Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts
Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts
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DOI：
10.1542/peds.2007-0819
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发表时间：
2008-01-01
期刊：
影响因子：
8
通讯作者：
Platt, Richard
中科院分区：
文献类型：
--
作者：
Finkelstein, Jonathan A.;Huang, Susan S.;Platt, Richard
目标。减少不必要的抗生素使用，特别是在儿童中，仍然是公共卫生的优先事项。以前的干预研究受到规模或设计的限制，结果喜忧参半。这项研究的目的是确定多方面的、社区范围的干预对幼儿总体抗生素使用和广谱制剂使用的影响。此外，我们试图比较干预对商业保险和医疗补助保险儿童的影响。方法：我们在1998年至2003年研究的16个不重叠的马萨诸塞州社区进行了一项对照的、社区水平的、整群随机的试验。在3年中，我们实施了医生行为改变策略，包括分发指南、小组教育、频繁更新和教育材料以及处方反馈。家长通过邮寄以及初级保健诊所、药房和托儿所收到教育材料。使用健康计划数据，我们测量了3至72个月大、居住在研究社区并由参与商业健康计划或Medicaid保险的儿童在每人每年观察中分配的抗生素的变化。结果：数据包括223 135人年的观察。在3岁至24岁、24岁至48岁和48岁至72个月的儿童中，抗生素使用率基线分别为每人每年2.8、1.7和1.4种抗生素。我们观察到，即使在没有干预的情况下，抗生素处方的数量也有大幅下降的趋势。这项干预对3到24个月大的儿童没有额外的影响，但导致24岁到48个月的儿童下降4.2%，48岁到72个月的儿童下降6.7%。结论：持续的、多方面的、社区层面的干预在减少总体抗生素使用方面只取得了一定的成功，超出了实质性的长期趋势。在医疗补助参保儿童和特定药物类别中产生的更强劲的影响，为为患者和医生行为改变确定具体目标提供了论据。
OBJECTIVES. Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.METHODS. We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to < 72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid.RESULTS. The data include 223 135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to < 24, 24 to < 48, and 48 to < 72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to < 24 months but was responsible for a 4.2% decrease among those aged 24 to < 48 months and a 6.7% decrease among those aged 48 to < 72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents.CONCLUSIONS. A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.