ganizations may be unable or may be perceived to be unable to provide appropriate educational messages. Providers and patients may feel—in some cases correctly—that interventions are more focused on cost savings than on quality of care. Perhaps most importantly, organizations may retain policies that perpetuate the very behavior that educational initiatives are trying to change. For example, imperatives for clinicians to see more patients per day may conflict with providers' ability and availability to explain the rationale for treatment decisions.

Efforts to decrease the spread of antibiotic resistance through improved antibiotic use practices illustrate the importance of managed care systems in the education of patients. The development and spread of antibiotic resistance were not considered major problems by managed care organizations. Now, however, many such organizations recognize the threat of hospital-acquired resistant pathogens and also realize that this threat is a growing problem among patients with community-acquired infections. Rising concern has resulted from increased rates of resistance and treatment failures, and the medical and public health communities have placed a greater focus on these problems. For example, pneumococci, which are the leading cause of community-acquired meningitis, the second leading cause of bloodstream infections, and the leading cause of pneumonia and otitis media, are increasingly resistant to antibiotics. Currently, in some areas of the United States, more than a third of invasive pneumococcal isolates are resistant to one or more antibiotics. In other instances, some strains are not susceptible to any oral antibiotic, raising the specter that common infections, like ear infections or sinusitis, will require parenteral therapy.

Clinicians who work in managed care settings recognize that a major factor contributing to the spread of antibiotic resistance is the widespread and frequently unnecessary use of antimicrobial agents. Nevertheless, they continue to prescribe them for viral infections, which do not respond to antibiotics. Each year, up to 50 million courses of antibiotics may be prescribed unnecessarily for the treatment of the common cold, acute bronchitis, sore throat not caused by streptococcus, fluid in the middle ear that does not represent infection, and purulent runny nose that has been misdiagnosed as sinusitis. These antibiotic courses contribute nothing to patient care but do select for resistant pneumococci and other pathogens that can then spread or that can later cause more severe or difficult-to-treat infections.

Overall, physicians who work in managed care organizations are aware that they are overprescribing antibiotics. In focus group discussions with these physicians (conducted by CDC without physician knowledge of the sponsoring organization), participants reported that they could decrease antibiotic use in their own practices by 10 to 50 percent without having a negative impact on patient care (Barden et al., 1998). A number of reasons for the overuse of antimicrobial agents have been proposed. Studies indicate that economic factors influence the prescription practices of physicians who work in managed care organizations. For example, some studies suggest that physicians in managed care prescribed more antibiotics and performed fewer laboratory tests for patients with respiratory infections than their fee-for-service colleagues. This may have resulted in



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