.

Physician-Reported Sources of Information About Judicious Antibiotic Prescribing

Source	Total No (%)	Intervention No (%)	Control No (%)	P Value
AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; CDC = Centers for Disease Control and Prevention; Mass = Massachusetts; REACH = REducing Antibiotics in CHildren.
Note: Numbers and percentages vary between items due to differing numbers of missing values.
REACH Mass	92 (55)	89 (91)	3 (4)	<.0001
Professional journals	154 (92)	89 (92)	65 (93)	.64
CDC	93 (55)	49 (50)	44 (63)	.10
AAP	125 (74)	67 (68)	58 (83)	.03
Other organizations (primarily AAFP)	23 (14)	15 (15)	8 (11)	.47
Lay press	64 (38)	34 (35)	30 (43)	.28
Pharmaceutical companies	45 (27)	25 (26)	20 (29)	.66
Professional meetings	106 (63)	63 (64)	43 (61)	.71

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Table 3.

Reported Attitudes About Bacterial Antibiotic Resistance and Prescribing

Question	Total	Intervention	Control	P Value
Note: All figures are numbers (percentages) of responses of “moderately” or “a lot” on a 4-point scale, except where noted in the last row. Numbers and percentages vary between items due to differing numbers of missing values.
Is bacterial antibiotic resistance a significant problem for children in your community? No. (%)	95 (57)	58 (60)	37 (54)	.43
Does antibiotic resistance currently have an impact on your own prescribing choices or patient outcomes? No. (%)	109 (66)	63 (65)	46 (68)	.72
Is parental demand for antibiotics a significant issue in your practice? No. (%)	76 (46)	42 (43)	34 (50)	.40
Do you believe antibiotics are overused in primary care practice for children? No. (%)	144 (87)	84 (88)	60 (87)	.92
How much, as a percentage, do you believe you could decrease your anti-biotic prescribing without changing the outcome? Mean % (SD)	19 (12)	18 (9)	20 (15)	.38

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Table 4.

Reported Practices Related to Judicious Antibiotic Prescribing

Practice	Total No. (%)	Intervention No. (%)	Control No. (%)	P Value
AOM = acute otitis media.
Note: Numbers and percentages vary between items due to differing numbers of missing values.
^a Fisher’s exact test.
During the past 3 years, has antibiotic use in your practice				.03^a
Decreased	113 (68)	73 (75)	40 (58)
Remained the same	49 (30)	23 (24)	26 (38)
Increased	4 (2)	1 (1)	3 (4)
During the past 3 years, has parental demand for inappropriate antibiotics in your practice^a				.19
Decreased	94 (57)	61 (63)	33 (49)
Remained the same	59 (36)	30 (31)	29 (43)
Increased	12 (7)	6 (6)	6 (9)
Use watchful waiting for uncomplicated AOM in children 2 years old or greater “occasionally” or more	100 (63)	64 (67)	36 (56)	.18
Use high-dose amoxicillin (75–90 mg/kg/d) for initial antibiotic treatment of AOM among otherwise healthy children under 2 years old (“most of the time” or “always”)	68 (41)	40 (41)	28 (41)	.99^a
Prescribe antibiotics for pharyngitis before test results known ≤10% of the time	148 (90)	89 (93)	59 (87)	.21
Days of symptoms before prescribing antibiotics for sinusitis in a 3-year-old child with cough but no fever ≥14 or “never”	96 (58)	56 (58)	40 (57)	.88

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Table 6.

Exposure to REACH Materials Among 88 REACH Intervention Group Respondents

Material	Reporting Yes No. (%)
REACH = REducing Antibiotics in CHildren.
Note: Percentages may vary because of missing responses for some items.
Attended dinner meeting	33 (38)
Received “REACH notes”	79 (93)
Among those reporting “yes,” those who read them most/all of the time	57 (73)
Received parent educational materials	80 (95)
Among those reporting “yes”
Displayed in waiting room sometimes/often	63 (80)
Displayed in examination room sometimes/often	53 (67)
Handed to parents by nurse sometimes/often	36 (46)
Handed to parents by physician sometimes/often	48 (61)

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Table 7.

Representative Quotes From Interviewed Physicians

ER = emergency department.
1. Regarding parent brochures and pressure to prescribe antibiotics	“I find patients reading them, and then I’ll walk into the room and they’ll actually confront me as if they’ve just had an epiphany, saying, ‘oh, I didn’t know that antibiotics weren’t useful for [some ear infections].…’ Patients grab the pamphlet and they read about it and then I don’t feel pressured at the end of the visit.”
2. Regarding simultaneous messages to multiple stakeholders	“The best thing is to get in touch [with] pediatricians, family practice doctors, and the ER doctors and the community at the same time. I know that’s hard, but that’s a good way to do it.… So there should be consistency in the message that we give to the community.”
3. Regarding patient education	“Every channel of education has to be sort of initiated so that whoever has a particular preference, their educational interest would be evoked. So it shouldn’t just be [patient pamphlets or anticipatory guidance]. It should be an all around effort of having every channel available, because as the awareness increases, then the educational efforts don’t need to be that intense.”
4. Regarding direct-to-consumer advertising	“I think we should have it in some type of written form that parents can see, even on television.… Why can’t we advertise the appropriate use of antibiotic? Why can’t we use the same media that they use to tell every-one on television to take [brand-name medications] or whatever else they are advertising?”

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Supplemental Appendix

Supplemental Appendix. Telephone Interview Script for Evaluation of REACH Mass Physicians

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Supplemental data: Appendix - PDF file, 3 pages, 104KB
The Article in Brief

Background The Centers for Disease Control and Prevention and other organizations have recommended that doctors in the United States reduce inappropriate prescribing of antibiotics. This article reports on the effectiveness of an educational program for doctors about antibiotic prescribing.

What This Study Found The program to promote cautious antibiotic prescribing reached its intended audience and was welcomed by doctors as a tool for parent education. According to participating doctors, the program had little influence on their attitudes and practices, but most report prescribing antibiotics appropriately. Doctors suggest that frequent repetition of brief, consistent messages to parents and doctors, brief handouts, and promotion in the mass media are effective ways to educate the public and the medical profession about antibiotic use.

Implications

Educational campaigns that repeat brief, consistent reminders to multiple groups may be most effective at assuring appropriate use of antibiotics.