Patient-Centered Stewardship to Improve Antibiotic Use in Ambulatory Care

背景：过度使用抗生素会引起不良反应并威胁患者的安全 抗生素的有效性是通过发展抗生素的耐药性来实现的。虽然我们的 研究团队和其他人已经成功地改善了办公室访问期间开出的抗生素处方 使用行为经济学和沟通策略，改进通常是 适度，一般关注临床医生的行为。以病人为导向的干预通常是 以访问为基础，具有教育性和通用性。我们已经写过需要以患者为中心 管理，这将使用一种理论知情的方法，直接与高级- 在探视之外不适当地使用抗生素的患者对他们自己的担忧和行为。 研究策略：为了了解和解决高度不适当的患者抗生素使用，我们将 实施混合方法项目，包括受控队列研究、定性分析和试点 以患者为中心的行为推动的随机对照试验(RCT)。具体目标1是 对2名健康成人和儿童进行回顾性、以患者为中心的对照队列研究 系统(超过150万名患者)适当地对抗生素的高使用率进行分类，部分 适当的、潜在的适当的和不适当的。具体目标2是进行定性 对抗生素使用率较高的患者进行访谈，以确定社会和行为因素 由理论领域框架了解到的影响就医和抗生素使用的因素 (TDF)框架。具体目标3是-基于目标1和2的调查结果-开发、改进和 在受控飞行员随机对照试验中评估以患者为中心的管理行为推动的影响 减少抗生素使用率高的患者不适当使用抗生素的干预措施。初级阶段 结果将是在8个月内不适当的抗生素处方的数量。次要的 结果将包括非抗生素药物处方、执行结果(可行性和 可接受性)、溢出效应和意想不到的后果。 影响和未来方向：我们寻求了解和干预患者的护理寻求 以及不适当的抗生素使用。该项目将为未来更大规模的随机对照试验奠定基础 干预的组成部分在更广泛的患者群体中的有效性。终极的 该项目以及后续干预和评估的目标是更好地了解患者 关注、寻求护理和抗生素使用；使护理能够有效参与；改善 诊断准确；并确保抗生素处方质量，提高患者安全性，减少 不良药物事件，并限制抗生素耐药性细菌的传播。

Background: Antibiotic overuse threatens patient safety by causing adverse effects and threatens the effectiveness of antibiotics through the development of antibiotic resistance. Although our research team and others have been successful in improving antibiotic prescribing during office visits using behavioral economics and communication strategies, the improvements have generally been modest and generally focus on clinician behavior. Patient-directed interventions have usually been visit-based, educational, and generic. We have written about a need for patient-centered stewardship, which would use a theory-informed approach to engage directly with high- inappropriate-antibiotic-utilizing patients outside of visits about their own concerns and behavior. Research Strategy: To understand and address high-inappropriate patient antibiotic use, we will conduct a mixed-methods project including controlled cohort studies, qualitative analyses, and a pilot randomized controlled trial (RCT) of a patient-centered behavioral nudge. Specific Aim 1 is to perform retrospective, patient-focused, controlled cohort studies of adults and children in 2 health systems (over 1.5 million patients) to categorize high-antibiotic-use as appropriate, partially appropriate, potentially appropriate, and inappropriate. Specific Aim 2 is to conduct qualitative interviews with high inappropriate-antibiotic-utilizing patients to identify social and behavioral factors that influence care-seeking and antibiotic use, informed by the Theoretical Domains Framework (TDF) framework. Specific Aim 3 is to – based on findings from Aims 1 and 2 – develop, refine, and evaluate in a controlled pilot RCT the impact of a patient-centered stewardship behavioral nudge intervention to reduce inappropriate antibiotic use among high-antibiotic-utilizing patients. The primary outcome will be the number of inappropriate antibiotic prescriptions over 8 months. Secondary outcomes will include non-antibiotic medication prescribing, implementation outcomes (feasibility and acceptability), spillover effects, and unintended consequences. Implications and Future Directions: We seek to understand and intervene on patient care-seeking and inappropriate antibiotic use. This project will lay the groundwork for a future, larger RCT testing the effectiveness of components of the intervention in a broader patient population. The ultimate goals of this project and subsequent interventions and evaluations are to better understand patient concerns, care-seeking, and antibiotic use; enable effective engagement with care; improve diagnostic accuracy; and ensure antibiotic prescribing quality to improve patient safety, decrease adverse drug events, and limit the spread of antibiotic resistant bacteria.