The “Be S.M.A.R.T. about Antibiotics” patient education campaign had different effects on antibiotic prescribing for pediatric pharyngitis and adult bronchitis. The negligible effect on antibiotic prescribing for pediatric pharyngitis, compared with the considerable effect on prescribing for adult acute bronchitis, probably reflects the different magnitudes of excess antibiotic prescribing (or “quality gap”) for each condition. For pediatric pharyngitis, antibiotic treatment is recommended only when the infection is because of group A Streptococcus
. Because the prevalence of group A, Streptococcus
in children has been estimated at approximately 30–35 percent of all visits for pharyngitis (Kaplan et al. 1971
; Needham, McPherson, and Webb 1998
; McIsaac et al. 2000
) there appears to have been little room for improvement upon the existing antibiotic prescription rates in our study population.
In contrast, antibiotic treatment for acute bronchitis (in the absence of chronic lung disease) is not routinely recommended because the vast majority of cases have a viral etiology, and randomized controlled trials show minimal or no clinical benefit (Fahey, Stocks, and Thomas 1998
; Bent et al. 1999
; Gonzales et al. 2001a
; Evans et al. 2002
). In the U.S., calls to limit antibiotic use for uncomplicated acute bronchitis through published reviews and dissemination of clinical practice guidelines have had only a modest effect (Gonzales et al. 2001a
). Faced with this persistent quality gap, it is encouraging that the patient education intervention resulted in a substantial decrease in antibiotic use.
Our results add further weight to the mounting evidence that patient education strategies bolster efforts to decrease unnecessary antibiotic use in the U.S. In previous studies, only combined physician and patient education interventions have been successful at reducing antibiotic use, but none has been able to distinguish the relative effects of each target audience. The “Be S.M.A.R.T. about Antibiotics” campaign is the first to demonstrate that the addition of patient-focused education to an ongoing physician quality improvement program results in a much larger decrease in antibiotic use for adults with acute bronchitis than the physician program alone (even if one assumes that all of the secular change at control sites is because of the quality improvement program). However, our study cannot quantify the degree to which this effect results from a synergy between physician and patient education, or whether the patient education alone would have resulted in the same effect.
The rationale for using a patient education intervention was based on findings of earlier clinician surveys that parent and patient expectations of receiving antibiotics were major factors promoting unnecessary antibiotic use (Barden et al. 1998
; Bauchner, Pelton, and Klein 1999
; Mangione-Smith et al. 1999
). Similarly, practice-based studies confirmed that patient desire for antibiotics was associated with higher antibiotic prescription rates for conditions unlikely to benefit from antibiotic therapy (Hamm, Hicks, and Bemben 1996
; Mangione-Smith et al. 1999
). Finally, community physicians have explicitly recommended patient education campaigns as the intervention with the greatest likelihood of reducing excess antibiotic use for ARIs (Deas et al. 2002
There are limitations to using administrative MCO data to measure antibiotic prescribing behavior. Capture of an antibiotic prescription in the pharmacy database requires that the antibiotic be dispensed by an outpatient pharmacy, and further, that the pharmacy participates in the MCO pharmacy benefits program. Thus, administrative pharmacy data fail to detect antibiotics given to patients in the office as samples, antibiotic prescriptions that patients decide not to fill, and antibiotic treatment rendered in an alternative facility such as the emergency department or hospital. In the case of pharyngitis, this is also complicated by antibiotic prescriptions that are pending a positive throat culture or rapid group A Streptococcus test, which could account for the lower sensitivity of administrative claims for detecting an antibiotic prescription decision in the chart. Further, because we merged pharmacy data with office visit data, we were unable to account for telephone, facsimile, and Internet-based antibiotic prescribing for ARIs, which were not associated with an office visit.
In addition, selection bias because of the nonrandomized nature of our study could have affected the results of our study. The practices that agreed to participate in the “Be S.M.A.R.T. about Antibiotics” campaign may represent a group of practices more willing to modify their prescribing behaviors than the comparison practices. This bias could explain the lack of effect observed in pharyngitis treatment, as well as the large decrease in antibiotic use for bronchitis.
In conclusion, the findings from this interventional study suggest that antibiotic prescribing patterns and behavior can be positively affected by patient education campaigns. Determining whether more efficient and wide-scale patient and public education campaigns can be equally effective will be examined in the second phase of the Minimizing Antibiotic Resistance in Colorado Project.