title: Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Ave, Sixth Floor; Boston, MA 02215, USA. jonathan_finkelstein@harvardpilgrim.org
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Finkelstein
authors.forename: Susan S
authors.initials: SS
authors.lastname: Huang
authors.forename: Ken
authors.initials: K
authors.lastname: Kleinman
authors.forename: Sheryl L
authors.initials: SL
authors.lastname: Rifas-Shiman
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Stille
authors.forename: James
authors.initials: J
authors.lastname: Daniel
authors.forename: Nancy
authors.initials: N
authors.lastname: Schiff
authors.forename: Ron
authors.initials: R
authors.lastname: Steingard
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Soumerai
authors.forename: Dennis
authors.initials: D
authors.lastname: Ross-Degnan
authors.forename: Donald
authors.initials: D
authors.lastname: Goldmann
authors.forename: Richard
authors.initials: R
authors.lastname: Platt
mesh_terms: D000293:Adolescent; D000367:Age Factors; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004352:Drug Resistance, Microbial; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006266:Health Education / Q000458:organization & administration*; D006801:Humans; D015994:Incidence; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D011336:Probability; D012016:Reference Values; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors
chemical_list: D000900:Anti-Bacterial Agents