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Impact of a Multidimensional Intervention on the Treatment of Uncomplicated Acute Bronchitis in Adults

Ralph Gonzales, MD, MSPH; John F. Steiner, MD, MPH; Andrew Lum, MD; Paul H. Barrett, Jr, MD, MSPH

JAMA. 1999;281:1512-1519.

Context  The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due, in part, to the excessive use of antibiotics for acute respiratory tract infections.

Objective  To decrease total antibiotic use for uncomplicated acute bronchitis in adults.

Design  Prospective, nonrandomized controlled trial, including baseline (November 1996-February 1997) and study (November 1997-February 1998) periods.

Setting  Four selected primary care practices belonging to a group-model health maintenance organization in the Denver, Colo, metropolitan area.

Participants  Consecutive adults diagnosed as having uncomplicated acute bronchitis. A total of 2462 adults were included at baseline and 2027 adults were included in the study. Clinicians included 56 physicians, 28 physician assistants or nurse practitioners, and 9 registered nurses.

Intervention  The full intervention site received household and office-based patient educational materials, as well as a clinician intervention consisting of education, practice-profiling, and academic detailing. A limited intervention site received only office-based educational materials, and control sites provided usual care.

Main Outcome Measure  Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods.

Results  Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period. During the study period, there was a substantial decline in antibiotic prescription rates at the full intervention site (from 74% to 48% [P=.003]), but not at the control and limited intervention sites (78% to 76% [P=.81] and 82% to 77% [P=.68], respectively). Compared with control sites, changes in nonantibiotic prescriptions (inhaled bronchodilators, cough suppressants, and analgesics) were not significantly different for intervention sites. Return office visits (within 30 days of the incident visit) for bronchitis or pneumonia did not change significantly for any of the sites.

Conclusions  Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions.

Author Affiliations: Division of General Internal Medicine (Drs Gonzales and Steiner), Department of Medicine (Drs Gonzales, Lum, and Steiner), University of Colorado Health Sciences Center, and Kaiser Permanente of Colorado (Drs Barrett and Lum), Denver.

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