A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis
A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis
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DOI：
10.1001/jamainternmed.2013.1589
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发表时间：
2013-02-25
影响因子：
39
通讯作者：
Metlay, Joshua P.
中科院分区：
文献类型：
--
作者：
Gonzales, Ralph;Anderer, Tammy;Metlay, Joshua P.
背景：国家质量指标显示无并发症急性支气管炎抗生素过度使用变化不大。我们比较了两种决策支持策略对非并发症急性支气管炎抗生素治疗的效果。方法：我们在宾夕法尼亚州中部的一个综合卫生保健系统的33个初级保健实践中进行了一项3组随机试验。打印决策支持干预站点（11个实践）通过基于打印的策略获得对急性咳嗽疾病的决策支持，计算机辅助决策支持干预站点（11个实践）通过基于电子病历的策略获得决策支持，对照站点（11个实践）作为对照组。两个干预点还接受了临床医生的教育和关于处方实践的反馈，以及登记时的患者教育手册。在引入干预措施后的冬季期间（2009年10月1日至2010年3月31日），无并发症急性支气管炎的抗生素处方率与前3个冬季期间的意向治疗分析进行了比较。结果：与基线期相比，在纸质决策支持干预点（从80.0%降至68.3%）和计算机辅助决策支持干预点（从74.0%降至60.7%），干预期青少年和成人处方抗生素的比例有所下降，而在对照点（从72.5%降至74.3%）略有上升。在控制了患者和临床医生的特征，以及临床医生和实践地点的观察结果聚类之后，干预站点与对照站点的差异具有统计学意义（对照站点与打印决策支持干预站点的差异为P= 0.003，对照站点与计算机辅助决策支持干预站点的差异为P= 0.01），但它们之间的差异没有统计学意义（打印决策支持干预站点与计算机辅助决策支持干预站点的差异为P= 0.67）。总访问量、30天回访率和诊断为无并发症急性支气管炎的比例的变化在各研究地点相似。结论：实施急性支气管炎决策支持策略有助于减少初级保健机构抗生素的过度使用。印刷决策支持策略与计算机辅助决策支持策略在提供决策支持方面的效果是相同的。试验注册：clinicaltrials.gov标识符：NCT00981994
Background: National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis.Methods: We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis.Results: Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P=.003 for control sites vs printed decision support intervention sites and P=.01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P=.67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites.Conclusions: Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent.Trial Registration: clinicaltrials.gov Identifier: NCT00981994