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Invited Commentary
Oct 22, 2012

Can Implementation Science Help to Overcome Challenges in Translating Judicious Antibiotic Use Into Practice?Comment on “National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis” and “Geographic Variation in Outpatient Antibiotic Prescribing Among Older Adults”

Author Affiliations

Author Affiliations: Departments of Medicine (Drs Gonzales, Ackerman, and Handley) and Epidemiology and Biostatistics (Drs Gonzales and Handley), University of California, and Division of General Internal Medicine, San Francisco General Hospital (Dr Handley), San Francisco.

Arch Intern Med. 2012;172(19):1471-1473. doi:10.1001/2013.jamainternmed.532

In this issue of the Archives, 2 national studies1,2 provide distinct perspectives on the problem of antibiotic overuse in the United States. Fairlie et al1 conducted a secondary analysis of National Ambulatory Medical Care Survey data covering a 10-year period to measure antibiotic prescription rates for the common condition of acute sinusitis. Zhang et al2 analyzed Medicare Part D claims data for patients 65 years or older from 2007 through 2009 to assess geographic and seasonal variation in antibiotic prescriptions, considering prevalence patterns of common acute respiratory tract infections (ARIs) and various covariates.Both studies used appropriate methods and advanced statistical analyses to show that the overuse of antibiotics remains high and that variation in overuse is not fully explained by clinical factors available in these data sets. Studies such as these are important reminders that the United States still has a long way to go in reducing antibiotic overuse.

In the context of past efforts to understand and improve antibiotic prescribing in the United States, the results from these 2 studies raise the question of why the problem of overprescribing persists. More than 15 years have elapsed since antibiotic overuse became a national priority, largely in response to the emergence of penicillin resistance to Streptococcus pneumoniae, a major threat to public health given its dominant role in severe community-acquired infections, such as pneumonia, meningitis, and sepsis.3,4 Beginning in 1995, studies57 based on the National Ambulatory Medical Care Survey have shown that approximately 3 of every 4 antibiotic prescriptions in US ambulatory practices were for the treatment of ARIs, most of which have a viral origin. In the lay press, reports and stories related to antibiotic resistance (such as superbugs) and antibiotic overuse have appeared on national television network news, in magazines, and in newspapers. Studies8,9 during this period have shown that nonclinical factors (such as patient volume or patient expectations and requests for antibiotics) influence prescribing decisions as much as or more than clinical factors (such as purulent secretions or duration of illness).

During the past 15 years, the Centers for Disease Control and Prevention have sponsored 2 multiagency task forces on strategies to address antibiotic resistance, havesupported public health departments to develop local campaigns to promote appropriate antibiotic use, and have established an office of Careful Antibiotic Use that has served as a clearinghouse for patient and provider (eg, physician, clinic, and community health center) educational materials and practice guidelines.10 Professional societies have also published multiple clinical practice guidelines on the topic, and the National Committee for Quality Assurance has established 2 quality indicators (Healthcare Effectiveness Data and Information Set measures) related to antibiotic overuse—antibiotic treatment and testing of children with acute pharyngitis (in 2004) and antibiotic treatment of adults with uncomplicated acute bronchitis (in 2006). Finally, systematic reviews of intervention strategies to reduce total antibiotic use and to improve antibiotic selection have also been published.11,12

Based on estimates from the National Ambulatory Medical Care Survey and retail pharmaceutical sales,13 one can reasonably estimate that antibiotic use has declined since 1995 by about 20% in the United States to a level that is slightly less than that for 2010 in France.14,15 However, comparisons with antibiotic use rates in the Netherlands and Scandinavian countries show rates that are less than half the rate in France.16 Therefore, if we aspire to reduce antibiotic use to levels that have been shown to be associated with lower S pneumoniae resistance rates, we have much more work to do.17,18

We believe that the persistence of antibiotic overuse in the United States is a failure to translate national public health priorities and evidence into local practice and policies. We ask whether the application of recent implementation frameworks could help to guide more successful evidence translation and provide a sharper focus for future intervention activities. To explore this idea, we developed a checklist for judging the likelihood of successful translation of evidence into practice for a given target or problem area, which was adapted from the framework for describing high-performance delivery systems by Shortell et al19 and from the Consolidated Framework for Implementation Research.20 In the Table, we apply this checklist to the problem of antibiotic overuse. For every item on the checklist, we provide a general summary rating for its effect on the potential for successful implementation of judicious antibiotic use practices by rating each as favorable, unfavorable, or neutral.

Table. Checklist for Judging the Likelihood of Successful Translation of Evidence Into Practice for the Problem of Antibiotic Overusea
Table. Checklist for Judging the Likelihood of Successful Translation of Evidence Into Practice for the Problem of Antibiotic Overusea
Table. Checklist for Judging the Likelihood of Successful Translation of Evidence Into Practice for the Problem of Antibiotic Overusea

What can we conclude from this exercise? Although challenges are seen in all 3 domains (significance of the problem area, organization and stakeholder readiness for change, and feasibility of intervention), we know from previous studies2224 that coordinated, multidimensional interventions can be successful in reducing antibiotic overuse in local delivery systems. Challenges presented in the first 2 domains (Table) may explain the failure to achieve wide-scale dissemination and adoption of these interventions. We need to find better ways to compel individuals and organizations to address the significance of the problem of antibiotic overuse and to increase the readiness for change and quality improvement of ambulatory practices in the United States. Strategies to achieve transformation at these levels may need to differ substantially from the current educational approaches that have been in use among patients and clinicians thus far.

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Article Information

Published Online: September 24, 2012. doi:10.1001/2013.jamainternmed.532

Correspondence: Dr Gonzales, Department of Medicine, University of California, San Francisco, 3333 California St, PO Box 1211, Ste 430, San Francisco, CA 94118 (ralphg@medicine.ucsf.edu).

Financial Disclosure: None reported.

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