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

诊断管理作为“推动”减少尿路感染抗生素的不当使用

• 批准号: 10237120
• 负责人: Daniel J Morgan
• 金额: --
• 依托单位: BALTIMORE VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-10-01 至 2024-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10237120
• 关键词: Acute; Address; Adverse event; Ambulatory Care; American; Antibiotics; Antimicrobial Resistance; Area; Award; Bacterial Antibiotic Resistance; Bladder; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Clostridium difficile; Combating Antibiotic Resistant Bacteria; Communicable Diseases; Computerized Medical Record; Consensus; Diagnosis; Diagnostic; Diagnostic tests; Focus Groups; Funding; Goals; Health system; Healthcare; Healthcare Systems; Hospitals; Infection; Infection prevention; Inflammation; Intervention; Interview; Laboratories; Learning; Life; Literature; Long-Term Care; Maryland; Measures; Medical center; Methods; Nurses; Outcome; Patient Care; Physicians; Pilot Projects; Population; Process; Protocols documentation; Psychology; Reporting; Research; Research Priority; Risk; Safety; Sampling; Technology; Testing; Training; United States Centers for Medicare and Medicaid Services; Universities; Urinary tract infection; Urine; Veterans; Work; acute care; adverse outcome; antimicrobial; base; behavioral economics; catheter associated UTI; cost; data warehouse; design; effective intervention; effectiveness implementation study; implementation barriers; implementation facilitators; implementation research; implementation science; implementation strategy; implementation tool; improved; improved outcome; innovation; interest; novel strategies; prevent; programs; provider behavior; response; tool; uptake; urinary; user centered design

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.

背景：抗生素耐药菌由疾病控制中心估计， 美国疾病控制和预防中心（CDC）每年杀死23，000多名美国人。过度使用抗生素是一个主要原因， 减少不必要的抗生素使用是国家的优先事项。抗生素过度使用的一个主要因素是 不适当或不必要的培养，特别是不必要的尿液培养， 尿路感染（UTI）是泌尿系统疾病的一种常见表现。 意义/影响：诊断管理是一种通过修改抗生素使用限制抗生素使用的新方法。 订购、处理或报告通常不应处理的“阳性”培养物。初步 工作，我们发现显着减少不必要的尿培养和相关的抗生素使用， 诊断管理诊断管理与抗菌管理是协同作用的， 治疗前尿液检测的价值和准确性。该提案解决了以下差距： UTI诊断管理方法，由专家和临床医生告知;制定实施方案 UTI诊断管理的方法;以及，评估真实的UTI诊断管理的影响- 包括急性护理、长期护理和门诊护理的益处和任何危害。这符合HSR&D 质量/安全、医疗保健价值、跨领域HSR方法的研究优先事项 实施科学/供应商行为和在整个RD范围内VA研究对现实世界影响的优先级 除了CDC、医疗保险和医疗补助服务中心（CMS）和 总统的国家行动计划对抗抗生素耐药细菌（CARB）。 创新：修改测试的排序、处理和报告方式有助于改善患者护理， 更有效地利用现有技术。这是一种“轻推”方法，从心理学发展而来， 行为经济学这项工作使用的电子病历（EMR）在一个创新的，大多落后 场景的时尚，以提高适当的排序和报告的测试。一个实用的证明- 在VA医疗保健系统的现有网络中进行概念研究，使用VA的自动化结果 企业数据仓库（CDW）是有效的，并与VA的目标是一个学习健康一致 系统 我们的目标如下： 目的1：基于文献和德尔菲法专家组，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：对UTI进行实用的概念验证混合有效性实施研究 3个CDC-CREATE网络医疗保健系统中的诊断管理干预评估效益 以及任何不良事件。 项目方法：目标1和2将使用专家小组制定共识标准，并以用户为中心， 设计过程，包括最终用户访谈和焦点小组，以创建和完善实施 工具.目标3将在现有的VA CDC-CREATE网络中进行准实验性的前后研究。 后续步骤/实施：诊断管理的系统应用有可能限制 不适当的尿液培养;从而减少不必要的抗生素的使用过度诊断的UTI在一个 成本最低，没有不良后果。如果成功的话，这一建议的方法可能是 易于实施，以减少VA医疗保健系统和其他医院的抗菌素耐药性; 减少导管相关性UTI（CUTI）和C.艰难的利率;并改善护理和安全性 老兵