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Research ArticleOriginal Research

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

Christopher J. Stille, Sheryl L. Rifas-Shiman, Ken Kleinman, Jamie B. Kotch and Jonathan A. Finkelstein
The Annals of Family Medicine May 2008, 6 (3) 206-212; DOI: https://doi.org/10.1370/afm.839
Christopher J. Stille
MD, MPH
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Sheryl L. Rifas-Shiman
MPH
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Ken Kleinman
ScD
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Jamie B. Kotch
SM
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Jonathan A. Finkelstein
MD, MPH
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Article Figures & Data

Tables

  • Additional Files
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    Table 1.

    Demographic Characteristics of Respondents

    CharacteristicTotalInterventionControlP Value
    Note: Numbers and percentages vary between items due to differing numbers of missing values.
    a Fisher’s exact test.
    Number responding1689870
    Specialty, No. (%).05a
        Pediatrics123 (74)66 (67)57 (81)
        Family medicine41 (25)30 (31)11 (16)
        Other2 (1)1 (1)1 (1)
    Male106 (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. (%).93a
        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
    • View popup
    Table 2.

    Physician-Reported Sources of Information About Judicious Antibiotic Prescribing

    SourceTotal 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 Mass92 (55)89 (91)3 (4)<.0001
    Professional journals154 (92)89 (92)65 (93).64
    CDC93 (55)49 (50)44 (63).10
    AAP125 (74)67 (68)58 (83).03
    Other organizations (primarily AAFP)23 (14)15 (15)8 (11).47
    Lay press64 (38)34 (35)30 (43).28
    Pharmaceutical companies45 (27)25 (26)20 (29).66
    Professional meetings106 (63)63 (64)43 (61).71
    • View popup
    Table 3.

    Reported Attitudes About Bacterial Antibiotic Resistance and Prescribing

    QuestionTotalInterventionControlP 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
    • View popup
    Table 4.

    Reported Practices Related to Judicious Antibiotic Prescribing

    PracticeTotal 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.03a
        Decreased113 (68)73 (75)40 (58)
        Remained the same49 (30)23 (24)26 (38)
        Increased4 (2)1 (1)3 (4)
    During the past 3 years, has parental demand for inappropriate antibiotics in your practicea.19
        Decreased94 (57)61 (63)33 (49)
        Remained the same59 (36)30 (31)29 (43)
        Increased12 (7)6 (6)6 (9)
    Use watchful waiting for uncomplicated AOM in children 2 years old or greater “occasionally” or more100 (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).99a
    Prescribe antibiotics for pharyngitis before test results known ≤10% of the time148 (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
  • Table 5.
    • View popup
    Table 6.

    Exposure to REACH Materials Among 88 REACH Intervention Group Respondents

    MaterialReporting Yes No. (%)
    REACH = REducing Antibiotics in CHildren.
    Note: Percentages may vary because of missing responses for some items.
    Attended dinner meeting33 (38)
    Received “REACH notes”79 (93)
    Among those reporting “yes,” those who read them most/all of the time57 (73)
    Received parent educational materials80 (95)
    Among those reporting “yes”
        Displayed in waiting room sometimes/often63 (80)
        Displayed in examination room sometimes/often53 (67)
        Handed to parents by nurse sometimes/often36 (46)
        Handed to parents by physician sometimes/often48 (61)
    • View popup
    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?”

Additional Files

  • Tables
  • Supplemental Appendix

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

    Files in this Data Supplement:

    • 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.
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The Annals of Family Medicine: 6 (3)
The Annals of Family Medicine: 6 (3)
Vol. 6, Issue 3
1 May 2008
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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
The Annals of Family Medicine May 2008, 6 (3) 206-212; DOI: 10.1370/afm.839

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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
The Annals of Family Medicine May 2008, 6 (3) 206-212; DOI: 10.1370/afm.839
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