Multifaceted Interventions

Multifaceted interventions are described as those that combine audit and feedback, point-of-care reminders, local input in clinical guideline development, and the support of local opinion leaders (20). Multifaceted interventions may also be referred to as continuous quality improvement (CQI) initiatives, and are often attractive to physicians for several reasons. First, the focus lies on improving the delivery and quality of health care, rather than on individual physician behaviors or the bottom line of cost (42). Second, there is no mandate of change in individual physician practice, but rather a focus on the efficiency of delivery of care. Many health care systems are implementing CQI activities in specific areas of patient care and clinical service, but few randomized clinical trials exist to document the benefit of this approach.

The only study to examine a multifaceted approach in the outpatient setting focused on improving the treatment of uncomplicated acute bronchitis in adults (47). Four office practices were selected for the study: one practice was provided with a full intervention, one practice received a limited intervention, and two practices served as the control sites. In the full intervention site, household educational materials were mailed to all patients (magnets, pamphlets, a letter from the medical director of the practice) regarding appropriate management of common infections. Office-based educational material specific for acute bronchitis was delivered to the office for the examination rooms. Clinicians were detailed on the patient education activities included in the intervention, and were provided with antibiotic prescribing rates for acute bronchitis at their site during the previous winter. They participated in an interactive educational session on evidence-based management of acute bronchitis, and how to say "no" to patient demands for antibiotics. These sessions were led by the medical director, the opinion leader, of each practice, and were attended by all disciplines. In the limited intervention site, office-based educational materials were distributed to the nursing manager at the practice, and were displayed in the patient examination rooms. The control sites provided usual care.

The study was conducted over a 3-mo period, with baseline data from the same months of the prior year. Although antibiotic prescribing rates were similar among the four practices in the baseline period, prescribing fell significantly at the intervention site (from 74% to 48%) but did not change in the control or limited intervention site in the study period. Prescriptions for nonantibiotic medications (i.e., bronchodilators) did not differ among sites, nor did return office visits for bronchitis or pneumonia. There fore, in this focused intervention, antibiotic utilization for acute bronchitis improved in one office practice using a multifaceted intervention.

Ideally, using a multifaceted intervention, tailored to each practice group, would be the ideal way to improve the system of care. Realistically, however, the continued success of such programs in everyday clinical practice is less likely, particularly when the focus of interventions expands to include other acute and chronic illnesses. In addition, the generalizability of this controlled intervention to a wider prescribing community requires further study.

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