Published online December 31, 2007
PEDIATRICS Vol. 121 No. 1 January 2008, pp. e15-e23 (doi:10.1542/10.1542/peds.2007-0819)

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ARTICLE

Impact of a 16-Community Trial to Promote Judicious Antibiotic Use in Massachusetts

Jonathan A. Finkelstein, MD, MPH^a,b, Susan S. Huang, MD, MPH^a,c, Ken Kleinman, ScD^a, Sheryl L. Rifas-Shiman, MPH^a, Christopher J. Stille, MD, MPH^d, James Daniel, MPH^e, Nancy Schiff, MPH^f, Ron Steingard, MD^g, Stephen B. Soumerai, ScD^a, Dennis Ross-Degnan, ScD^a, Donald Goldmann, MD^h and Richard Platt, MD^a

^a Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
^b Divisions of General Pediatrics
^h Infectious Diseases, Children's Hospital Boston, Boston, Massachusetts
^c Channing Laboratory and Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
^d Department of Pediatrics and Meyers Primary Care Institute
^g Departments of Psychiatry and Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
^e Massachusetts Department of Public Health, Boston, Massachusetts
^f MassHealth, Boston, Massachusetts

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 223135 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.

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Key Words: antibiotic use • parental knowledge • randomized trial

Abbreviations: CDC—Centers for Disease Control and Prevention • REACH Mass—Reducing Antibiotics for Children in Massachusetts

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Accepted Jun 7, 2007.

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