Effects of clinical pathways for common outpatient infections on antibiotic prescribing.

BACKGROUND: Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS: Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS: In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS: This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Discrimination learning induced by training with identical stimuli.

Sensory stimuli become easier to detect or distinguish with practice. It is generally assumed that the task-relevant stimulus dimension becomes increasingly more salient as a result of attentively performing the task at a level that is neither too easy nor too difficult. However, here we show improved auditory frequency discrimination following training with physically identical tones that were impossible to discriminate. We also show that learning transfers across tone frequencies and across modalities: training on a silent visuospatial computer game improved thresholds on the auditory discrimination task. We suggest that three processes are necessary for optimal perceptual learning: sensitization through exposure to the stimulus, modality- and dimension-specific attention, and general arousal.