Steinman Michael A, Ranji Sumant R, Shojania Kaveh G, Gonzales Ralph
Division of Geriatrics, San Francisco VA Medical Center; Department of Medicine, University of California-San Francisco, 4150 Clement Street, San Francisco, CA 94121, USA.
Med Care. 2006 Jul;44(7):617-28. doi: 10.1097/01.mlr.0000215846.25591.22.
We sought to assess which interventions are most effective at improving the prescribing of recommended antibiotics for acute outpatient infections.
We undertook a systematic review with quantitative analysis of the Cochrane Registry Effective Practice and Organization of Care (EPOC) database, supplemented by MEDLINE and hand-searches. Inclusion criteria included clinical trials with contemporaneous or strict historical controls that reported data on antibiotic selection in acute outpatient infections. The effect size of studies with different intervention types were compared using nonparametric statistics. To maximize comparability between studies, quantitative analysis was restricted to studies that reported absolute changes in the amount of or percent compliance with recommended antibiotic prescribing.
Twenty-six studies reporting 33 trials met inclusion criteria. Most interventions used clinician education alone or in combination with audit and feedback. Among the 22 comparisons amenable to quantitative analysis, recommended antibiotic prescribing improved by a median of 10.6% (interquartile range [IQR] 3.4-18.2%). Trials evaluating clinician education alone reported larger effects than interventions combining clinician education with audit and feedback (median effect size 13.9% [IQR 8.6-21.6%] vs. 3.4% [IQR 1.8-9.7%], P = 0.03). This result was confounded by trial sample size, as trials having a smaller number of participating clinicians reported larger effects and were more likely to use clinician education alone. Active forms of education, sustained interventions, and other features traditionally associated with successful quality improvement interventions were not associated with effect size and showed no evidence of confounding the association between clinician education-only strategies and outcome.
Multidimensional interventions using audit and feedback to improve antibiotic selection were less effective than interventions using clinician education alone. Although confounding may partially account for this finding, our results suggest that enhancing the intensity of a focused intervention may be preferable to a less intense, multidimensional approach.
我们试图评估哪些干预措施在改善急性门诊感染推荐抗生素的处方开具方面最为有效。
我们对Cochrane循证医学图书馆有效实践与医疗组织（EPOC）数据库进行了系统评价并进行定量分析，同时补充了MEDLINE数据库检索结果及手工检索结果。纳入标准包括采用同期对照或严格历史对照的临床试验，这些试验报告了急性门诊感染中抗生素选择的数据。使用非参数统计方法比较不同干预类型研究的效应大小。为了使各研究之间具有最大可比性，定量分析仅限于报告推荐抗生素处方量的绝对变化或依从率百分比变化的研究。
26项研究报告的33项试验符合纳入标准。大多数干预措施单独使用临床医生教育或与审核及反馈相结合。在适合进行定量分析的22项比较中，推荐抗生素处方开具的改善中位数为10.6%（四分位间距[IQR] 3.4 - 18.2%）。单独评估临床医生教育的试验报告的效应大于将临床医生教育与审核及反馈相结合的干预措施（效应大小中位数分别为13.9% [IQR 8.6 - 21.6%] 和3.4% [IQR 1.8 - 9.7%]，P = 0.03）。该结果受到试验样本量的混淆影响，因为参与临床医生数量较少的试验报告的效应更大，且更有可能单独使用临床医生教育。积极的教育形式、持续的干预措施以及其他传统上与成功的质量改进干预措施相关的特征与效应大小无关，也没有证据表明它们混淆了仅采用临床医生教育策略与结果之间的关联。
使用审核及反馈来改善抗生素选择的多维度干预措施不如单独使用临床医生教育的干预措施有效。尽管混淆因素可能部分解释了这一发现，但我们的结果表明，加强针对性干预的强度可能比强度较低的多维度方法更可取。
