Comparing Higher and Lower Intensity Parent-Clinician Communication Trainings to Reduce Antibiotic Misuse in Children [Internet]

Excerpt

Background: In the United States, children with acute respiratory tract infections (ARTIs) are prescribed at least 11.4 million unnecessary antibiotic prescriptions annually. One chief contributor to overprescribing is inadequate parent–provider communication, born out of providers' misconceptions about parents' desire for antibiotics. However, efforts to reduce overprescribing have only indirectly targeted communication or been impractical to implement in US settings because of the time required for providers to explain why antibiotics are not necessary and are potentially harmful.

Objectives: The aim of this study was to compare 2 feasible interventions for enhancing parent–provider communication (lower-intensity communication vs higher-intensity communication) to reduce the rate of inappropriate antibiotic prescribing among children with ARTIs.

Methods: This mixed-methods study consisted of a cluster-randomized comparative effectiveness trial at an academic children's hospital and private practice as well as qualitative assessment methods. Using a 1:1 randomization, we assigned 41 providers (pediatricians and nurse practitioners) to receive a higher-intensity or lower-intensity intervention. All providers received a 20-minute, in-person general education training on the pros and cons of antibiotics, the impact of inappropriate use, antibiotic-prescribing guidelines, and common reasons for antibiotic misuse. Providers in the higher-intensity arm received an additional 50-minute, in-person training to enhance their confidence in the use of parent-centered communication strategies (eg, open-ended questions, affirming and eliciting parents' thoughts/concerns) and the study educational trifold brochure during consultations. We then enrolled 1600 parent–child dyads (children aged 1-5 years; higher intensity, n = 696; lower intensity, n = 904) in which the children presented with ARTI symptoms to a provider trained to use 1 of the 2 interventions. Before their consultation, all parents completed a baseline survey and viewed a 90-second gain-framed antibiotic educational video. In addition, parent–child dyads consulting with providers trained in the higher-intensity intervention received a gain-framed educational trifold brochure promoting cautious use of antibiotics and rated their interest in receiving an antibiotic, which was shared with their provider before the visit.

Data for the primary outcome (rate of inappropriate antibiotic prescribing) were garnered from independent medical record reviews conducted by physicians according to diagnostic and treatment guidelines. Secondary outcomes (quality of parent–provider communication, shared decision-making, and visit satisfaction) were collected via parent surveys immediately following the visit as well as by a 2-week follow-up telephone call with parents to assess revisits (ie, additional clinic visits for the same illness, not including scheduled follow-ups) and adverse drug reactions. Due to the 2-stage nested design (parents nested within providers and clinics), we employed a generalized linear mixed-effect regression model (GLMM) to compare intervention outcomes. We also conducted and analyzed qualitative interviews with providers following the intervention period.

Results: The overall rate of inappropriate prescriptions among all enrolled patients was similar among those who consulted with a higher-intensity (7.8%) vs a lower-intensity (9.4%) provider (difference = −1.6%; 95% CI, −4.4% to 1.1%). In the GLMM, we found that the odds of receiving inappropriate antibiotic treatment did not vary significantly between intervention arms. Secondary outcomes of revisits and adverse drug reactions did not vary between arms, and parent ratings of shared decision-making, satisfaction with quality of parent–provider communication, and visit satisfaction were similarly high in both arms. Provider satisfaction with the interventions was high, with all stating they would recommend the program to others.

Conclusions: The higher-intensity intervention (which consisted of additional patient-provider communication training and support materials) did not produce a meaningful difference in inappropriate antibiotic prescription compared with the lower-intensity arm. Qualitative and survey results suggest that implementing these 2 evidence-based interventions is feasible in pediatric outpatient settings.

Limitations: As a comparative effectiveness trial, our study is limited in that it cannot determine the effectiveness of either intervention compared with baseline or usual care. Another limitation was the uneven distribution of patients across sites and providers, possibly reducing the power to detect a difference between intervention arms.