Decreasing Antibiotic Misuse: Taking a Cue from the Pharmaceutical Reps
December 1, 2001
Decreasing Antibiotic Misuse: Taking a Cue from the Pharmaceutical Reps
Abstract & Commentary
Synopsis: A one-on-one educational interaction targeted at reducing inappropriate antibiotic prescription led to a 41% reduction in such prescription in this randomized controlled trial in a major teaching hospital.
Source: Solomon DH, et al. Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center. Arch Intern Med. 2001;161: 1897-1902.
Numerous studies have demonstrated that antibiotic misuse is both common and exceedingly costly. In hospitalized patients, it leads to unnecessary adverse effects and increased costs, and fuels the raging fire of emerging antibiotic resistance among common bacterial species. This study from the Divisions of Pharmacoepidemiology, Pharmacoeconomics, and Infectious Diseases at Brigham and Women’s Hospital in Boston explored a novel means for reducing this inappropriate antibiotic usage: one-on-one, patient-specific communication with ordering physicians, or "antibiotic detailing." In carrying out this innovative investigation, Solomon and associates adopted a familiar strategy used by pharmaceutical representatives, using detailing not to promote sales of a particular drug but to bring antibiotic prescription more in line with accepted guidelines.
In Solomon et al’s 700-bed teaching hospital, the medical service (receiving one-third of all admissions) is made up of 4-person teams, each consisting of an attending physician, a senior resident, and 2 interns. During an 18-week study period and using a blocked randomization design, half of the teams were assigned to the intervention and the other half served as controls. Solomon et al selected levofloxacin and ceftazadime as the target drugs, and used the hospital’s computerized pharmacy records to track all orders for their use by the interns and residents on the teams. Strict definitions of appropriate and inappropriate prescription of these drugs were applied, consistent with current guidelines, and all inappropriate (unnecessary) orders were flagged for review.
The interns and residents on the teams randomized to receive the study intervention underwent one-on-one educational academic detailing each time an inappropriate order for levofloxacin or ceftazidime was received, delivered by 3 clinician-educators, 2 infectious diseases physicians, and 1 clinical pharmacist. The detailers presented standardized materials to the intern or resident interactively in a case-relevant, concise manner, stressing microbiologic data, local resistance patterns, and the clinical literature. They also provided copies of the guidelines and suggested alternative antibiotic regimens to the one ordered. House staff teams were unaware that their ordering patterns were being studied.
During the 4-week baseline period before randomization and throughout the 18-week study period, there were more than 4500 patients admitted to the medicine services at the study hospital. Patients and baseline antibiotic prescription patterns during the baseline period were similar for intervention and control teams. During the study period, 490 patients were prescribed levofloxacin or ceftazidime. After exclusions according to pre-established criteria, 260 patients received 278 unnecessary prescriptions for the study antibiotics. The number of days of unnecessary antibiotic use was 37% lower for the intervention services than for the controls (P < 0.001). In multivariate analyses that controlled for baseline prescribing and 2-week study interval, the rate of unnecessary use of the 2 target antibiotics was reduced by 41% on the intervention services as compared with the controls (95% confidence interval, 44%-78%; P < 0.001). There were no significant differences in length of stay, transfers to the ICU, readmission rates, or in-hospital deaths.
Comment by David J. Pierson, MD
As Solomon et al point out, about one third of all patients admitted to a hospital receive 1 or more antibiotics, and several studies indicate that at least half of all antibiotic orders are either unnecessary, poorly chosen, or incorrectly dosed. In one study of vancomycin use in a large teaching hospital, 70% of the orders for that drug during a 2-month period were judged inappropriate, and the rates of inappropriate usage on the medical and surgical services were the same.1 These observations mean that any measure that decreased antibiotic misuse would have the potential both to improve patient care and to save the health care system a great deal of money, since antibiotics account for a large proportion of overall drug expenditures.
The strategy used by Solomon et al for attacking the problem of inappropriate antibiotic usage is well known to every physician. Pharmaceutical companies know that one-on-one, personal contact that includes the imparting of a take-home message, typically sweetened by the presentation of free food or a gift to cast the interaction in a positive light, is highly effective in modifying physician behavior. That is why they each spend as much as $5000 annually on marketing for each target physician, a substantial amount of it on one-on-one physician detailing. The marketing practices of the pharmaceutical industry,2 and specifically the subject of detailing directed to housestaff at teaching hospitals,3 have been the subject of considerable discussion lately, although this important topic is beyond the scope of the present comment.
Several aspects of this study potentially limit its applicability to routine clinical practice in the ICU and elsewhere. Although the techniques used by Solomon et al to approach and educate target physicians have been well described4 and used in a variety of settings,5 they tend to be labor intensive and expensive to implement. In the present study the estimated annual cost of academic detailing to the target physician population was $21,750, in an institution in which highly experienced and motivated personnel were already in place. Transplantation of Solomon et al’s system to a community hospital would take a fair amount of initiative and effort, and it is unclear whether practicing physicians would respond to the intervention the same way as the interns and residents did in this study.
Nonetheless, the central messages of the study should be emphasized: inappropriate antibiotic prescription is widespread, has a number of important negative effects, and can be decreased through the use of clinician-targeted educational interventions. How to bring the latter about amidst the complexities and market forces of current practice is a challenge that deserves a widespread and concerted response.
References
1. Lipsky BA, et al. Improving the appropriateness of vancomycin use by sequential interventions. Am J Infect Control. 1999;27:84-91.
2. Angell M. The pharmaceutical industry—To whom is it accountable? N Engl J Med. 2000;342:1902-1904.
3. Kassirer JP. A piece of my mind: Financial indigestion. JAMA. 2000;284(17):2156-2157.
4. Soumerai SB, Avorn J. Principles of educational outreach ("academic detailing") to improve clinical decision making. JAMA. 1990;263:549-556.
5. Avorn J, et al. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992;327:168-173.
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