Characteristics of included studies
| Interventions targeting clinicians and parents | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Study | Design | Setting | Participants | Children | Intervention | Comparison | Length of follow-up | Outcome | Method of assessing outcome |
| Cohen15 2000 France | RCT | PCC | Generalists n= 703 Paediatricians n= 413 Parents | <10 yr with nasopharyngitis, (mean 2.5 yr) | Written educational material for clinicians and parents on natural history, symptomatic treatment, reasons to re-consult, and lack of need for AB for acute uncomplicated rhinopharyngitis | No intervention | 7 days receiving ABx | Proportion | Medical records I = 1957 C = 1807 |
| Doyne16 2004 US | CRCT | 11 PCC or FQHC | Community paediatric practices I = 6 C = 6 Parents | Not described | Clinician academic detailing on appropriate AB use (5 sessions); clinician focus groups (identified reasons for prescribing); parent focus groups (identified expectations around ABx). Clinicians received prescribing guidelines plus patient education materials (CDC poster, pamphlet, handouts) to give to parents (on illness prevention, when to consult, what to expect at consultation, effect of AB on outcomes, resistance, and AB treatment recommendations) | Receipt of locally developed guidelines (once) plus practice-specific feedback (twice) | 12 mo | ABx filled per consultation | Medical records and health information provider data |
| Finkelstein17 2001 US | CRCT | 12 PCC | Clinicians I = 86 C = 71 Parents | 3 mo <72 mo I = 7050 C = 6410 | Clinicians given group education (2 sessions) on problem of AB resistance and accurate diagnosis of AOM and written materials (6 evidence-based summaries and prescribing feedback from previous year); parents were mailed educational pamphlet with letter signed by paediatricians | Unclear (study reports that control group received no feedback) | 12 mo | ABx per person–year for children | Pharmacy data |
| Francis18 2006 US | P/P | HMO | Paediatricians n= 153 Parents | With AOM | Clinicians attended lectures on appropriate use of AB for AOM (financial incentive for attendance); newsletters, program website, and academic AOM. Patients received educational handouts that explained treatment recommendations | (Historical data prior to intervention) | 14 mo | Exceptions to care pathway per 1000 episodes of care | Claims data |
| Francis19 2009 UK | CRCT | 61 PCC | Practices n= 61 Parents Clinicians | 6 mo–14 yr with RTI lasting < 7 day I = 274 (mean 5.1 yr) C = 284 (mean 5.3 yr) | 8-page interactive book given to parents and used during consultation with clinician to foster discussion of parental concerns, expectations, and to explain symptom course, treatment, and need for re-consultation. Booklet included information normal duration and effectiveness of AB for common RTIs, interpretation of symptoms, self-care advice, negative aspects of AB use, and reasons to re-consult | Usual care | 2 wks | ABx/ index consultation | Phone interview |
| Juzych20 2005 US | NRCT | 4 PCC | Paediatricians I = 9 C = 6 Pharmacists Nurses Parents | Not described | Group education (1 half day session) on antimicrobial resistance, appropriate treatment and diagnosis for bronchitis, AOM, pharyngitis, and non-specific URI. Participants received guideline handouts, literature on AB resistance and patient handouts | No intervention | 12 mo | ABx per index consultation | Pharmacy claims data |
| Mainous21 2000 US | RCT | PCC | Clinicians I1 = 53 I2 = 49 I3 = 52 C = 62 Parents | <18 yr Medicaid enrollees | I1: Patient education pamphlet on AB use I2: Clinician feedback (prescribing profile on (URI, bronchitis, pharyngitis, with number of episodes, number of ABx, proportion of ABx, total cost of episode, proportionate cost of ABx) mailed with letter explaining that prescribing was being evaluated I3: Clinician feedback; and patient education | No intervention | 5 mo | ABx per URI episode of care | Medicaid data |
| Regev -Yochay22 2011 Israel | CRCT | 50 PCPC | Clinicians I = 26 C = 24 Parents | <18 yr registered at HMO practices I = 46 043 ± 3050 children per year (mean age: 5.6 (SD 0.02) yr C = 46 602 ± 1628 children per year (mean age: 5.9 (SD 0.02) yr | Multifaceted intervention involving five (I) group clinicians serving as ‘local leaders’, three workshops, focus groups, and seminars. Workshops took place at the beginning of years 1, 2, and 3 and focused on reasons for non-judicious prescribing and interventions to address this; parent–clinician communication; and prescribing feedback. Following workshops, participants joined focus groups to (1) develop local diagnostic and prescribing guidelines; (2) run seminar on AOM diagnosis and assess access to other diagnostic tools; (3) disseminate current research abstracts related to antibiotic resistance to clinicians; (4) disseminate educational posters, handouts, colouring books to parents and children in clinic; (5) run a simulation seminar on parent-clinician communication. (Most intervention activity took place during year 1). | No intervention | 1 yr | Change in annual ABx per 100 patient years; ABx rates for penicillin, macrolide, and cephalosporin | HMO pharmacy data |
| Smabrekke23 2002 Norway | NRCT | 2 ECS | Clinicians Nurses Parents | 1–15 yr I = 210 C = 125 | Doctors and nurses attended an evidence-based session on AOM care, received guidelines on appropriate diagnosis, AB treatment, and delayed prescribing. Pamphlets on limited benefits of AB, AB resistance, self-limiting nature, and symptomatic treatment of AOM were available in waiting rooms for parents; same information was given to parents during telephone contact | No educational activities | 4 mo | ABx per child with AOM | Pharmacy data |
| Wilson24 2003 Australia | RCT | 54 PCC | Clinicians I = 24 C = 30 Parents | <2 yr with acute respiratory infection, n= 502 | Clinicians participated in workshops and parents in focus groups to develop treatment guideline for acute respiratory infection. Clinicians received guidelines, prescribing feedback (1 session) Parent material included handouts, prescription pads, and poster with information on RTI symptoms, symptomatic treatment, course, and explanation that AB is not necessary. | No intervention during months clinician 0–15; group education (1 session) on local guidline plus patient education (handout, prescription pads, posters) | 24 mo | ABx per 100 Medicare services | Australia Health Insurance Commission data |
| Interventions targeting clinicians only | |||||||||
| Bauchner25 2006 US | CRCT | 12 PCPC | Paediatric practices I = 6 C = 6 | 3 mo – 3 yr (mean 1.41 yr) with acute otitis media, I = 1382 C = 1146 | Clinician given group education (2 sessions, information on CDC treatment recommendations and appropriate diagnosis of AOM), chart reminders to classify child as high or low risk, newsletters with feedback on local prescribing and adherence to AB treatment recommendations | Clinician group education (2 sessions, focus on AOM diagnosis and pneumococcal conjugate vaccine) | 29 mo | ABx in adherence to guideline per all ABx | Medical records |
| Bourgeois26 2010 US | CRCT | 12 PCC | Clinicians I = 112 C = 34 | <18 yr with acute respiratory infection, I = 9409 (mean 7.6 yr) C = 2907 (mean 6.6 yr) | CDSS for acute respiratory infection: clinicians record symptoms, receive management options based on symptoms, over-the-counter treatment, watchful waiting guidelines, and additional diagnostic testing and patient handouts to print out. Clinicians were sent email reminders to use CDSS. | No intervention (not described) | 7 mo | ABx per consultation | Electronic health record |
| Christakis27 2001 US | CRCT | 1 UPC | Resident and attending physicians, nurse practitioners I = 12 C = 16 | Not described | CDSS for otitis media. Clinicians greeted with pop-up window when they wrote e-prescription; CDSS included evidence summary, link to more information, link to abstracts, and studies that informed summary | No intervention | 7 mo | Change in proportion of ABx <10 days. Change in frequency of ABx | Unclear |
| Mainous21 2000 US | RCT | PCC | Clinicians I1 = 53 I2 = 49 I3 = 52 C = 62 Parents | <18 yr Medicaid enrollees | I1: Patient education pamphlet on AB use I2: Clinician feedback (prescribing profile on (URI, bronchitis, pharyngitis, with number of episodes, number of ABx, proportion of ABx, total cost of episode, proportionate cost of ABx) mailed with letter explaining that prescribing was being evaluated; and I3: Clinician feedback and patient education | No intervention | 5 mo | ABx per URI | Medicaid data episode of care |
| Margolis28 1992 Israel | RCT | 1 PCPC | Clinicians n= 6 | <16 yr | Clinicians received at least one computerised care algorithm (gave treatment guidance and produced a record of consultation) for otitis media, pharyngitis, or URI | No care algorithm (clinician could receive algorithm for other condition) | 5 wks | Records of incorrect use of ABx per all ABx | Medical records |
| Razon29 2005 Israel | P/P | 5 PCC | Clinicians n= 27 | 3 mo–18 yr with acute otitis media, tonsillopharyngitis, sinusitis, or upper RTI | Clinicians attended a 1 day group educational session, on appropriate diagnosis and treatment of paediatric viral respiratory tract infection, acute otitis media, acute tonsillopharyngitis, and acute sinusitis (content based on CDC principles of judicious AB use) | (Historical data prior to intervention) | 4 mo | ABx per diagnosis Appropriate ABx per diagnosis | Medical records |
| Interventions targeting parents only | |||||||||
| Ashe30 2006 US | P/P | 3 PCC | Clinicians n= 7 (Intervention was targeted to parents) | 6 mo–10 yr (mean 4.2 yr) with respiratory tract infection, n= 720 | Waiting room poster, targeted to parents, with information on causes of common cold, symptomatic treatment, appropriate use of AB, and AB resistance | Historical data (prior to intervention) | 1 mo | ABx per RTI consultation | Medical records |
| Mainous21 2000 US | RCT | PCC | Clinicians I1 = 53 I2 = 49 I3 = 52 C = 62 Parents | <18 yr Medicaid enrollees | I1: Patient education pamphlet on AB use I2: Clinician feedback (prescribing profile on (URI, bronchitis, pharyngitis, with number of episodes, number of ABx, proportion of ABx, total cost of episode, proportionate cost of ABx) mailed with letter explaining that prescribing was being evaluated I3: Clinician feedback and patient education | No intervention | 5 mo | ABx per URI | Medicaid data episode of care |
| Taylor31 2005 US | RCT | PCPC | Parents I = 252 C = 247 | <24 mo | Parents were given a 5-minute personalised videotape message featuring a paediatrician from the local clinic; pamphlet on judicious use of AB; and instruction to review material and discuss any questions with child’s clinician (clinicians were blinded to parent groups). Pamphlet and questionnaire mailed to parents 6 wks and 6 mo after enrolment. | 3 pamphlets on injury prevention (each focusing on different age group); instruction to review material child’s clinician. Pamphlets and questionnaire mailed to parents 6 wks and 6 mo after enrolment | 12 mo | Number of consultations resulting in ABx | Medical records |
AB = antibiotic. ABx = antibiotic prescription. AOM = acute otitis media. C = control. CDC = Centers for Disease Prevention. CDSS = computerised decision support. CRCT = cluster randomised controlled trial. ECS = emergency call service (urgent care after hours clinic). FQHC = federally qualified health center. HMO = health maintenance organisation. I = intervention. mo = months. NRCT = non-randomised controlled trial. P/P = one group pre/post test. PCC = primary care clinic. PCPC = primary care paediatric clinic. RCT = randomised controlled trial. RTI = respiratory tract infection. SD = Standard deviation. UPC = university paediatric clinic. URI = upper respiratory infection. wks = weeks. yr = years.