Effect of an Educational Program on the Treatment of RSV Lower-Respiratory-Tract Infection

Kevin Purcell, Jaime Fergie

Disclosures

Am J Health Syst Pharm. 2003;60(8) 

In This Article

Abstract and Introduction

The effectiveness and outcomes of an educational program to decrease ribavirin and antimicrobial prescribing rates and associated costs for patients with respiratory syncytial virus (RSV) lower-respiratory-tract infection are described.

An educational program on the appropriate treatment for RSV infections was conducted for attending physicians and medical residents with multiple methods and forums during the 1994-95 RSV season. A retrospective chart review of 2396 patients admitted to a pediatric teaching hospital from July 1, 1991, through June 30, 1998, was conducted to measure the frequencies of ribavirin and antimicrobial prescribing in infants and young children hospitalized with RSV lower-respiratory-tract infection. The results before and after the educational program were compared.

Ribavirin was prescribed for 37.9% of patients before the program, and only 9.0% received it afterward (p < 0.001). Before the program, 24.8% of patients with no risk factors received ribavirin compared with 1.6% of patients after the program (p < 0.001). However, more patients with three or more risk factors for morbidity and mortality received ribavirin before the program than afterward (97.8% versus 39.2%, respectively). A broad-spectrum i.v. antimicrobial was prescribed for 85.6% of patients before the program while 60.6% received one afterward (p < 0.001). The cost savings for ribavirin and antimicrobials during the three-year period after the program were $1,235,484 and $34,839, respectively. Hospital length of stay decreased from 5.6 to 5.1 days (p < 0.001). No readmissions occurred during the study period.

A multifaceted educational intervention program may have been somewhat effective in modifying physician's prescribing habits for the treatment of RSV lower-respiratory-tract infection.

Respiratory syncytial virus (RSV) is the most common cause of hospitalization for lower-respiratory-tract infection in infants and young children.[1] RSV infection has been associated with 50-90% of hospitalizations for bronchiolitis and 5-40% of pneumonia-related hospitalizations.[2] In 1985, the Institute of Medicine estimated that approximately 90,000 infants and children younger than five years of age were hospitalized annually in the United States for RSV bronchiolitis or pneumonia at a cost of about $300 million per year.[3] More recent estimates using hospitalization rates from 1994 to 1996 and hospitalization costs in 1998 dollars place these figures at 113,000-182,000 annual admissions at a cost of $800 million-$1.2 billion per year.[4,5]

Previously healthy infants and young children hospitalized for RSV infection usually improve within a few days with only supportive care, and the mortality rate is less than 1%.[6] However, many of these infants and young children receive antimicrobials and ribavirin, adding to the cost of hospitalization. Although antimicrobials have been shown to be of no benefit in the treatment of bronchiolitis,[7] a prospective study in Canada revealed that 57-81% of infants with bronchiolitis receive antimicrobials.[8] In addition, there is evidence that treatment of RSV lower-respiratory-tract infection with broad-spectrum intravenous antimicrobials actually increases the risk of bacterial superinfection.[9] Also, because of the controversy surrounding the clinical effectiveness and cost benefit of ribavirin, the American Academy of Pediatrics (AAP) Committee on Infectious Diseases developed guidelines for the appropriate use of ribavirin.[10,11,12] A recent review of the effectiveness of ribavirin therapy concluded that the existing clinical trials lacked the power to provide useful information.[13] However, a meta-analysis showed that ribavirin reduced length of mechanical ventilator support and may reduce days of hospitalization.

Publication of consensus statements or practice guidelines alone has not been effective in changing physicians' practice patterns.[14,15] However, implementation of guidelines for ribavirin therapy[16] and for inpatient care of infants with bronchioloitis[17] has been shown to decrease inappropriate use of antimicrobials and ribavirin and reduce costs. In addition, educational programs targeting physicians have been effective in changing physician prescribing habits and improving rational drug therapy, especially those using face-to-face personal educational visits with pharmacist or physician experts (academic detailing).[18,19,20,21,22,23,24,25] Many programs have specifically attempted to change physicians' antimicrobial prescribing patterns.[26,27,28,29,30,31,32] Interventions using three or more educational strategies may be more effective than single- or double-method approaches,[21] and the components of an ideal academic detailing program have been described.[33]

During the early 1990s, ribavirin was the number-one drug expenditure in the annual pharmacy drug budget at Driscoll Children's Hospital (DCH). Also, most infants and young children hospitalized with RSV lower-respiratory-tract infections received i.v. broad-spectrum antimicrobials. A multifaceted educational intervention program was jointly designed and implemented during the 1994-95 RSV season by the department of pharmacy and the pediatric infectious diseases service. The primary objective of this program was to improve the appropriateness of ribavirin and antimicrobial prescribing in infants and young children hospitalized with RSV bronchiolitis or pneumonia.

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