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Ranji SR, Steinman MA, Shojania KG, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 4: Antibiotic Prescribing Behavior). Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Jan. (Technical Reviews, No. 9.4.)

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Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 4: Antibiotic Prescribing Behavior).

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Appendix BSummaries of Included Studies, Grouped by Setting and Measured Population

Table 1Antibiotic treatment studies conducted in the U.S

S TUDY S ETTING AND TARGET M EASURED P OPULATION AND CONDITION * I NTERVENTION D ESCRIPTION AND Q UALITY I MPROVEMENT S TRATEGIES R ESULTS **
Studies targeting prescribing for children
Finkelstein JA, Pediatrics, 2001 United States Children in Managed Care Organizations with respiratory infections. Clinician education (distribution of materials, education meetings), Patient education (distribution of materials), Audit and feedback Overall antibiotic prescriptions were reduced by 0.08 courses per child per year for children aged 3–36 months, and 0.04 courses per child per year for children aged 36–72 months.
12 practices affiliated with 2 managed care organizations (located in northwest Washington state and eastern Massachusetts) The intervention consisted of small group provider education sessions with a peer leader and a reinforcing visit four months after the start of the intervention. Providers also received feedback on practitioner and practice-level antibiotic prescribing rates. Parent education consisted of a mailed CDC-produced brochure with a cover letter signed by their pediatrician. Educational pamphlets and posters were also present in the waiting room and examination rooms of the intervention practices.
Belongia EA, Pediatrics, 2001 United States Children in managed care and fee-for-service practices with respiratory infections. Clinician education (distribution of materials, educational meetings, educational outreach), Patient education (distribution of materials) Absolute effect size: 1.5%
Multiple counties in Northern Wisconsin This study was a community-based trial with patient and provider education targeting antibiotic prescribing for ARIs. Patient education involved distribution of educational materials to clinics, daycare facilities, and schools. Providers received academic detailing in small groups, led by study authors and lasting 30–60 minutes. At the meetings, clinical practice guidelines, educational materials from CDC (on appropriate antibiotic use), and parent education pamphlets were distributed. Project nurses visited each practice to educate office staff as well. The percentage of patients receiving antibiotics for ARIs declined by 3.6% in the intervention region. In the control region, the prescribing rate declined by 5.1%. Although the percentage of patients receiving antibiotics when seeing a physician was not statistically significantly changed, the total number of antibiotic prescriptions (for both solid and liquid antibiotics) decreased significantly in the intervention region compared to the control region.
Christakis DA, Pediatrics, 2001 United States Children receiving care at academic primary care clinic with otits media. Clinician reminder There was no significant impact on the percentage of patients receiving antibiotics in either the intervention or control groups. A statistically significant increase in prescribing at the appropriate duration of therapy was found.
Academic pediatric primary care clinic Providers received an electronic evidence-based reminder to avoid treating otitis media with antibiotics, and if using antibiotics to treat for less than 10 days. Reminder was electronic in nature, incorporated into existing electronic prescription program. When providers selected an antibiotic to prescribe, a pop-up screen displayed information on appropriate use and appropriate dosage. The pop-up window contained options for receiving more information.
Mainous AG, Family Medicine, 2000 [comparison 1] United States Children in Medicaid program with respiratory infections Patient education (distribution of materials) Absolute effect size: -9.9%
8 Medicaid administrative regions in Kentucky The intervention consisted of a statewide program that used direct patient education to reduce antibiotic prescribing for pediatric respiratory infections. Each physician received 25 pamphlets that they were to distribute themselves to patients with upper respiratory infections. In the intervention group, prescribing rates increased from 31.9% to 44.5% over the study period. The control group increased from 31.0% to 53.5%. This difference was not statistically significant.
Mainous AG, Family Medicine, 2000 [comparison 2] United States Children in Medicaid program with respiratory infections Audit and feedback Absolute effect size: -7.3%
8 Medicaid administrative regions in Kentucky The intervention consisted of a statewide program that used physician feedback. Physicians received a prescribing profile, consisting of the percent of patients with pediatric respiratory conditions to whom they prescribed antibiotics and information on total and relative costs. It also contained their percentile ranking for antibiotics prescribing compared to peers. In the intervention group, prescribing rates increased from 28.4% to 43.6% over the study period. The control group increased from 31.0% to 53.5%. This difference was not statistically significant.
Mainous AG, Family Medicine, 2000 [comparison 3] United States Children in Medicaid program with respiratory infections Patient education (distribution of materials), Audit and feedback Absolute effect size: -7.2%
8 Medicaid administrative regions in Kentucky The intervention was a combination of physician feedback and patient education. Physicians received a prescribing profile, consisting of the percent of patients with pediatric respiratory conditions to whom they prescribed antibiotics and information on total and relative costs. It also contained their percentile ranking for antibiotic prescribing compared to peers. Physicians also received 25 patient education leaflets that they were to distribute themselves to patients with upper respiratory infections. In the intervention group, prescribing rates increased from 34.4% to 49.7%. The control group increased from 31.0% to 53.5%. This difference was not statistically significant.
Perz JF, JAMA, 2002 United States Children in Medicaid program Clinician education (distribution of materials, educational meetings, educational outreach), Patient education (distribution of materials, mass media educational campaign) The intervention achieved a reduction of about 0.16 antibiotic courses per child per year, an 11% intervention-attributable relative reduction in antibiotic prescriptions. This difference was statistically significant.
4 counties in Tennessee A year long intervention targeting providers, parents, and the general public was performed. Provider education consisted of lectures from an expert, presentations at conferences, distribution of guidelines, and newsletters. Parent education consisted of distribution of pamphlets by mail, via the providers, to all parents of newborns. Public education consisted of mass media advertisements and distribution of pamphlets at hospitals, clinics, dental offices, and pharmacies.
Studies targeting prescribing for adults
Gonzales R, JAMA, 1999 [ comparison 1 ] United States Kaiser Permanente patients with acute bronchitis Patient education (distribution of materials, other) Clinician education (distribution of materials, educational meetings), Audit and feedback Absolute effect size: -24.0%
4 HMO primary care practices The study consisted of a multifaceted educational intervention provided to Kaiser patients and providers with the goal of reducing antibiotic use for acute bronchitis. Patients received mailed educational materials (refrigerator magnets, pamphlets, letters), and educational materials in the provider's office (posters). Providers received site-specific antibiotic prescription rates, education on evidence-based management of bronchitis. Provider education was carried out by the medical director of the facility in a one-time, 30-minute meeting. In the intervention group, the percentage of visits at which antibiotics were prescribed for acute bronchitis declined from 74% before the intervention to 48% after the intervention. In the control group, the prescribing rate declined from 78% to 76%. This difference was statistically significant.
Gonzales R, JAMA, 1999 [ comparison 2 ] United States Kaiser Permanente patients with acute bronchitis Patient education (distribution of materials), Clinician education (other) Absolute effect size: -2.0%
4 HMO primary care practices In this study arm, the intervention consisted of office-based patient educational materials only. These were colorful posters placed on the walls of each room, accompanied by information on the ineffectiveness of antibiotic for bronchitis, as well as information on antimicrobial resistance. In the intervention group, the percentage of visits at which antibiotics were prescribed for acute bronchitis declined from 82% to 78%. In the control group, the prescribing rate declined from 78% to 76%. This difference was not statistically significant.
Studies targeting prescribing for patients of all ages
Hickman DE, Annals of Pharmacotherapy, 2003 United States Patients enrolled in non-profit medical group (approximately 50% in capitated health plans) with acute bronchitis Patient education (distribution of materials), Clinician education (distribution of materials, educational meetings, educational outreach), Audit and feedback Absolute effect size: -9.7%
Suburban community-based physician group The intervention consisted of as patient education delivered via a newsletter and posters and pamphlets in the waiting room. Providers received pharmacist-led seminars, written materials, and provider-specific prescription profiling. This took place during a 20 minute presentation by a clinical pharmacist at regular staff meetings. Feedback was provided confidentially in a folder, which also contained educational materials. In the intervention group, the prescribing rate declined from 48.3% of visits to 38.6% after the intervention. There was no change in the prescribing rate in the control group (31.8% before and after the intervention.) This difference was statistically significant.
McConnell TS, Western Journal of Medicine, 1982 United States Medicaid patients with respiratory infections Clinician education (distribution of materials, educational outreach), Audit and feedback The intervention achieved a reduction of 6.4 prescriptions for tetracycline per clinician per 6-month period. No change in prescribing was found in the control group. The investigators did not report if this difference was statistically significant.
United States New Mexico Medicaid program Physicians who were found on audit to be inappropriately prescribing tetracycline for acute respiratory infections (ARIs) received educational visits. Visits took about 30 minutes and occurred a single time. Information on their prescribing was presented, as well as educational materials. Visits were carried out by physician consultants in the physician's office.
Foxman B, Journal of Chronic Diseases, 1987 United States Comparison of cost-sharing insurance plans (intervention) versus fee-for-service insurance (control) Financial or regulatory incentives for patients Antibiotic use declined by 0.43 courses per insured family per year in the intervention group compared to the control group. This difference was statistically significant.
6 cities: Dayton, OH; Seattle, WA; Fitchburg, MA; Franklin County, MA; Charleston, SC; Georgetown County, SC This study was the RAND health insurance experiment, where patients were randomized to insurance plans varying by level of cost-sharing. How antibiotic use varies by insurance plan, diagnosis and health status, geographic area, and demographic characteristics were also examined.
Hennessy TW, Clinical Infectious Diseases, 2002 United States Patients receiving care through Indian Health Service with respiratory infections Patient education (distribution of materials, mass media educational campaign), Clinician education (educational outreach, educational workshops) Absolute effect size: -12.0%
13 rural Alaskan villages The investigators described the intervention as a community-based educational intervention provided with the goal of reducing inappropriate antibiotic use for acute respiratory infections. Physicians and community health aides received workshops on antibiotic use. Residents received information at village-wide meetings, community fairs, and high school classrooms. Residents also received a total of four informational mailings. In the intervention villages, antibiotic prescribing declined from 64% of visits for ARIs to 47%. In control villages, prescribing declined from 54% to 49%. The investigators did not report if this difference was statistically significant.
*

The measured population refers to the patient population in which prescribing data was measured. This population is the group to which the study results are most generalizable.

**

The Absolute effect size is provided for studies that were used in the median effects analysis. These studies reported data as the percentage of visits at which patients received an antibiotic prescription. The individual study Absolute effect size was calculated as: [(Intervention) post - (Intervention) pre ] - [(Control) post - (Control) pre ]. A negative effect size means an overall reduction in the rate of antibiotic prescribing. The % sign refers to the percent of patients with a particular diagnosis.

Table 2Antibiotic treatment studies conducted outside the U.S

S TUDY S ETTING AND TARGET M EASURED P OPULATION AND CONDITION * I NTERVENTION D ESCRIPTION AND Q UALITY I MPROVEMENT S TRATEGIES R ESULTS **
Studies targeting prescribing for children
Smabrekke L, Scandinavian Journal of Infectious Diseases, 2002 Norway Children with otitis media Patient education (distribution of materials), Clinician education (distribution of materials, educational meetings) Absolute effect size: -12.0%
Physicians and nurses at urgent care clinic The intervention consisted of a symposium on evidence-based management of otitis media for physicians and nurses at an acute care clinic. Guidelines on appropriate treatment were distributed. The guideline recommended narrow-spectrum antibiotic use when necessary, and suggested use of delayed prescriptions. Pamphlets for patients were made available in exam rooms; the pamphlets stressed that most patients recover without antibiotic and indiscriminate use of antibiotic leads to resistance. This information was also provided to patients who called the clinic. The percentage of patients receiving antibiotics decreased 16.0% (from 90.0% before the intervention to 74.0% after). In the control group, the prescribing rate decreased 4.0% (from 95.0% to 91.0%). This difference was statistically significant.
Cates C, BMJ, 1999 UK Children with otitis media Patient education (distribution of materials), Delayed prescriptions In the intervention clinic, the number of amoxicillin prescriptions per month decreased from 75 to 47 (a 32% relative reduction.) In the control group, the number of amoxicillin prescriptions decreased from 72 to 66 per month (a 12% relative reduction.) This difference was statistically significant.
General practitioners in outpatient clinics in Hertfordshire Parents of children with acute otitis media who were “not particularly ill” were given a handout summarizing the limited benefit of antibiotics. Parents also received a delayed prescription for antibiotics with instructions to fill the script if the child did not improve in the next “day or two.” The comparison was another nearby clinic that followed usual care.
Little P, BMJ, 2001 UK Children with otitis media Delayed prescriptions In the intervention group, 24.0% of patients used antibiotics, compared to 98.5% of patients in the control group. This difference was statistically significant.
General practices in southwest England Children with otitis media were randomized to receive either immediate antibiotics or delayed treatment. Patients in the delayed treatment group were to receive antibiotics after 72 hours if their symptoms did not improve.
Gonzalez Ochoa E, Bulletin of the Pan American Health Organization, 1996 [comparison 1] Cuba Children with respiratory infections Patient education (group educational sessions, distribution of materials), Clinician education (distribution of materials, educational meetings, educational outreach visits, educational workshops) Absolute effect size: -28.5%
General practitioners in 4 areas of Havana The intervention consisted of education of health care providers and community education components. For education of health care providers, there was a special refresher course for family physicians which included videos and slide presentations on treatment of acute respiratory infections in children. There were also opportunities for provider group discussions. The community education program consisted of group discussions in the participants' homes and talks given to mothers in the clinics. The percentage of patients receiving antibiotics decreased 27.8% (from 36.6% before the intervention to 7.8% after). In the control group, the prescribing rate increased 0.7% (from 19.6% to 20.3%).
Gonzalez Ochoa E, Bulletin of the Pan American Health Organization, 1996 [comparison 2] Cuba Children with respiratory infections Clinician education (distribution of materials, educational meeting) Absolute effect size: -9.6%
General practitioners in 4 areas of Havana This study arm consisted of health care provider education. For education of health care providers, there was a special refresher course for family physicians which included videos and slide presentations on treatment of acute respiratory infections in children. There were also opportunities for provider group discussions. In the intervention group, prescribing decreased 8.9% (from 20.6% before the intervention to 11.7% after the intervention). In the control group, the prescribing rate increased 0.7% (from 19.6% to 20.3%). The investigators did not report if this difference was statistically significant.
Gonzalez Ochoa E, Bulletin of the Pan American Health Organization, 1996 [comparison 3] Cuba Children with respiratory infections Patient education (individual educational sessions, group educational sessions, distribution of materials) Absolute effect size: 0.2%
General practitioners in 4 areas of Havana This study arm consisted of a community education program. The community education program consisted of group discussions in the participants' homes and talks given to mothers in the clinics. In the intervention group, prescribing increased 0.9% (from 11.4% before the intervention to 12.3% after.) In the control group, the prescribing rate increased 0.7% (from 19.6% to 20.3%). The investigators did not report if this difference was statistically significant.
Pshetizky Y, Family Practice, 2003 Israel Children with otitis media Patient education (individual educational sessions), Delayed prescriptions In the intervention group, 37.0% of patients used antibiotics after the intervention. In the comparison group, 63.0% of patients used antibiotics. This difference was statistically significant.
General practitioners The intervention targeted parents of children with acute otitis media. All patients were given an antibiotic prescription. Parents in the intervention group received instruction to only use antibiotics if the child's condition did not improve in 24– 48 hours. The intervention group also received a brief explanation from the physician, stressing that most patients recover regardless of whether antibiotics are used, and that serious complications of acute otitis media are not necessarily prevented by antibiotics.
Wilson EJ, Communicable Diseases Intelligence, 2003 Australia Children with respiratory infections Clinician education (distribution of materials, consensus building sessions), Patient education (distribution of materials), Self-management In the intervention group, prescriptions decreased by 0.78 prescriptions per 100 visits; in the control group, prescribing increased by 0.35 prescriptions per 100 visits. This difference was statistically significant.
General practitioners in Canberra Physicians participated in focus groups with parents of young children and workshops with other GP's; these were used to develop a practice guideline for antibiotic prescribing in upper respiratory infection. All intervention general practitioners then received a packet containing the guideline, information sheets on otitis media and sore throat for patient education, prescription pads for nonprescription medicines, patient self-management advice, and a poster advocating the guideline.
Santoso B, Social Science & Medicine, 1996 [comparison 1] Indonesia Children with diarrhea Clinician education (distribution of materials, educational outreach, educational workshops) Absolute effect size: -13.7%
General practitioners in Yogyakarta and Java provinces The study consisted of a small group intervention designed to reduce antibiotic prescribing in cases of acute diarrhea. The small group meetings consisted of face-to-face, interactive discussions involving 8–12 providers at a health center. Discussions were led by a trained physician moderator, assisted by a pharmacologist or pediatrician. Each lasted approximately two hours. A booklet on appropriate management of diarrhea was also provided. In the intervention group, prescribing rates decreased by 17.0% (from 77.4% before the intervention to 60.4% after the intervention.) In the control group, prescribing rates decreased by 3.3% (from 82.6% before the intervention to 79.3% after the intervention.)
Santoso B, Social Science & Medicine, 1996 [comparison 2] Indonesia Children with diarrhea Clinician education (distribution of materials, educational meetings) Absolute effect size: -6.7%
General practitioners in Yogyakarta and Java provinces The study consisted of a two hour seminar on appropriate prescribing for acute diarrhea targeted at physicians and paramedical personnel. The goal was to reduce antibiotic use and encourage use of oral rehydration solution. The presentation was by two physicians from the district office and the university. Question-and-answer sessions followed the seminar. Written materials on management of diarrhea were also provided. In the intervention group, prescribing rates decreased by 10.0% (from 82.3% to 72.3%.) In the control group, prescribing rates decreased by 3.3% (from 82.6% before the intervention to 79.3% after the intervention.)
Studies targeting prescribing for adults
McIsaac WJ, Medical Decision Making 1998 Canada Adults with sore throat Clinician reminder In the intervention group, 27.8% of patients received antibiotics, compared to 35.7% in the comparison group. This difference was not statistically significant.
Family physicians in Ontario Physicians received a mailing containing both a modified scoring system to help guide antibiotic prescribing and management recommendations. The intervention group also received an encounter form for a specific patient visit with the scoring system and recommendations for testing or treating based on the score. The control group received a similar encounter form without the scoring system or treatment recommendations.
Coenen SJ, Antimicrobial Agents and Chemotherapy, 2004 Belgium Adults with respiratory infections Clinician education (distribution of materials, educational outreach) Absolute effect size: 6.5%
General practitioners Physicians received a mailed guideline for treatment of patients with acute cough, which was followed by a reminder phone call. Provides also received an educational outreach visit from a pharmacist and “former medical representative”, which focused on guideline adherence and dialogue with the provider to overcome barriers to appropriate prescribing. Following this, the providers received a mailing with the key messages from the guideline. The percentage of patients receiving antibiotics decreased 15.6% (from 43.0% before the intervention to 27.4% after). In the control group, the prescribing rate decreased 9.1% (from 37.8% to 28.7%). This difference was statistically significant.
Macfarlane J, BMJ, 2002 UK Adults with acute bronchitis Patient education (distribution of materials), Delayed prescriptions Patients in the intervention group used antibiotics in 47.0% of cases, compared to 62.0% in the comparison group. This difference was statistically significant.
General practices Patients with acute bronchitis not requiring immediate treatment received a delayed prescription for antibiotics. They also were given a patient information leaflet about symptoms and the advantages/disadvantages of antibiotic use. The leaflet described when to fill the prescription and methods of self-treatment.
Studies targeting prescribing for patients of all ages
McNulty CA, Journal of Antimicrobial Chemotherapy, 2000 UK All patients Clinician education (educational workshops), Audit and feedback In the intervention group, the number of antibiotic prescriptions per provider per year declined from 395.9 before the intervention to 382.3 after the intervention. In the control group, prescriptions declined from 356.7 per provider per year to 348.7. This difference was not statistically significant.
General practices in Gloucestershire General practitioners received twelve antibiotic educational workshops, which were delivered over a seven week period. Workshops focused on promoting antibiotic guidelines, reducing antibiotic use for unnecessary conditions and making better prescribing decisions.
Melander E, Scandinavian Journal of Primary Health Care, 1999 [comparison 1] Sweden All patients with respiratory infections Clinician education (educational workshops), Audit and feedback Absolute effect size: -2.0%
General practitioners The intervention consisted of an audit of physician's antibiotic prescribing behavior. Based on the results of this audit, group discussions on appropriate management of ARIs were held, and an educational program was developed using local opinion leaders. Prescribing data was fed back to the individual physicians. The percentage of patients receiving antibiotics for ARIs decreased 4.0% (from 13.0% before the intervention to 9.0% after). In the control group, the prescribing rate decreased 2.0% (from 37.0% to 35.0%). The investigators did not report if this difference was statistically significant.
Molstad S, Family Practice, 1989 Sweden All patients with respiratory infections Clinician education (consensus building sessions) Absolute effect size: -23.3%
General practitioners at community health centers Physicians designed and administered an educational program consisting of developing indications for antibiotic treatment and reviewing regional resistance patterns. Physicians were encouraged to use rapid streptococcal assays when warranted. The percentage of patients receiving antibiotics decreased 23.7% (from 67.6% before the intervention to 43.9% after). In the control group, the prescribing rate decreased 0.4% (from 71.5% to 71.1%). The investigators did not report if this difference was statistically significant.
Zwar N, Family Practice, 1999 Australia All patients with respiratory infections Clinician education (distribution of materials, educational outreach, other), Audit and feedback Absolute effect size: -15.0%
General practitioner trainees in New South Wales The intervention consisted of a mailed packet of individualized feedback to providers, management guidelines, and patient handouts. Providers who exceeded thresholds for inappropriate prescriptions based on feedback data also received an academic detailing session, in person or over the telephone. The percentage of patients receiving antibiotics decreased 5.3% (from 25.0% before the intervention to 19.7% after). In the control group, the prescribing rate increased 9.7% (from 22.0% to 31.7%). This difference was statistically significant.
Angunawela I, International Journal of Epidemiology, 1991 [comparison 1] Sri Lanka All patients Clinician education (distribution of materials) Absolute effect size: -7.0%
General practitioners at rural primary care clinics The intervention consisted of newsletters mailed fortnightly to providers, which covered topics about treatment of common infections, encouraged use of penicillin, discouraged use of antibiotics in viral infections and tetracycline to children. The percentage of patients receiving antibiotics decreased 7.4% (from 31.5% before the intervention to 24.1% after). In the control group, the prescribing rate decreased 0.4% (from 32.2% to 31.8%). This difference was not statistically significant.
Angunawela I, International Journal of Epidemiology, 1991 [comparison 2] Sri Lanka All patients Clinician education (distribution of materials, educational meetings) Absolute effect size: -6.9%
General practitioners at rural primary care clinics In addition to the newsletters described above, providers participated in a seminar conducted by two clinical pharmacologists, one microbiologist, and one general physician. The seminar reinforced the information in the newsletter. The percentage of patients receiving antibiotics decreased 7.3% (from 38.8% before the intervention to 31.5% after). In the control group, the prescribing rate decreased 0.4% (from 32.2% to 31.8%). This difference was not statistically significant.
Arroll B, Journal of Family Practice, 2002 New Zealand All patients with common cold Delayed prescriptions In the intervention group, 48% of patients used antibiotics; in the comparison group, 89% of patients used them. This difference was statistically significant.
General practitioners Patients with the common cold who requested antibiotics were given a prescription with instructions to fill it only if their symptoms did not improve after 3 days. The comparison group was given antibiotics immediately.
Bexell A, Journal of Clinical Epidemiology, 1996 Zambia All patients with diarrhea and respiratory infections Clinician education (educational meetings) Absolute effect size: -8.1%
General practices in The intervention consisted of three 2-day seminars for providers on rational drug prescribing. Educational content consisted of standardized guidelines for managing “common conditions seen in primary care.” Seminars were led by pharmacists, clinical officers, medical officers, and a nurse. Specific diseases discussed included diarrheal diseases and acute respiratory infections. The percentage of patients receiving antibiotics decreased 7.0% (from 41.2% before the intervention to 34.2% after). In the control group, the prescribing rate increased 1.1% (from 41.0% to 42.1%). This difference was statistically significant.
Flottorp S, BMJ, 2002 Norway All patients with sore throat Patient education (distribution of materials, other), Clinician education (distribution of materials, other), Clinician Reminders, Organizational change, Regulatory changes for providers, Financial or regulatory incentives for patients Absolute effect size: -3.0%
142 General practices The investigators conducted a multifaceted intervention to improve management of sore throat. Providers received guidelines on sore throat management, in electronic and poster format. Computer based decision support, reminders, and interactive courses were offered to providers. Patients received electronic and paper-based educational materials. Patients had to pay an increased fee for a telephone consult (but not for office visit.) Only practices using an electronic medical records system were eligible. The percentage of patients receiving antibiotics decreased 4.3% (from 48.1% before the intervention to 43.8% after). In the control group, the prescribing rate decreased 1.3% (from 50.8% to 49.5%). This difference was statistically significant.
Gutierrez G, Medical Care, 1994 Mexico All patients with diarrhea Clinician education (distribution of materials, educational workshops, consensus building session), Audit and feedback After the intervention, the prescribing rate in the intervention group was 20.2%, compared to 35.4% before the intervention. Corresponding comparison group values were not provided.
General practitioners at health care clinics of the Mexican Social Security Institute Physicians received an educational workshop on treatment of acute diarrhea for physicians. They received literature and had group discussions to develop a treatment algorithm and discuss management of simulated cases. Five months after the workshops, physicians' practice habits were audited and reviewed by a committee including study physicians.
McIsaac WJ, Journal of Family Practice, 2002 Canada All patients with sore throat Clinician reminder The prescribing rate in the intervention group was 28.1%, compared to 27.9% in the comparison group. This difference was not statistically significant.
Family physicians in Ontario Physicians received a sample encounter form for patients with sore throat, which explicitly described a scoring system (to help guide antibiotic prescribing) and provided management recommendations. The form also had space to record the score. The control group did not receive the sticker, and the encounter form did not have the prompt to record the score.
Meyer JC, Medical Education, 2001 South Africa All patients with diarrhea Clinician education (educational workshops) Absolute effect size: -28.6%
Nurses at primary health clinics Nurses in primary health care centers received training focused on teaching rational drug prescribing, conducted during a 4-day workshop. A World Health Organization manual was used as the framework for the training course. The target was reducing antibiotic prescribing for ARIs. The percentage of patients receiving antibiotics decreased 36.9% (from 66.3% before the intervention to 29.4% after). In the control group, the prescribing rate decreased 8.3% (from 53.9% to 45.6%). This difference was statistically significant.
O'Connell DL, BMJ, 1999 Australia All patients Clinician education (distribution of materials), Audit and feedback In the intervention group, median antibiotic prescribing rates changed from 10.7 prescriptions per 100 patients before the intervention to 10.5 prescriptions per 100 patients after the intervention. Corresponding comparison group values were 10.7 prescriptions per 100 patients before the intervention and 10.1 after the intervention. This difference was not statistically significant.
General practitioners in rural area Physicians received a graphical display of their level of prescribing of five different drug groups (including oral antibiotics) over the past eight quarters. These data were provided as graphs displaying the individual physician's prescribing in comparison to all physicians. This intervention was repeated twice, six months apart. The first intervention was accompanied by a general prescribing educational letter. The second was accompanied by a letter with specific antibiotic prescribing information.
Welschen I, BMJ, 2004 The Netherlands All patients with respiratory infections Patient education (distribution of materials), Clinician education (distribution of materials, educational meetings, educational workshops, consensus building sessions), Audit and feedback Absolute effect size: -12.0%
General practitioners in Utrecht Physicians attended a group educational meeting, at which feedback data on antibiotic prescribing was provided, evidence on the effectiveness of antibiotic for upper respiratory infections was presented, and used to develop consensus on indications for antibiotic use and choice. These were formalized into guidelines that were mailed to participations. Six months later physicians received repeat feedback on their prescribing. Physician assistants and pharmacists also received a 2 hour session on antibiotic prescribing guidelines. Physicians, assistants, and pharmacists also received communication skills training. Patient education materials, consisting of brochures and posters, were provided in offices, pharmacies, and municipal health services. The percentage of patients receiving antibiotics decreased 4.0% (from 27.0% before the intervention to 23.0% after). In the control group, the prescribing rate increased 8.0% (from 29.0% to 37.0%).
*

The measured population refers to the patient population in which prescribing data was measured. This population is the group to which the study results are most generalizable.

**

The Absolute effect size is provided for studies that were used in the median effects analysis. These studies reported data as the percentage of visits at which patients received an antibiotic prescription. The individual study Absolute effect size was calculated as: [(Intervention) post - (Intervention) pre ] - [(Control) post - (Control) pre ]. A negative effect size means an overall reduction in the rate of antibiotic prescribing. The % sign refers to the percent of patients with a particular diagnosis.

Table 3Antibiotic selection studies conducted in the U.S

S TUDY S ETTING AND TARGET M EASURED P OPULATION AND CONDITION * I NTERVENTION D ESCRIPTION AND Q UALITY I MPROVEMENT S TRATEGIES R ESULTS **
Studies targeting prescribing for children
Bush PJ, Medical Care, 1979 [comparison 1] United States Children enrolled in HMO with otitis media Clinician education (distribution of materials, consensus building session) Absolute effect size: 22.7%
Pediatricians at 3 HMO sites in Washington, DC The intervention consisted of a drug therapy protocol for otitis media, which specified drugs, doses, and days of therapy by patient age. The protocol was developed and implemented by a physician group at one site. The intervention encouraged use of ampicillin or penicillin. The control group received no intervention. In the intervention group, the prescribing rate for recommended antibiotics increased 0.1% (from 87.7% before the intervention to 87.8% after). In the control group, the prescribing rate for recommended antibiotics decreased 22.6% (from 89.6% to 67.0%). The investigators did not report if the difference between groups was statistically significant.
Bush PJ, Medical Care, 1979 [comparison 2] United States Children enrolled in HMO with otitis media Clinician education (distribution of materials) Absolute effect size: 35.6%
Pediatricians at 3 HMO sites in Washington, DC In this study, the drug therapy protocol (above) was implemented at a separate site from the one that created the protocol. In the intervention group, the prescribing rate for recommended antibiotics increased 13.0% (from 64.3% before the intervention to 77.3% after). In the control group, the prescribing rate decreased 22.6% (from 89.6% to 67.0%). The investigators did not report if the difference between groups was statistically significant.
Studies targeting prescribing for adults
Klein LE, Journal of Medical Education, 1981 United States Adults with urinary tract infections Clinician education (educational meetings) Absolute effect size: 48.0%
Residents in academic emergency room and primary care center The intervention consisted of an educational tutorial that addressed four misconceptions about the treatment of urinary tract infection. This tutorial aimed to encourage use of sulfisoxazole or tetracycline, and discourage use of ampicillin or trimethoprim-sulfamethoxazole. The tutorial was presented to each participant for 15 minutes. In addition to the tutorial, the authors gave a ten minute talk just before the post-intervention data collection period on options for treating urinary tract infection. In the intervention group, the prescribing rate for recommended antibiotics increased 65.0% (from 12.0% before the intervention to 77.0% after). In the control group, the prescribing rate increased 17% (from 22.0% to 39.0%). This difference was statistically significant.
Studies targeting prescribing for patients of all ages
Avorn J, New England Journal of Medicine, 1983 [comparison 1] United States Medicaid patients Clinician education (distribution of materials) In the intervention group, the number of non-recommended antibiotic prescriptions was reduced by 31% relative to the control group. This difference was statistically significant.
Physicians in 4 state Medicaid programs (Arkansas, New Hampshire, Vermont, and the District of Columbia) Physicians received an office-based education program consisting of a visit from a clinical pharmacist to discuss ways to reduce prescribing of targeted drugs. Physicians also received mailed educational materials, including drug information letters and “unadvertisements” (specially designed brochures with colorful illustrations on appropriate prescribing practices.) These materials were distributed eight times over a period of four months. The objective was to reduce the prescribing of oral cephalosporins.
Avorn J, New England Journal of Medicine, 1983 [comparison 2] United States Medicaid patients Clinician education (distribution of materials) In the intervention group, the number of non-recommended antibiotic prescriptions was reduced by 10% relative to the control group. This difference was not statistically significant.
Physicians in 4 state Medicaid programs (Arkansas, New Hampshire, Vermont, and the District of Columbia) In this study, physicians received only the mailed drug information letters and “unadvertisements” described above.
Farris KB, Pharmaceutical Research, 1996 United States HMO patients with respiratory infection Clinician education (distribution of materials, educational meetings, educational outreach, educational workshops), Audit and feedback Absolute effect size: 7.2%
Family physicians in HMO in southeastern Michigan The intervention consisted of face to face group detailing sessions involving opinion leaders with written presentation summaries placed in physicians clinic mailboxes 3–6 weeks after the detailing session. Physicians also received personal and peer comparison feedback on prescribing trends for target medications, periodic posted reminders, summary poster displays, and a report of program results at the end of the intervention. In the intervention group, the prescribing rate for recommended antibiotics increased 8.0% (from 58.9% before the intervention to 66.9% after). In the control group, the prescribing rate increased 0.8% (from 58.9% to 59.7%). The investigators did not report if the difference between groups was statistically significant.
Schaffner W, JAMA, 1983 [comparison 1] United States Medicaid patients Clinician education (distribution of materials, educational outreach) In the intervention group, the number of prescriptions for contraindicated antibiotics was reduced by 35% relative to the pre-intervention period. In the control group, prescribing was reduced by 33% relative to the pre-intervention period. This difference was not statistically significant.
Physicians participating in Tennessee Medicaid program Physicians received an educational visit from a drug educator, who went over a brochure that discussed the reasons not to use contraindicated antibiotics (chloramphenicol, clindamycin, and tetracycline for children under age 8) and provided reasonable alternatives. The drug educator was a trained clinical pharmacist.
Schaffner W, JAMA, 1983 [comparison 2] United States Medicaid patients Clinician education (distribution of materials, educational outreach) In the intervention group, the number of prescriptions for contraindicated antibiotics was reduced by 50% relative to before the intervention. In the control group, prescribing was reduced by 33% relative to the pre-intervention period. This difference was statistically significant.
Physicians participating in Tennessee Medicaid program Physicians received an educational visit from a physician counselor, who went over a brochure that discussed the reasons not to use the contraindicated antibiotics (chloramphenicol, clindamycin, and tetracycline for children under age 8) and provided reasonable alternatives. The physician counselors were three senior physicians in part-time practice recruited by study advisory committee.
Schaffner W, JAMA, 1983 [comparison 3] United States Medicaid patients Clinician education (distribution of materials, educational outreach) In the intervention group, the number of prescriptions for cephalosporins was reduced by 67% relative to the pre-intervention period. In the control group, prescribing was reduced by 41% relative to the pre-intervention period. This difference was not statistically significant.
Physicians participating in Tennessee Medicaid program Physicians received an educational visit from a drug educator who went over a brochure that discussed the reasons not to use the oral cephalosporins and provided reasonable alternatives. The drug educator was a trained clinical pharmacist.
Schaffner W, JAMA, 1983 [comparison 4] Physicians participating in Tennessee Medicaid program Medicaid patients Clinician education (distribution of materials, educational outreach) Prescribing of cephalosporins was reduced by 85% in the intervention group in the follow-up period relative to before the intervention. In the control group, prescribing was reduced by 41% relative to the pre-intervention period. This difference was statistically significant.
Physicians received an educational visit from a physician counselor, who went over a brochure that discussed the reasons not to use oral cephalosporins counselors were three senior physicians in part-time practice recruited by study advisory committee.
*

The measured population refers to the patient population in which prescribing data was measured. This population is the group to which the study results are most generalizable.

**

The Absolute effect size is provided for studies that were used in the median effects analysis. These studies reported data as the percentage of visits at which patients received an antibiotic prescription. The individual study Absolute effect size was calculated as: [(Intervention) post - (Intervention) pre ] - [(Control) post - (Control) pre ]. A negative effect size means an overall reduction in the percentage of patients receiving a recommended antibiotic.

Table 4Antibiotic selection studies conducted outside the U.S

S TUDY S ETTING AND TARGET M EASURED P OPULATION AND CONDITION * I NTERVENTION D ESCRIPTION AND Q UALITY I MPROVEMENT S TRATEGIES R ESULTS **
Studies targeting prescribing for children
Dolovich L, Drug Information Journal, 1999 Canada Children with otitis media Clinician education (distribution of materials, educational outreach) The primary outcome was the percentage “market share” for amoxicillin, defined as the percentage of all antibiotic prescriptions written for amoxicillin. Amoxicillin's market share increased by 1.4% compared to the control group after the intervention. This difference was not statistically significant.
Family physicians in Southern Ontario The intervention consisted of verbal and written evidence-based academic detailing on prescribing for acute otitis media. The academic detailers were pharmaceutical sales representatives that were asked to promote the message that physicians use amoxicillin as the first line drug. (The sales representatives worked for a company that sold a different second-line agent, pivampicillin.) Commission-based financial incentives tied to the volume of products sold were eliminated in the intervention region. Each physician had at least two follow up visits during the six month intervention period.
Smabrekke L, Scandinavian Journal of Infectious Diseases, 2002 Norway Children with otitis media Patient education (distribution of materials), Clinician education (distribution of materials, educational meetings) Absolute effect size: 2.4%
Physicians at an acute care center The intervention was a symposium on evidence-based management of otitis media for physicians and nurses at an acute care clinic. Guidelines on appropriate treatment were distributed. The guideline recommended Penicillin V use when antibiotics were necessary. Pamphlets for patients were made available in exam rooms; the pamphlets stressed that most patients recover without antibiotic and indiscriminate use of antibiotic leads to resistance. This information was also provided to patients who called the clinic. In the intervention group, the prescribing rate for recommended antibiotics increased 12.2% (from 72.3% before the intervention to 84.5% after). In the control group, the prescribing rate for recommended antibiotics increased 9.8% (from 68.2% to 78%). This difference was not statistically significant.
Studies targeting prescribing for adults
Coenen SJ, Antimicrobial Agents and Chemotherapy, 2004 Belgium Adults with acute cough Clinician education (distribution of materials, educational outreach) Absolute effect size: 13.9%
General practitioners The intervention consisted of a mailed guideline for treatment of patients with acute cough, which was delivered to physicians by mail and followed by a reminder phone call. Provides also received an educational outreach visit from a pharmacist and “former medical representative”, which focused on guideline adherence and dialogue with the provider to overcome barriers to appropriate prescribing. Following this, the providers received a mailing with the key messages from the guideline. The recommended antibiotics were amoxicillin and doxycycline. In the intervention group, the prescribing rate for recommended antibiotics increased 13.7% (from 40.10% before the intervention to 53.8% after). In the control group, the prescribing rate decreased 0.2% (from 37.5% before to 37.3% after). This difference was statistically significant.
Dowell J, British Journal of General Practice UK Adults with cough Delayed prescriptions In the intervention group, 45.0% of patients used antibiotics after the intervention. In the comparison group, 100% of patients used antibiotics. This difference was statistically significant.
General practitioners in Scotland Patients presenting with acute cough were given an antibiotic prescription, but asked to wait one week before using the prescription.
Harrison A, AIDS, 2000 South Africa Adults with sexually transmitted diseases Clinician education (distribution of materials, educational outreach, educational workshops), Patient education (distribution of materials) Absolute effect size: 43.1%
Practitioners in 10 primary care clinics in rural KwaZulu - Natal The intervention was a training and supervision program for health care workers. The training was an initial two day workshop attended by a senior primary health care nurse from each clinic. Three follow up sessions were held in each clinic. There were also monthly follow up visits to each clinic by a member of the district STD team. The intervention also included the development and implementation of syndrome packets, including recommended drug treatment information, condoms, partner cards and patient information leaflet. In the intervention group, the prescribing rate for recommended antibiotics increased 47.7% (from 36.3% before the intervention to 84.0% after). In the control group, the prescribing rate increased 4.6% (from 45.4% before to 50.0% after). This difference was statistically significant.
Veninga CC, Journal of Clinical Epidemiology, 2000 Netherlands Adults with urinary tract infection Clinician education (educational workshops, other), Audit and feedback Absolute effect size: -1.0%
General practitioners The intervention was a series of meetings constituting a self-learning auditing program for providers. These meetings took place two times over a four month period. The first consisted of reviewing a guideline for urinary tract infection treatment and going over case vignettes. Decision strategy feedback was given on the provider's responses to the vignettes. At the second meeting, providers received individualized feedback on their prescribing behavior over the previous six months. The goals of the intervention were to increase prescription of recommended antibiotics (trimethoprim, nitrofurantoin, and sulfamethoxazole), and to encourage short courses of treatment. In the intervention group, the prescribing rate for recommended antibiotics remained unchanged at 0.0% (from 89.0% before the intervention to 89.0% after). In the control group, the prescribing rate decreased 1.0% (from 86.0% before to 85.0% after). This difference was not statistically significant.
Lagerlov P, Quality in Health Care, 2000 Norway Adults with urinary tract infections Clinician education (distribution of materials, educational workshops, consensus building sessions), Audit and feedback The intervention resulted in a 13% relative increase in the proportion of UTI treatments of appropriate duration in the intervention group. This change was statistically significant.
General practitioners The intervention consisted of two group meetings in which the doctors (with the help of guidelines, and review of their own prescribing habits) established their own criteria for inappropriate and appropriate prescribing for urinary tract infection. The goal was to encourage treatment of urinary tract infection with 4 or fewer days of antibiotics.
Lundborg CS, Journal of Clinical Epidemiology, 1999 Sweden Adults with urinary tract infections Clinician education (distribution of materials, educational workshops), Audit and feedback Absolute effect size: 17.0%
36 General practitioner groups The intervention was a two-part educational session based on national treatment guidelines for urinary tract infection, which recommended the use of first-line antibiotics with a treatment duration of 3–7 days. Sessions, which were run by an external GP-pharmacist team, involved feedback on simulated written cases and on actual physician-level prescriptions. In the intervention group, the prescribing rate for recommended antibiotics increased 18% (from 52.0% before the intervention to 70.0% after). In the control group, the prescribing rate increased 1.0% (from 57.0% before to 58.0% after). This difference was statistically significant.
Rokstad K, Journal of Clinical Epidemiology, 1995 Norway Adults with urinary tract infection Audit and feedback Absolute effect size: 13.9%
General practitioners in 2 counties The intervention consisted of a one time report sent by mail that included a prescription profile for treatment of urinary tract infection, for both the individual physician and the total sample of general practitioners in the study. In the intervention group, the prescribing rate for recommended antibiotics increased 7.2% (from 22.8% before the intervention to 30.0% after). In the control group, the prescribing rate decreased 6.7% (from 21.1% before to 14.4% after). The study did not report if this difference was statistically significant.
MacCara ME, Annals of Pharmacotherapy, 2001 Canada Adults over age 65 enrolled in Nova Scotia Seniors' Pharmacare Program Regulatory changes for providers, Financial and regulatory incentives for patients After instituting the policy, flouroquinolone use declined from 20.2% of all antibiotic prescriptions to 4.2% of all prescriptions. This change was statistically significant.
General practitioners A policy change which limited reimbursement of the fluoroquinolones and other antimicrobials was instituted. In order to prescribe fluoroquinolones, the physician filled out a special form and a pharmacist determined whether the request was within the established criteria. Flouroquinolones use was limited to treatment of infections due to Pseudomonas and infections resistant to other drugs.
Hux JE, CMAJ, 1999 Canada Adults with respiratory infections or urinary tract infections Clinician education (distribution of materials), Audit and feedback Absolute effect size: 4.3%
Family physicians in Ontario The intervention consisted of mailings with prescribing feedback and targeted educational bulletins stressing the use of less expensive first-line antibiotics, which took place every 2 months over 6 month period. In the intervention group, the prescribing rate for recommended antibiotics increased 2.6% (from 67.2% before the intervention to 69.8% after). In the control group, the prescribing rate decreased 1.7% (from 68.5% before to 66.8% after). This difference was statistically significant.
Peterson GM, Journal of Clinical Pharmacy & Therapeutics, 1997 Australia Adults with urinary tract infection Clinician education (distribution of materials, educational outreach) Absolute effect size: 8.8%
General practitioners in Southern Tasmania The investigators described the intervention as educational mailings sent to general practitioners. The materials were designed to encourage rational prescribing of antibiotics in the management of acute, uncomplicated urinary tract infection. After two weeks, each general practitioner was contacted by telephone to confirm receipt of materials and to set up an appointment with a pharmacist to discuss materials. In the intervention group, the prescribing rate for recommended antibiotics increased 11.0% (from 73.5% before the intervention to 84.5% after). In the control group, the prescribing rate increased 2.2% (from 81.1% before to 83.3% after). This difference was statistically significant.
Studies targeting prescribing for patients of all ages
Braybrook S, Journal of Clinical Pharmacy & Therapeutics, 1996 [comparison 1] UK All patients with urinary tract infections Clinician education (educational outreach), Audit and feedback, Regulatory changes for providers Prescribing of generic amoxicillin (the recommended antibiotic) increased by 21 items per 1000 patients in the control group. In the intervention group, prescribing of generic amoxicillin increased by 33 items per 1000 patients. The study did not report if this difference was statistically significant.
66 family health practices in Wales Intervention practices received visits from a pharmaceutical prescribing adviser to discuss rational antibiotic use and to give feedback on current antibiotic use. This information was presented in a graphical computer slide show. Participating physicians received postgraduate education credit
Braybrook S, Journal of Clinical Pharmacy & Therapeutics, 1996 [comparison 2] UK All patients with urinary tract infections Clinician education (distribution of materials), Audit and feedback, Regulatory changes for providers Prescribing of generic amoxicillin (the recommended antibiotic) increased by 21 items per 1000 patients, in both the control and intervention groups.
66 family health practices in Wales The intervention consisted of practice-specific feedback on prescribing practices (identical in layout to the information given in comparison 1 above) contained within a workbook and accompanied with a series of discussion questions. One general practitioner within each practice received the workbook and organized discussion sessions on rational prescribing. Participating physicians received postgraduate education credit.
De Santis G, Medical Journal of Australia, 1994 Australia All patients with tonsillitis Clinician education (distribution of materials, educational outreach) Absolute effect size: 8.4%
General practitioners in 8 rural and metropolitan Victorian Health Department regions The intervention consisted of a 3-month educational campaign directed at providers. The campaign was initiated with a mailed brochure, which contained the recommended guidelines. These guidelines encouraged use of penicillin V or erythromycin to treat tonsillitis. The brochure was used as a focus of discussion by an academic detailer (project pharmacist) who visited doctors to discuss the campaign messages. Providers received five additional mailings, reiterating key messages. In the intervention group, the prescribing rate for recommended antibiotics increased 27.2% (from 60.5% before the intervention to 87.7% after). In the control group, the prescribing rate increased 18.8% (from 52.9% before to 71.7% after). This difference was statistically significant.
Friis H, Danish Medical Bulletin, 1991 [comparison 1] Denmark All patients with respiratory infections or skin or soft tissue infections Clinician education (distribution of materials, educational meetings) Absolute effect size: 5.1%
General practitioners in 5 counties An informational campaign stressed the importance of reducing ampicillin and co-trimoxazole, while increasing penicillin usage. Written materials were distributed and a series of ten lectures were held. In this comparison, the meetings were arranged by the department of clinical microbiology. In the intervention group, the prescribing rate for recommended antibiotics increased 19.1% (from 56.9% before the intervention to 76.0% after). In the control group, the prescribing rate increased 14.0% (from 58.0% before to 72.0% after). This difference was statistically significant
Friis H, Danish Medical Bulletin, 1991 [comparison 2] Denmark All patients with respiratory infections or skin or soft tissue infections Clinician education (distribution of materials, educational meetings) Absolute effect size: 3.1%
General practitioners in 5 counties An informational campaign stressed the importance of reducing ampicillin and co-trimoxazole, while increasing penicillin usage. Written materials were distributed and a series of ten lectures were held. In this comparison, the meetings were sponsored by a pharmaceutical company and held free of charge. In the intervention group, the prescribing rate for recommended antibiotics increased 17.1% (from 56.9% before the intervention to 74.0% after). In the control group, the prescribing rate increased 14.0% (from 58.0% before to 72.0% after). This difference was not statistically significant.
Ilett KF, British Journal of Clinical Pharmacology, 2000 Australia All patients with respiratory infections or urinary tract infections Clinician education (distribution of materials, educational outreach) Absolute effect size: 14.9%
General practitioners in the Perth metropolitan area The investigators described the intervention as a one time visit by an academic detailer to providers. The visit consisted of a brief discussion of best practice guidelines and included the distribution of a laminated copy of a chart summarizing prescribing guidelines. The recommended antibiotics were amoxicillin and doxycycline for ARIs, and penicillin for UTIs. In the intervention group, the prescribing rate for recommended antibiotics increased 10.0% (from 30.6% before the intervention to 40.6% after). In the control group, the prescribing rate decreased 4.9% (from 38.6% before to 33.7% after). The investigators did not report if this difference was statistically significant.
McNulty CA, Journal of Antimicrobial Chemotherapy, 2000 UK All patients with respiratory infections or urinary tract infections Clinician education (educational workshops), Audit and feedback Absolute effect size: 2.5%
84 general practices in Gloucestershire The intervention consisted of twelve antibiotic educational workshops, which were delivered to providers over a seven week period. Workshops focused on promoting antibiotic guidelines, reducing antibiotic use for unnecessary conditions and making better prescribing decisions. In the intervention group, the prescribing rate for recommended antibiotics increased 0.6% (from 21.1% before the intervention to 21.7% after). In the control group, the prescribing rate decreased 1.9% (from 19.8% before to 17.9% after). The investigators did not report if this difference was statistically significant.
Melander E, Scandinavian Journal of Primary Health Care, 1999 [comparison 2] Sweden All patients with respiratory infections Clinician education (educational workshops), Audit and feedback Absolute effect size: -7.7%
General practices in 3 communities Physician's antibiotic prescribing behavior was audited and fed back to the individual physicians. Group discussions and an educational program were based on the results of these data. Physicians were encouraged to use penicillin V as the first choice drug. In the intervention group, the prescribing rate for recommended antibiotics increased 4.1% (from 61.4% before the intervention to 65.5% after). In the control group, the prescribing rate increased 12.8% (from 37.1% before to 49.9% after). This difference was not statistically significant.
Molstad S, Family Practice, 1989 Sweden All patients with respiratory infections Clinician education (consensus building sessions) Absolute effect size: 20.0%
General practitioners at 3 community health centers Clinicians received an educational program consisting of reviewing regional resistance patterns and indications for antibiotic treatment. Phenoxypenicillin was agreed upon as the first-choice antibiotic, with amoxicillin or pivampicillin for treatment failures and erythromycin for penicillin-allergic patients. In the intervention group, the prescribing rate for recommended antibiotics increased 16.2% (from 62.3% before the intervention to 78.5% after). In the control group, the prescribing rate decreased 4.2% (from 57.3% before to 53.1% after). The investigators did not report if this difference was statistically significant.
Raz R, Israel Journal of Medical Sciences, 1995 Israel All patients with pharyngitis Clinician education (distribution of materials, educational meetings) Absolute effect size: 12.5%
Physicians and nurses at 3 community outpatient clinics Two 1-hour educational sessions on antibiotic prescribing for pharyngitis were given by the study physicians to the entire medical staff (physicians, nurses and pharmacists.) Written handouts were distributed recommending treatment with penicillin V for streptococcal pharyngitis. In the intervention group, the prescribing rate for recommended antibiotics increased 11.5% (from 57.5% before the intervention to 69.0% after). In the control group, the prescribing rate decreased 1.0% (from 44.4% before to 43.4% after). This difference was statistically significant.
Sondergaard J, Scandinavian Journal of Primary Health Care, 2003 Denmark All patients with respiratory infections Clinician education (distribution of materials), Audit and feedback Absolute effect size: 2.0%
181 general practices The intervention consisted of mailed information to general practitioners on their prescribing practices combined with a clinical guideline on the diagnosis and treatment of respiratory tract infections. The feedback provided some aggregate data so the general practitioner could compare the prescription rates of their own practice to other local practices. The clinical guidelines recommended restricting antibiotics used for respiratory tract infections to the lowest justifiable level, and that narrow-spectrum antibiotics (e.g. penicillin V) should be preferred to broad-spectrum antibiotics. In the intervention group, the prescribing rate for recommended antibiotics decreased 7.0% (from 52.0% before the intervention to 45.0% after). In the control group, the prescribing rate decreased 9.0% (from 52.0% before to 43.0% after). This difference was not statistically significant.
Zwar N, Family Practice, 1999 Australia All patients with pharyngitis Clinician education (distribution of materials, educational outreach, other), Audit and feedback Absolute effect size: 18.6% In the intervention group, the prescribing rate for recommended antibiotics increased 17.5% (from 55.5% before the intervention to 73.0% after). In the control group, the prescribing rate decreased 1.1% (from 59.6% before to 58.5% after). This difference was statistically significant.
General practitioner trainees in New South Whales The intervention consisted of a mailed packet of individualized feedback to providers, management guidelines, and patient handouts. Providers also received an academic detailing session, in person or over phone, for doctors who exceeded thresholds for inappropriate prescriptions based on feedback data. Providers were encouraged to use narrow-spectrum penicillin or erythromycin for streptococcal pharyngitis.
*

The measured population refers to the patient population in which prescribing data was measured. This population is the group to which the study results are most generalizable.

**

The Absolute effect size is provided for studies that were used in the median effects analysis. These studies reported data as the percentage of visits at which patients received an antibiotic prescription. The individual study Absolute effect size was calculated as: [(Intervention) post - (Intervention) pre ] - [(Control) post - (Control) pre ]. A negative effect size means an overall reduction in the percentage of patients receiving a recommended antibiotic.

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