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 meetings.

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 public’s attention on the seriousness of antibiotic resistance. Pharmaceutical representatives also helped distribute program information to physician’s 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 strategies included:

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 stories.
Print advertisements in two local newspapers and radio commercials on five local radio stations.
Articles targeted to the general public were highlighted on Sentara Healthcare’s website.
Banner ad on the main webpage for a popular community web resource.
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 infections.