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Gonzales 2013
Gonzales 2013
Background: National quality indicators show little and at the computer-assisted decision support interven-
change in the overuse of antibiotics for uncomplicated tion sites (from 74.0% to 60.7%) but increased slightly
acute bronchitis. We compared the effect of 2 decision at the control sites (from 72.5% to 74.3%). After con-
support strategies on antibiotic treatment of uncompli- trolling for patient and clinician characteristics, as well
cated acute bronchitis. as clustering of observations by clinician and practice site,
the differences for the intervention sites were statisti-
Methods: We conducted a 3-arm cluster randomized cally significant from the control sites (P=.003 for con-
trial among 33 primary care practices belonging to an in- trol sites vs printed decision support intervention sites
tegrated health care system in central Pennsylvania. The and P = .01 for control sites vs computer-assisted deci-
printed decision support intervention sites (11 prac- sion support intervention sites) but not between them-
tices) received decision support for acute cough illness selves (P=.67 for printed decision support intervention
through a print-based strategy, the computer-assisted de- sites vs computer-assisted decision support interven-
cision support intervention sites (11 practices) received tion sites). Changes in total visits, 30-day return visit rates,
decision support through an electronic medical record and proportion diagnosed as having uncomplicated acute
based strategy, and the control sites (11 practices) served bronchitis were similar among the study sites.
as a control arm. Both intervention sites also received cli-
nician education and feedback on prescribing practices, Conclusions: Implementation of a decision support strat-
as well as patient education brochures at check-in. An- egy for acute bronchitis can help reduce the overuse of
tibiotic prescription rates for uncomplicated acute bron- antibiotics in primary care settings. The effect of printed
chitis in the winter period (October 1, 2009, through vs computer-assisted decision support strategies for pro-
March 31, 2010) following introduction of the interven- viding decision support was equivalent.
tion were compared with the previous 3 winter periods
in an intent-to-treat analysis. Trial Registration: clinicaltrials.gov Identifier:
NCT00981994
Results: Compared with the baseline period, the per-
centage of adolescents and adults prescribed antibiotics JAMA Intern Med.
during the intervention period decreased at the printed Published online January 14, 2013.
decision support intervention sites (from 80.0% to 68.3%) doi:10.1001/jamainternmed.2013.1589
T
Author Affiliations: Division of Author Affil
General Internal Medicine, HE OVERUSE OF ANTIBIOT- because most of these illnesses have a General Inte
Department of Medicine, and ics for acute respiratory viral origin and do not benefit from Department
Department of Epidemiology tract infections (ARIs) is antibiotic treatment. 2,3 About 30% of Department
and Biostatistics, University of an important contributor office visits for the common cold and and Biostatis
California, San Francisco to worsening trends in for nonspecific upper respiratory tract California, S
(Drs Gonzales and McCulloch antibiotic-resistance patterns among (Drs Gonzal
and Ms Maselli); and and Ms Mas
Susquehanna Health, community-acquired pathogens. In the See Invited Susquehann
Williamsport (Dr Anderer), United States among persons 5 years Williamspor
Geisinger Health System, and older, ARIs in 2006 accounted for Commentary Geisinger H
Danville (Drs Bloom and Graf 8% of all visits to ambulatory practices Danville (Dr
and Mss Stahl, Yefko, and and emergency departments and for infections, as well as up to 80% of all and Mss Stah
Molecavage), and Division of 58% of all antibiotics prescribed in visits for bronchitis, are treated with Molecavage)
General Internal Medicine, antibiotics in the United States each General Inte
Department of Medicine,
these settings.1 Particularly relevant to Department
Perelman School of Medicine, reducing total antibiotic use are bron- year.4-7 Although antibiotic prescribing Perelman Sc
University of Pennsylvania, chitis, the common cold, and nonspe- for ARIs among children has declined University o
Philadelphia (Dr Metlay). cific upper respiratory tract infections and is less than that among adults, anti- Philadelphia
Comorbidities
Antibiotic-responsive
secondary diagnoses
riod. Adjusted odds ratios (95% CIs) for antibiotic treatment RESULTS
during the intervention period were calculated from variable
estimates. As a secondary analysis, we also examined changes
in antibiotic prescription rates at the clinician level to assess A total of 9808 incident visits for uncomplicated acute
the variation in clinician prescribing behavior change. We re- bronchitis took place during the baseline winter peri-
stricted this analysis to clinicians with at least 10 patient visits ods, and 6242 incident visits occurred during the inter-
in each study period to achieve more precise estimates of base- vention winter period (October 1, 2009, through March
line and intervention prescription rates; these included 31 of 31, 2010). The number of visits and proportion of ARIs
68 PDS clinicians (45.6%), 26 of 41 CDS clinicians (63.4%), diagnosed as uncomplicated acute bronchitis remained
and 27 of 46 control clinicians (58.7%). All statistical analyses stable across study sites between the baseline and inter-
were performed using a software program (Statistical Applica-
vention periods. The proportions of total ARIs diag-
tion Program, release 9.2; SAS Institute, Inc).
This study was approved by the institutional review boards nosed as uncomplicated acute bronchitis during the base-
at the participating clinical sites, at the University of Pennsyl- line period and the intervention period, respectively, were
vania, and at the University of California, San Francisco. The 9.0% and 8.3% for PDS intervention sites, 7.8% and 8.0%
study was registered with ClinicalTrials.gov (Identifier: for CDS intervention sites, and 10.3% and 9.5% for con-
NCT00981994) before enrolling patients. trol sites. The comparison of patient and clinician char-
75
volume of patient visits during the baseline and inter-
70 vention periods (10 visits each period). This subset
of clinicians accounted for 81.8% of the total visits. The
65 P = .003
mean change in antibiotic prescription rates of these cli-
60
P = .01
nicians in the baseline and intervention periods was simi-
55
lar to the change based on the patient-level analysis
P = .67 (Figure 4). However, a significant proportion (about
50
one-third) of clinicians reduced antibiotic prescription
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ein
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Pr
Pr
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60
P = .006
P = .003
40
P = .84
Change in Prescription Rate, %
20
20
40
60
Figure 4. Distribution of changes in clinician-level antibiotic prescription rates for adolescents and adults diagnosed as having uncomplicated acute bronchitis
following implementation of the decision support interventions. Each bar represents the absolute difference in antibiotic prescription rates between intervention
and baseline years for an individual clinician. Clinicians were required to have at least 10 visits in the baseline and intervention periods to be eligible for this
analysis. Statistical comparison between groups yielded the following P values: P = .006 for control sites vs printed decision support intervention sites, P = .003
for control sites vs computer-assisted decision support intervention sites, and P = .84 for printed decision support intervention sites vs computer-assisted
decision support intervention sites.