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Open Access Research article

One size does not fit all: evaluating an intervention to reduce antibiotic prescribing for acute bronchitis

Sara L Ackerman1*, Ralph Gonzales2, Melissa S Stahl3 and Joshua P Metlay4

Author Affiliations

1 Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA

2 Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA

3 Geisinger Health System, Center for Health Research, Danville, PA, USA

4 General Medicine Division, Massachusetts General Hospital, Boston, MA, USA

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BMC Health Services Research 2013, 13:462  doi:10.1186/1472-6963-13-462

Published: 4 November 2013

Abstract

Background

Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians.

Methods

Clinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29).

Results

Compared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions—including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components’ effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy.

Conclusions

Future efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.

Keywords:
Antibiotics; Clinician practice patterns; Patient education; Quality improvement