Antibiotic Treatment of Acute Respiratory Tract Infections in the Elderly: Effect of a Multidimensional Educational Intervention

Authors

  • Ralph Gonzales MD, MSPH,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Angela Sauaia MD, PhD,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Kitty K. Corbett PhD, MPH,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Judith H. Maselli MSPH,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Kathleen Erbacher MPA,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Bonnie A. Leeman-castillo MS,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Carol A. Darr BA,

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • Peter M. Houck MD

    1. From the *Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CaliforniaDivision of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver ColoradoColorado Foundation for Medical Care, Aurora, Colorado§Department of AnthropologyHealth and Behavioral Sciences Program, University of Colorado, Denver, ColoradoCenters for Medicare and Medicaid Services, Baltimore, Maryland.
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  • This study was sponsored by Centers for Medicare and Medicaid Services Contract 500–99-CO-01, the Department of Health and Human Services, and Agency for Healthcare Research and Quality Contract 1 R01HS13001-01.
    The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this Contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.

Address correspondence to Ralph Gonzales, MD, MSPH, Associate Professor of Medicine, University of California, San Francisco, 3333 California Street, Suite 430, Box 1211, San Francisco, CA 94118.

Abstract

Objectives: To measure and improve antibiotic use for acute respiratory tract infections (ARIs) in the elderly.

Design: Prospective, nonrandomized controlled trial.

Setting: Ambulatory office practices in Denver metropolitan area (n=4 intervention practices; n=51 control practices).

Participants: Consecutive patients enrolled in a Medicare managed care program who were diagnosed with ARIs during baseline (winter 2000/2001) and intervention (winter 2001/2002) periods. A total of 4,270 patient visits were analyzed (including 341 patient visits in intervention practices).

Intervention: Appropriate antibiotic use and antibiotic resistance educational materials were mailed to intervention practice households. Waiting and examination room posters were provided to intervention office practices.

Measurements: Antibiotic prescription rates, based on administrative office visit and pharmacy data, for total and condition-specific ARIs.

Results: There was wide variation in antibiotic prescription rates for ARIs across unique practices, ranging from 21% to 88% (median=54%). Antibiotic prescription rates varied little by patient age, sex, and underlying chronic lung disease. Prescription rates varied by diagnosis: sinusitis (69%), bronchitis (59%), pharyngitis (50%), and nonspecific upper respiratory tract infection (26%). The educational intervention was not associated with greater reduction in antibiotic prescription rates for total or condition-specific ARIs beyond a modest secular trend (P=.79).

Conclusion: Wide variation in antibiotic prescription rates suggests that quality improvement efforts are needed to optimize antibiotic use in the elderly. In the setting of an ongoing physician intervention, a patient education intervention had little effect. Factors other than patient expectations and demands may play a stronger role in antibiotic treatment decisions in elderly populations.

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