Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial.
Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial.
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DOI：
10.1001/jama.2016.0275
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发表时间：
2016-02-09
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影响因子：
--
通讯作者：
Doctor JN
中科院分区：
文献类型：
--
作者：
Meeker D;Linder JA;Fox CR;Friedberg MW;Persell SD;Goldstein NJ;Knight TK;Hay JW;Doctor JN
基于行为科学的干预可能会减少不适当的抗生素处方。评估急性呼吸道感染门诊访视期间行为干预的效果和不适当（不符合指南）抗生素处方率。在波士顿和洛杉矶的47个初级保健实践中进行的群集随机临床试验。参与者是248名登记的临床医生，随机接受0、1、2或3次干预，持续18个月。所有临床医生在入组时均接受了抗生素处方指南的教育。干预开始于2011年11月1日至2012年10月1日。最晚开始的研究中心的随访于2014年4月1日结束。排除了合并症和合并感染的成人患者。三种行为干预措施，单独或联合实施：建议替代品提供电子订单集，建议非抗生素治疗;负责任的理由促使临床医生将处方抗生素的自由文本理由输入患者的电子健康记录;同行比较向临床医生发送电子邮件，将他们的抗生素处方率与“表现最佳者”（不适当处方率最低的人）的抗生素处方率进行比较。从干预前18个月到干预后18个月，对诊断不恰当的患者（非特异性上呼吸道感染、急性支气管炎和流感）进行抗生素处方率，调整每种干预措施对同时发生的干预措施和干预前趋势的影响，并对实践和临床医生进行随机影响。在基线期间，有14 753次（平均患者年龄47岁; 69%为女性）因不适当使用抗生素的急性呼吸道感染就诊，在干预期间有16 959次（平均患者年龄48岁; 67%为女性）就诊。平均抗生素处方率从干预开始时的24.1%降至干预18个月时的13.1%（绝对差异，-11.0%）;从22.1%降至6.1%（绝对差异，−16.0%）（差异差异，-5.0%[95% CI，-7.8%至0.1%];轨迹差异P = 0.66）;从23.2%降至5.2%（绝对差异，-18.1%）（差异差异，-7.0%[95% CI，-9.1%至2.9%]; P < .001）;从19.9%至3.7%（绝对差异，-16.3%）用于同行比较（差异差异，-5.2%[95%CI，-6.9%至1.6%]; P < .001）。干预措施之间没有统计学显著的相互作用（既没有协同作用，也没有干扰）。在初级保健实践中，使用负责任的理由和同行比较作为行为干预措施，导致急性呼吸道感染的不适当抗生素处方率较低。clinicaltrials.gov标识符：
Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of “top performers” (those with the lowest inappropriate prescribing rates). Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention’s effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. There were 14 753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16 959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, −11.0%) for control practices; from 22.1% to 6.1% (absolute difference, −16.0%) for suggested alternatives (difference in differences, −5.0% [95% CI, −7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, −18.1%) for accountable justification (difference in differences, −7.0% [95% CI, −9.1% to −2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, −16.3%) for peer comparison (difference in differences, −5.2% [95% CI, −6.9% to −1.6%]; P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions. Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. clinicaltrials.gov Identifier:
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影响因子：
3.2
作者：
Gunst, Richard F.;Mason, Robert L.
通讯作者：
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影响因子：
120.7
作者：
Grijalva, Carlos G.;Nuorti, J. Pekka;Griffin, Marie R.
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影响因子：
120.7
作者：
Gerber, Jeffrey S.;Prasad, Priya A.;Zaoutis, Theoklis E.
通讯作者：
Zaoutis, Theoklis E.
DOI：
10.1197/jamia.m1780
发表时间：
2006-01-01
影响因子：
6.4
作者：
Linder, JA;Bates, DW;Middleton, B
通讯作者：
Middleton, B
影响因子：
39
作者：
Gonzales, Ralph;Anderer, Tammy;Metlay, Joshua P.
通讯作者：
Metlay, Joshua P.