Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94118, USA.
JAMA Intern Med. 2013 Feb 25;173(4):267-73. doi: 10.1001/jamainternmed.2013.1589.
National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis.
We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis.
Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites.
Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent.
clinicaltrials.gov Identifier: NCT00981994.
国家质量指标显示，在治疗单纯性急性支气管炎时，抗生素的过度使用几乎没有变化。我们比较了两种决策支持策略对单纯性急性支气管炎抗生素治疗的影响。
我们在宾夕法尼亚州中部一个综合医疗系统的 33 个初级保健诊所中进行了一项 3 臂集群随机试验。接受基于印刷的决策支持干预的印刷决策支持干预点（11 个实践）通过基于电子病历的策略获得急性咳嗽疾病的决策支持，接受计算机辅助决策支持干预的干预点（11 个实践）通过基于电子病历的策略获得决策支持，而对照组（11 个实践）则作为对照组。两个干预点还接受了关于处方实践的临床医生教育和反馈，以及在入住时的患者教育手册。在引入干预措施后的冬季（2009 年 10 月 1 日至 2010 年 3 月 31 日）期间，比较了单纯性急性支气管炎的抗生素处方率与前 3 个冬季的意图治疗分析。
与基线期相比，在印刷决策支持干预点（从 80.0%降至 68.3%）和计算机辅助决策支持干预点（从 74.0%降至 60.7%）接受治疗的青少年和成年人开抗生素的比例下降，但对照组略有增加（从 72.5%增至 74.3%）。在控制患者和临床医生特征以及按临床医生和实践地点聚类观察后，干预组与对照组之间的差异具有统计学意义（对照组与印刷决策支持干预组相比，P=0.003；对照组与计算机辅助决策支持干预组相比，P=0.01），但彼此之间无差异（印刷决策支持干预组与计算机辅助决策支持干预组相比，P=0.67）。研究地点的总就诊次数、30 天复诊率和单纯性急性支气管炎诊断比例的变化相似。
实施急性支气管炎决策支持策略有助于减少初级保健环境中抗生素的过度使用。提供决策支持的印刷与计算机辅助决策支持策略的效果相当。
clinicaltrials.gov 标识符：NCT00981994。
