Results Summary
What was the research about?
Each year, millions of children take antibiotics to treat ear, nose, throat, and chest infections. Antibiotics don’t work to treat infections caused by viruses, such as the common cold or flu. Educating parents and clinicians, such as doctors and nurses, about antibiotic use may help reduce unneeded prescriptions.
In this study, the research team compared two ways of helping clinicians and parents discuss whether to use antibiotics:
- Less intense training. Clinicians received a 20-minute training on antibiotic use. Parents viewed a 90-second video about safe antibiotic use before their clinic visit.
- More intense training. Clinicians and parents had the same training on antibiotics as those in the less intense group. Clinicians also received a 50-minute training on how to talk with parents about antibiotics. Parents received a brochure to take home. Clinicians also received parents’ rating about their desire for an antibiotic before their visit.
What were the results?
The rate of unneeded antibiotic prescriptions didn’t differ between the less and more intense training. The trainings also didn’t differ in parent reports of
- Quality of communication between parents and clinicians
- Shared decision making, or the process in which patients and doctors work together to make healthcare decisions
- Satisfaction with care
- Needing to go back to the clinic
- Side effects
Who was in the study?
The study included 1,600 parents whose children had symptoms of ear, nose, throat, or chest infections. All received care at one of two clinics in the Kansas City area. Children were ages 1–5. Among parents in the less intense training, 80 percent were white, 12 percent were Black, and 8 percent were another race, more than one race, or did not answer. Among parents in the more intense training, 77 percent were white, 13 percent were black, and 10 percent were another race, more than one race, or did not answer. Among all parents in the study, 19 percent were Hispanic, and 84 percent were women.
A total of 41 clinicians took part in the study. They had an average of eight years in practice, and 78 percent were women.
What did the research team do?
The research team assigned clinicians and their patients by chance to the less or more intense training. Then the team looked at children’s health records after their visit. Based on symptoms and diagnoses, the team decided whether antibiotics prescribed during the visit were needed.
Parents completed surveys before and after the visit, and again two weeks later.
Parents, clinicians, and members of a community advisory board helped design, plan, and conduct the study.
What were the limits of the study?
The study didn’t look at how the trainings compared with no training. The number of patient visits that happened after training differed across clinicians, which could have affected the findings.
Future research could continue to look at ways to reduce the rate of unneeded antibiotic prescribing.
How can people use the results?
Clinics can use the results as they consider ways to reduce unneeded antibiotic prescriptions.
Professional Abstract
Objective
To compare the effectiveness of higher and lower intensity parent-provider communication interventions for reducing the rate of inappropriate antibiotic prescribing in children
Study Design
| Design Element | Description |
|---|---|
| Design | Cluster randomized trial |
| Population | 1,600 parents and their children ages 1–5 with acute respiratory tract infection symptoms; 41 providers, including pediatricians and nurse practitioners, at two pediatric outpatient clinics |
| Interventions/ Comparators |
|
| Outcomes |
Primary: rate of inappropriate antibiotic prescribing Secondary: quality of parent-provider communication, shared decision making, patient satisfaction, revisits, adverse reactions |
| Timeframe | Up to 2 weeks for study outcomes |
This cluster randomized trial compared the effectiveness of two parent-provider communication interventions to reduce the rate of inappropriate antibiotic prescribing in children.
The research team stratified pediatric providers by lower and higher patient volume and randomized providers and their patients to receive one of two interventions:
- Lower intensity intervention. Providers completed a 20-minute general training on the benefits and harms of antibiotics, the risks of inappropriate use, prescribing guidelines, and common reasons for overprescribing. Parents viewed a 90-second video about safe antibiotic use prior to their child’s provider visit.
- Higher intensity intervention. In addition to the lower intensity training, providers received a 50-minute patient-centered communication skills training. Parents also received an educational brochure to accompany the video and completed a pre-visit rating of their desire for an antibiotic. Providers viewed the rating before the appointment.
The study included 1,600 parent-child dyads receiving care from 1 of 41 providers in two pediatric outpatient clinics within the Kansas City metropolitan area. Among parents whose children received care from providers in the lower intensity intervention, 80% were white, 12% were black, and 8% were another race, more than one race, or did not answer. Among parents whose children received care from providers in the higher intensity intervention, 77% were white, 13% were black, and 10% were another race, more than one race, or did not answer. Among all parents, 19% were Hispanic, and 84% were female. Their children were ages 1–5. Among providers, 78% were female and had an average of eight years in practice.
The research team reviewed the children’s medical records to determine if prescriptions were appropriate for the children’s symptoms and diagnoses. Parents completed surveys before and after the visit, and again two weeks later.
Parents, providers, and members of a community advisory board helped design, plan, and conduct the study.
Results
The rate of inappropriate prescriptions did not differ significantly between patients who received care from providers in the lower intensity intervention (9.4%) and patients who received care from providers in the higher intensity intervention (7.8%). Secondary outcomes did not differ significantly between the higher and lower intensity interventions.
Limitations
The study did not assess the rate of inappropriate antibiotic use for providers and patients who did not receive training. The number of patient visits after the training differed across providers, which could have influenced study findings.
Conclusions and Relevance
In this study, the rate of inappropriate prescriptions did not differ between higher and lower intensity communication interventions; rates in both groups were lower than recently published estimates of inappropriate prescribing (14.3%).
Future Research Needs
Future studies could continue to examine ways to reduce the rate of inappropriate antibiotic prescribing.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked the researchers to discuss in more detail the possibility that their inability to detect a significant difference in antibiotic prescribing between the high-intensity and low-intensity communication groups challenges the idea that more effective communication would necessarily reduce unnecessary antibiotic use. The researchers agreed that their findings may challenge the assumption that more intensive communication can meaningfully affect antibiotic prescription rates, at least in the context that they studied. However, the researchers pointed out that higher-intensity communication may have other benefits than the ones measured in this study.
- The reviewers noted that there were two intervention arms in the study but no control arm reflecting standard care, which made it impossible to answer whether the interventions affected the rate of inappropriate antibiotic prescribing. The researchers agreed this is an important point and added a statement in their discussion section on future research about the need to include a control or no intervention arm to better determine the impact of communication on inappropriate prescribing.
Conflict of Interest Disclosures
Project Information
Patient / Caregiver Partners
- Carey Bickford
Other Stakeholder Partners
- Christopher C. Butler, BA, MBChB, DCH, MD, FRCGP, (Hon) FFPH
- Bob Finuf, Executive Director of Integrated Care Solutions
- David Yu, MD, President of Heartland Primary Care