Diagnostic Stewardship as a 'nudge' to reduce inappropriate antibiotic use for urinary tract infections

背景：抗药性细菌由美国疾病控制和预防中心估计 预防(CDC)每年杀死超过23,000名美国人。过度使用抗生素是主要原因， 减少不必要的抗生素使用是国家的优先事项。过度使用抗生素的一个主要因素是 不适当的或不必要的培养，尤指不必要的尿液培养 并导致尿路感染(UTI)的过度诊断。 意义/影响：诊断管理是一种限制抗生素使用的新方法，通过修改 订购、处理或报告通常不应被处理的“积极”文化。在预赛中 工作中，我们发现不必要的尿液培养和相关抗生素的使用显著减少 诊断性管理。诊断管理与抗菌管理是协同的，通过改善 治疗前尿检的价值和准确性。该提案解决了以下方面的差距：定义最佳 UTI诊断管理方法，由专家和临床医生提供信息；制定实施方案 UTI诊断管理的方法；以及评估现实生活中UTI诊断管理的影响- 在急诊护理、长期护理和非卧床护理中既有好处也有危害。这符合HSR&D 质量/安全、保健价值、交叉高铁方法的研究重点 实施科学/提供商行为和退伍军人研究在现实世界中的影响 除了疾控中心、医疗保险和医疗补助服务中心(CMS)以及 总统抗击耐药细菌国家行动计划(CARB)。 创新：修改测试的排序、处理和报告方式可通过以下方式帮助改善患者护理 更有效地利用现有技术。这是一种“轻推”的方法，发展自心理学和 行为经济学。这项工作利用电子病历(EMR)进行了一次创新，大多落后 场景的风尚是为了提高测试排序和报告的适当性。一个实用的证据-- 使用来自退伍军人管理局的自动化结果，在现有退伍军人保健系统网络内进行概念研究 企业数据仓库(CDW)是高效的，并且与作为学习健康中心的VA目标一致 系统。 我们的目标是： 目的1：根据文献和德尔菲法专家小组，确定最佳UTI诊断管理标准。 目标2：使用迭代的以用户为中心的设计过程来开发EMR接口和实验室协议， 临床医生和其他利益相关者(护士、医生、技术人员和IT代表)。 目标3：开展实用概念验证混合有效性实施研究 3个疾控中心的诊断性管理干预--创建网络医疗系统评估效益 以及任何不良事件。 项目方法：目标1和目标2将利用专家小组制定协商一致的标准和以用户为中心 设计流程，包括最终用户访谈和重点小组，以创建和完善实施 工具。AIM 3将在现有的VA CDC-CREATE网络中进行准实验前后研究。 下一步/实施：诊断管理的系统应用有可能限制 不适当的尿液培养；从而减少过度诊断的尿路感染患者不必要地使用抗生素 成本最低，没有不良后果。如果成功，这项提案的方法可能是 易于实施，以减少退伍军人管理局医疗保健系统和其他医院的抗菌素耐药性； 降低导管相关性尿路感染(CAUTI)和艰难梭菌的发生率；改善患者的护理和安全性 退伍军人。

Background: Antibiotic-resistant bacteria are estimated by the Centers for Disease Control and Prevention (CDC) to kill over 23,000 Americans yearly. Overuse of antibiotics is a leading cause, and reducing unnecessary antibiotic use is a national priority. A major factor in antibiotic overuse is inappropriate or unnecessary culturing, particularly unnecessary urine culturing that identifies colonization and leads to overdiagnosis of urinary tract infections (UTI). Significance/ Impact: Diagnostic stewardship is a novel approach to limiting antibiotic use by modifying the ordering, processing, or reporting of a “positive” culture that generally should not be treated. In preliminary work, we found significant reductions in unnecessary urine cultures and associated antibiotic use through diagnostic stewardship. Diagnostic stewardship is synergistic with antimicrobial stewardship by improving the value and accuracy of urine testing before treatment. This proposal addresses gaps including: Defining best UTI diagnostic stewardship methods, informed by experts and clinicians; developing implementation methods for UTI diagnostic stewardship; and, assessing the impact of real life UTI diagnostic stewardship— both benefits and any harms across acute-care, long-term care, and ambulatory care. This meets HSR&D Research priorities of quality/safety, health care value, cross-cutting HSR methods priorities of implementation science/provider behavior and ORD-wide priority of real-world impact of VA research in addition to national priorities from CDC, Centers for Medicare and Medicaid Services (CMS) and the President’s National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB). Innovation: Modifying how tests are ordered, processed, and reported can help improve patient care by using existing technology more effectively. This is a ‘nudge’ approach, developed from psychology and behavioral economics. This work uses the electronic medical record (EMR) in an innovative, mostly behind the scenes fashion to improve appropriateness of ordering and reporting of tests. A pragmatic proof-of- concept study within an existing network of VA health care systems, using automated outcomes from the VA Corporate Data Warehouse (CDW) is efficient and consistent with the VA goal of being a Learning Health System. Our aims are as follows: Aim 1: Define best UTI diagnostic stewardship criteria, based on literature and Delphi method expert panel. Aim 2: Use iterative user-centered design process to develop EMR interface and lab protocols, with clinicians and other stakeholders (nurses, doctors, technicians, and IT representatives). Aim 3: Conduct a pragmatic proof-of-concept hybrid effectiveness implementation study of the UTI diagnostic stewardship interventions in 3 CDC-CREATE Network Healthcare Systems evaluating benefits and any adverse events. Project Methods: Aims 1 and 2 will use expert panels for developing consensus criteria and a user-centered design process, including end-user interviews and focus groups, for creating and refining implementation tools. Aim 3 will conduct a quasi-experimental before-after study in the existing VA CDC-CREATE Network. Next Steps/Implementation: Systematic application of diagnostic stewardship has the potential to limit inappropriate urine culturing; and thereby, reduce unnecessary use of antibiotics for over-diagnosed UTI at a minimal cost and without adverse consequences. If successful, the approaches from this proposal could be readily implemented to reduce antimicrobial resistance across the VA healthcare system and other hospitals; reducing catheter-associated UTI (CAUTI) and C. difficile rates; and improving the care and safety of Veterans.