Examining Non-Visit-Based Antibiotic Use to Improve Safety and Limit Resistance

项目总结/摘要 背景：抗生素过度使用通过引起不良反应威胁患者安全， 抗生素的有效性通过抗生素耐药性的发展。然而，研究表明， 解决这些安全风险的干预措施集中在基于访问的抗生素处方上。非访视 抗生素的使用和处方在很大程度上是不可见的。在初步工作中，我们发现23%的患者 接受抗生素处方的受试者在研究年内没有就诊。我们还发现 39%的抗生素处方是在患者没有就诊的日子开的。非访视 患者填写抗生素和临床医生处方可能会增加患者发生不良事件的风险， 加速抗生素耐药性的传播，但非基于访问的抗生素处方尚未得到测量。 研究策略：衡量和描述安全风险和抗生素耐药性压力 当代非访问为基础的抗生素在美国的使用，我们提出了补充的具体目标 使用索赔数据和电子健康记录（EHR）处方数据。我们的主要假设是：（1）非- 基于访视的抗生素处方占抗生素使用的很大比例（>20%），2） 大多数（>50%）非就诊抗生素使用与近距离门诊或慢性复发性 问题.为了解决这些假设并规划未来的干预措施，我们有3个具体目标。具体 目的1是进行一项回顾性队列研究的医疗和处方药索赔的护理收到的 超过1000万的商业健康计划和5000万的医疗补助登记者来衡量和描述非访问， 相对于所有抗生素处方填充量，具体目标2是进行一项队列研究， 电子健康记录（EHR）处方，以衡量和描述非基于访视的抗生素处方， 以及对EHR数据进行混合方法研究，并与临床医生进行定性访谈，以了解 非访视抗生素处方的基本原理。具体目标3是利用国家研究的结果， 队列研究和混合方法子研究，以开发可供其他研究人员使用的循证工具包。 临床医生、卫生系统、支付者和利益相关者，以衡量和解决非就诊抗生素使用问题。 意义和未来方向：在短期内，该项目将迅速开辟一个新的研究前沿， 扩大我们对美国抗生素使用的了解。从长远来看，当美国 卫生保健系统正在朝着减少基于访问的护理-这个项目将奠定基础， 干预措施，鼓励明智的抗生素处方和使用，即使在没有诊所访问。的 该项目和后续干预措施的最终目标是保持抗生素的有效性，限制 耐药性细菌的传播，并促进门诊病人的安全。

Project Summary/Abstract Background: Antibiotic overuse threatens patient safety by causing adverse effects and threatens the effectiveness of antibiotics through the development of antibiotic resistance. However, studies to describe and interventions to address these safety risks have focused on visit-based antibiotic prescribing. Non-visit-based antibiotic use and prescribing has been largely invisible. In preliminary work, we found that 23% of patients who received an antibiotic prescription did not have an office visit in the study year. We have also found that clinicians prescribed 39% of antibiotic prescriptions on days when patients did not have visits. Non-visit-based antibiotic fills by patients and prescribing by clinicians may contribute to patients' risk of adverse events and hasten the spread of antibiotic resistance, but non-visit-based antibiotic prescribing has not been measured. Research Strategy: To measure and describe the safety risk and antibiotic resistance pressure from contemporary non-visit-based antibiotic use in the United States, we propose complementary specific aims using claims data and electronic health record (EHR) prescribing data. Our main hypotheses are that 1) non- visit-based antibiotic prescribing accounts for a significant proportion (>20%) of antibiotic use and 2) the majority (>50%) of non-visit-based antibiotic use is untethered to a proximate clinic visit or a chronic, recurrent problem. To address these hypotheses and plan for future interventions, we have 3 Specific Aims. Specific Aim 1 is to perform a retrospective cohort study of medical and prescription drug claims of care received by over 10 million commercial health plan and 50 million Medicaid enrollees to measure and describe non-visit- based antibiotic prescription fills relative to all antibiotic fills. Specific Aim 2 is to perform a cohort study of electronic health record (EHR) prescribing to measure and describe non-visit-based antibiotic prescribing as well as conduct a mixed-methods study of EHR data and qualitative interviews with clinicians to understand the rationales for non-visit-based antibiotic prescribing. Specific Aim 3 is to use the results of the national study, cohort study, and mixed-methods sub-study to develop an evidence-based toolkit that can be used by other clinicians, health systems, payors, and stakeholders to measure and address non-visit-based antibiotic use. Implications and Future Directions: In the near term, this project will open a novel research front, quickly expanding our understanding of antibiotic use in the United States. In the longer-term – at a time when the US health care system is moving towards less visit-based care – this project will lay the foundation for interventions to encourage judicious antibiotic prescribing and use, even in the absence of clinic visits. The ultimate goal of this project and subsequent interventions is to preserve antibiotic effectiveness, limit the spread of antibiotic-resistant bacteria, and to promote patient safety in ambulatory settings.