退伍军人人群中急性呼吸道感染的门诊抗生素处方差异：一项横断面研究。

Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study.

出版信息

Ann Intern Med. 2015 Jul 21;163(2):73-80. doi: 10.7326/M14-1933.

DOI:10.7326/M14-1933

PMID:26192562

Abstract

BACKGROUND

Despite efforts to reduce antibiotic prescribing for acute respiratory infections (ARIs), information on factors that drive prescribing is limited.

OBJECTIVE

To examine trends in antibiotic prescribing in the Veterans Affairs population over an 8-year period and to identify patient, provider, and setting sources of variation.

DESIGN

Retrospective, cross-sectional study.

SETTING

All emergency departments and primary and urgent care clinics in the Veterans Affairs health system.

PARTICIPANTS

All patient visits between 2005 and 2012 with primary diagnoses of ARIs that typically had low proportions of bacterial infection. Patients with infections or comorbid conditions that indicated antibiotic use were excluded.

MEASUREMENTS

Overall antibiotic prescription; macrolide prescription; and patient, provider, and setting characteristics extracted from the electronic health record.

RESULTS

The proportion of 1 million visits with ARI diagnoses that resulted in antibiotic prescriptions increased from 67.5% in 2005 to 69.2% in 2012 (P < 0.001). The proportion of macrolide antibiotics prescribed increased from 36.8% to 47.0% (P < 0.001). Antibiotic prescribing was highest for sinusitis (adjusted proportion, 86%) and bronchitis (85%) and varied little according to fever, age, setting, or comorbid conditions. Substantial variation was identified in prescribing at the provider level: The 10% of providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, and the 10% who prescribed the least did so during 40% or fewer of their ARI visits.

LIMITATION

Some clinical data that may have influenced the prescribing decision were missing.

CONCLUSION

Veterans with ARIs commonly receive antibiotics, regardless of patient, provider, or setting characteristics. Macrolide use has increased, and substantial variation was identified in antibiotic prescribing at the provider level.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention.

摘要

背景

尽管已经采取措施来减少急性呼吸道感染（ARI）的抗生素处方量，但有关驱动处方的因素的信息仍然有限。

目的

在 8 年期间内，检测退伍军人事务人群中抗生素处方的趋势，并确定患者、医生和就诊环境的变化来源。

设计

回顾性、横截面研究。

设置

退伍军人事务医疗系统中的所有急诊部、初级保健和紧急护理诊所。

参与者

2005 年至 2012 年间所有因 ARI 而就诊的患者，这些患者的主要诊断通常具有较低的细菌感染比例。排除有感染或表明需要使用抗生素的合并症的患者。

测量方法

从电子健康记录中提取的抗生素总体处方、大环内酯类抗生素处方以及患者、医生和就诊环境的特征。

结果

有 ARI 诊断的 100 万就诊患者中，接受抗生素处方的比例从 2005 年的 67.5%增加到 2012 年的 69.2%（P<0.001）。开大环内酯类抗生素的比例从 36.8%增加到 47.0%（P<0.001）。抗生素处方最多的疾病是鼻窦炎（调整后比例为 86%）和支气管炎（85%），而根据发热、年龄、就诊环境或合并症情况，处方量变化很小。在医生层面上确定了大量的处方差异：处方量最多的 10%的医生在至少 95%的 ARI 就诊中都开了抗生素，而处方量最少的 10%的医生在 40%或更少的 ARI 就诊中开了抗生素。