Sikkens Jonne J, van Agtmael Michiel A, Peters Edgar J G, Lettinga Kamilla D, van der Kuip Martijn, Vandenbroucke-Grauls Christina M J E, Wagner Cordula, Kramer Mark H H
Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.
EMGO+ Institute for Health and Care Research, Amsterdam, the Netherlands.
JAMA Intern Med. 2017 Aug 1;177(8):1130-1138. doi: 10.1001/jamainternmed.2017.0946.
Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs.
To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals.
DESIGN, SETTING, AND PARTICIPANTS: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study.
We offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing.
Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time.
A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found.
Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.
不恰当的抗菌药物处方会导致抗菌药物耐药性及欠佳的临床结局。改变抗菌药物处方是一个复杂的行为过程，抗菌药物管理计划中常常未予考虑。
探讨一种基于行为理论、注重维护开处方者自主权和参与度的抗菌药物管理方法，对于提高医院抗菌药物处方的恰当性是否有效。
设计、设置和参与者：荷兰抗菌药物管理独特方法（DUMAS）研究是一项前瞻性、阶梯式、参与性干预研究，于2011年10月1日至2015年12月31日进行。在16个月的基线期和12个月的干预期内对结果进行测量。该研究在荷兰一家三级医疗中心和一家普通教学医院的7个临床科室（2个内科、3个外科和2个儿科）开展。纳入在研究期间为参与科室收治的患者开具任何适应证的全身性抗菌药物的医生。
我们让开处方者自由选择如何改善其抗菌药物处方。基于对不恰当处方的根本原因分析，激励开处方者选择有更高成功潜力的干预措施。
采用基于指南依从性和合理的指南偏离的经验证方法确定抗菌药物处方的恰当性，并通过重复的时点患病率调查（每年6次）进行测量。在研究期间，恰当性判断是盲法的。从药房记录中提取抗菌药物消耗量，并以每次住院的治疗天数衡量。我们使用线性和逻辑混合模型回归分析对随时间变化的结局进行建模。
在基线期共评估了1121例患者病例的700份抗菌药物处方，在干预期评估了882例患者病例的531份抗菌药物处方。抗菌药物的平均恰当性从干预开始时的64.1%提高到12个月随访时的77.4%（提高了13.3%；相对风险，1.17；95%CI，1.04 - 1.27），斜率无变化。未发现抗菌药物消耗量减少。
采用维护开处方者自主权的行为学方法可使抗菌药物恰当性提高，并持续至少12个月。该方法成本低廉，且可轻松推广至各种医疗环境。
