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

项目摘要/摘要 背景：过度使用抗生素会引起不良反应，从而威胁患者的安全 抗生素的有效性是通过发展抗生素耐药性来实现的。然而，要描述的研究和 应对这些安全风险的干预措施侧重于以就诊为基础的抗生素处方。不以访问为基础 抗生素的使用和处方在很大程度上是无形的。在前期工作中，我们发现23%的患者 在研究年度，接受抗生素处方的人没有去过办公室。我们还发现， 临床医生在患者没有就诊的日子里开出了39%的抗生素处方。不以访问为基础 患者填写抗生素和临床医生开出处方可能会增加患者发生不良事件和 加速了抗生素耐药性的传播，但尚未对非就诊抗生素处方进行测量。 研究策略：测量和描述来自中国的安全风险和抗生素耐药性压力 当代美国非访视抗生素的使用，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 基于访问的抗生素处方占抗生素使用的很大比例(&gt；20%)；2) 大多数(&gt；50%)非就诊抗生素的使用与就诊或慢性、复发无关。 有问题。为了解决这些假设并计划未来的干预措施，我们有三个具体目标。特定的 目标1是对以下人群接受护理的医疗和处方药索赔进行回顾性队列研究 超过1000万个商业健康计划和5000万个医疗补助参与者来衡量和描述未就诊- 基于抗生素处方的填充物相对于所有抗生素填充物。具体目标2是进行一项队列研究 电子健康记录(EHR)处方，用于测量和描述非就诊抗生素处方为 并对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 不以访问为基础的抗生素处方的理由。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，以开发一个可供其他人使用的循证工具包 临床医生、卫生系统、付款人和利益相关者，以衡量和解决非就诊抗生素的使用。 影响和未来方向：在短期内，该项目将很快开辟一条新的研究前沿 扩大了我们对抗生素在美国使用的了解。从长远来看--在美国 医疗保健系统正在向减少以访问为基础的护理方向发展--该项目将为 鼓励合理开出和使用抗生素的干预措施，即使在没有就诊的情况下也是如此。这个 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 减少耐抗生素细菌的传播，并促进患者在门诊环境中的安全。

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.