减少不适当抗生素处方的行为干预措施：一项随机试点试验。
Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial.
作者信息
Persell Stephen D, Doctor Jason N, Friedberg Mark W, Meeker Daniella, Friesema Elisha, Cooper Andrew, Haryani Ajay, Gregory Dyanna L, Fox Craig R, Goldstein Noah J, Linder Jeffrey A
机构信息
Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
Center for Primary Care Innovation, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
出版信息
BMC Infect Dis. 2016 Aug 5;16:373. doi: 10.1186/s12879-016-1715-8.
BACKGROUND
Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.
METHODS
Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.
RESULTS
We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44-0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54-0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53-0.995).
CONCLUSIONS
We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.
TRIAL REGISTRATION
ClinicalTrials.gov: NCT01454960 .
背景
临床医生经常不恰当地为急性呼吸道感染（ARI）患者开具抗生素。我们的目标是在一项随机对照试验中测试基于信息技术的行为干预措施，以减少ARI患者不恰当的抗生素处方。
方法
基层医疗临床医生被随机分配到一个2×2×2析因实验中，该实验包含3种干预措施：1）责任说明；2）建议替代方案；3）同行比较。事先，参与者完成了一个教育模块。测量指标包括：针对以下情况的抗生素处方率：不适合使用抗生素的ARI诊断、急性鼻窦炎/咽炎、所有其他呼吸道感染诊断/症状，以及所有这三类ARI的综合情况。
结果
我们检查了干预前一年的3276次就诊和干预当年的3099次就诊。不适合使用抗生素的ARI的抗生素处方率下降（从干预前一年中的24.7%降至干预当年的5.2%）；鼻窦炎/咽炎（从50.3%降至44.7%）；所有其他呼吸道感染诊断/症状（从40.2%降至25.3%）；以及所有类别综合起来（从38.7%降至24.2%；所有p<0.001）。对于不适合使用抗生素的ARI诊断或鼻窦炎/咽炎，任何干预措施与抗生素处方之间均无显著关联。建议替代方案与其他呼吸道感染诊断或症状的抗生素处方减少相关（优势比[OR]，0.62；95%置信区间[CI]，0.44 - 0.8）以及所有ARI类别综合起来（OR，0.72；95%CI，0.54 - 0.96）。同行比较与所有ARI类别综合起来的处方减少相关（OR，0.73；95%CI，0.53 - 0.995）。
结论
无论研究参与者是否接受干预，我们都观察到抗生素处方大幅减少，这表明存在压倒性的霍桑效应或可能存在临床医生之间的相互影响。较低的基线不恰当处方可能导致了下限效应。
试验注册
ClinicalTrials.gov：NCT01454960 。
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