Antibiotic Usage Project
Timothy S. Jennings, Pharm.D., Mark A. Szalwinski, M.H.A.,
Randy Axelrod, M.D.
Sentara Healthcare, Norfolk, Virginia
During 1998, prevalence of penicillin resistance, in Sentara
Healthcare reference labs, was almost twice the national average
for the Hampton Roads, Virginia metropolitan statistical area.
Sentara Healthcare believed overuse and incorrect antibiotic
use was a driving factor contributing to the difference. The
need to increase public awareness about drug-resistant bacteria
and change physician-prescribing practices for the treatment
of viral infections was evident. In 1999, Sentara Healthcare
received unrestricted educational grants to combat the antibiotic
resistance problem in Hampton Roads. Sentara Healthcare, in
partnership with pharmaceutical companies, middle schools,
and others in the community, introduced Resistance Kills,
a community-wide public awareness campaign designed to educate
people about the dangers of drug-resistant bacteria. The goals
of the three-year program are to reduce antibiotic resistance
rates for citizens in Hampton Roads by coordinating consumer
and physician education; reduce physician antibiotic prescription
rates for the treatment of viral infections; and create a
template for community education that other health care systems
in the country can emulate. The program uses direct to consumer
marketing strategies to inform the public that antibiotics
only treat bacterial infections that cause illnesses such
as strep throat and pneumonia; but do nothing to cure viral
infections such as the flu or common cold.
Analytical models were constructed to identify and analyze
antibiotic usage patterns and required integration of sociodemographic,
pharmacy, and medical claims data. Data sets were linked to
create an individual sample of members with primary care providers.
The data were aggregated to produce antibiotic usage patterns
for product lines, physician practice groups, and physician
specialty. The broad scope of antibiotic use was examined
to identify the extent to which antibiotics were being prescribed.
Antibiotic use to manage upper respiratory tract infections
or bronchitis was examined since these viral conditions do
not warrant antibiotic therapy. The model required linking
antibiotic prescription fills to corresponding physician visits.
Antibiotic pharmacy claims and physician office visits for
the same time frame were extracted from the pharmacy and medical
claims database. Antibiotics prescribed within three days
of the office visit were attributed to URI or bronchitis management.
Overall, 64% of office visits, for URI or bronchitis, were
matched with antibiotic prescription fills within 3 days.
The infection control team asked local physicians, employers,
and community leaders to identify potential, primary drivers
of antibiotic use. The problem of increasing antibiotic resistance
was traced to consumer behavior and physician response to
consumer behavior and expectations.
The initial solution was to implement a community-wide education
plan about appropriate antibiotic use and provide targeted
feedback to local prescribers about their patterns of antibiotic
use. The specific solutions evolved through a partnership
with pharmaceutical manufacturers and ongoing internal multidisciplinary
1. Partnering with Pharmaceutical Companies/The Pharmacy
Action Team: The goal of this alliance was to develop
an effective direct to consumer marketing campaign. Sentara
Healthcare representatives explained the antibiotic resistance
problem in the area and the nation-wide and local antibiotic
resistance statistics to demonstrate the need for a comprehensive
program and described how the pharmaceutical companies might
participate. Pharmaceutical representatives were enthusiastic
about the program and recommended the campaign be kept simple
and deliver one key message while maintaining a similar look
for all marketing strategies to facilitate public awareness
of the program. Resistance Kills slogan was developed to capture
the publics attention on the seriousness of antibiotic
resistance. Pharmaceutical representatives also helped distribute
program information to physicians offices and reinforced
the message with area health care professionals. The main
goal of forming the Pharmacy Action Team was to benefit from
their knowledge and expertise about program design; however
financial support to facilitate program implementation was
also solicited from pharmaceutical companies.
2. Other Community Partners: Key partnerships were
developed with Eckerd Drugstores and Harris Teeter grocery
stores in Hampton Roads. The partnership goal was to elicit
input about the willingness of community pharmacists to share
the antibiotic resistance message by displaying and disseminating
"Resistance Kills" posters in their stores. Other
community-based organizations, such as the Peninsula Boy Scouts
of America, were involved in helping Sentara Healthcare understand
the role of grassroots, face-to-face educational initiatives.
The solution consisted of two main initiatives 1) physician
education and feedback and 2) community-wide education. Individual
antibiotic usage reports were constructed for each primary
care provider and by practice. Information related to the
Hampton Roads resistance rate, compared to national rates
were also provided. Antibiotic usage data for physician peer
groups enable the practitioners to compare their rate with
select peer groups and specialists.
3. Physician Education and Involvement: Primary care
physicians believed the program provided a tremendous service
to residents and actively participated in the program. Before
launching the program to the community, letters were mailed
to physicians explaining the purpose, goals, and objectives
for the program. Sentara healthcare staff personally visited
physicians and held meetings to introduce and emphasize the
importance of the program and gain feedback on the program,
its potential message points and marketing materials. Materials
used to educate physicians included:
- Pamphlet describing the program with a letter from the
health system executive medical director was mailed to all
health plan physicians.
- Eye-catching posters for display in the physician offices
to reinforce the antibiotic resistance message
- At the program onset, physicians were mailed a report
card outlining their antibiotic prescription patterns for
the previous year. The report graphed specific antibiotics
and office visits by month for the five-month baseline with
comparative trend lines for the area and national benchmarks.
- During flu season, physicians received reports on individual
antibiotic prescription rates used to treat viral infections.
- At the conclusion of the first year, follow-up report
cards were mailed to physicians accompanied by a thank you
letter from the executive medical director.
4. Educating Sentara Employees: The Pharmacy Action
Team recommended community education efforts to begin at home.
The internal education campaign included presentations at
various department meetings, recurring e-mail messages during
flu season to discourage overuse of antibiotics to treat viral
infections, internal print and electronic publications, posters
placed on employee bulletin boards, and reminder messages
printed on payroll checks.
5. Educating the Community: Direct to consumer marketing
- Direct mail postcards (designed to match posters) sent
to more than 60,000 member households in the area.
- Postcards inserted into two area newspapers with a circulation
rate of 115,000.
- Newspaper, television, and radio coverage with an estimated
public relations value of $70,000 including prominent front-page
- Print advertisements in two local newspapers and radio
commercials on five local radio stations.
- Articles targeted to the general public were highlighted
on Sentara Healthcares website.
- Banner ad on the main webpage for a popular community
- Published campaign articles in company newsletters for
major employers in the area.
- Program postcards distributed by the Boy Scouts at a local
mall as part of their merit badge shows and mailed to members
in their newsletter.
- One hour segment spotlighting the program aired on local
cable TV channel.
- Banner ad located on AOL health page for 5 weeks linking
to the program website.
- School campaign targeted at middle school students to
help curb antibiotic usage among students and their parents.
The student-driven project involved sending letters and
postcards to parents, asking parents to sign a pledge letter,
making in-school announcements over the loudspeaker, putting
posters up and drawing for prizes from those students who
had submitted pledge forms.
The program proved to have an immediate impact on antibiotic
use in the area. Based on the prescription patterns of the
HMO members, doctors prescribed 13 percent fewer courses of
antibiotic treatment for patients for a 5 month period compared
to the same period the previous year. The 13 percent reduction
was realized even though the campaign was only public for
half the time period that was tracked. The second year demonstrated
an additional 7% reduction in antibiotic courses in a commercial
population. Patients behavior patterns indicated they
were heeding the warnings about the seriousness of antibiotic
resistance. Physicians reported many patients came into the
office and emergency rooms already educated about the dangers
of antibiotic resistance and with a greater understanding
of when an antibiotic is really needed.
"Resistance Kills" program is a highly effective
program that has demonstrated success in changing consumer
behaviors and is the first step in addressing the growing
problem of antibiotic resistance. By building partnerships
with community organizations and pharmaceutical companies,
Sentara Healthcare has been able to align many different organizations
to exert a more positive influence than any of them could
have done by acting alone. The program was successful in increasing
public awareness about drug-resistant bacteria and changing
physician-prescribing practices for the treatment of viral