title: One size does not fit all: evaluating an intervention to reduce antibiotic prescribing for acute bronchitis.
abstract: BACKGROUND
  Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians.
  
  
  METHODS
  Clinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29).
  
  
  RESULTS
  Compared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions-including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components' effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy.
  
  
  CONCLUSIONS
  Future efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.
authors.affiliation: Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA. sara.ackerman@ucsf.edu.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Ackerman
authors.forename: Ralph
authors.initials: R
authors.lastname: Gonzales
authors.forename: Melissa S
authors.initials: MS
authors.lastname: Stahl
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Metlay
mesh_terms: D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D001991:Bronchitis / Q000188:drug therapy*; D003661:Decision Support Techniques; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control*; D008297:Male; D010353:Patient Education as Topic / Q000379:methods; D010414:Pennsylvania / Q000453:epidemiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D015397:Program Evaluation
chemical_list: D000900:Anti-Bacterial Agents