长期护理机构中抗生素治疗的开始、选择和持续时间的影响。
Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities.
机构信息
Institute for Clinical Evaluative Sciences (Daneman, Campitelli, Giannakeas, Bell, Maxwell, Austin, Bronskill), Toronto, Ont.; Sunnybrook Research Institute and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Department of Medicine (Daneman, Morris, Bell); Institute of Health Policy, Management and Evaluation (Daneman, Bell, Austin, Bronskill); Sinai Health System (Morris, Bell); St. Michael's Hospital (Jeffs), University of Toronto, Toronto, Ont.; University of Waterloo (Maxwell), Waterloo, Ont.
出版信息
CMAJ. 2017 Jun 26;189(25):E851-E860. doi: 10.1503/cmaj.161437.
BACKGROUND
Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities.
METHODS
We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices.
RESULTS
Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice.
INTERPRETATION
Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities.
背景
了解当前抗生素处方行为在多大程度上受到临床医生既往实践模式的影响，将有助于针对优化长期护理中抗生素使用的干预措施。我们的目的是评估临床医生的既往处方行为是否会影响长期护理机构居民抗生素治疗的起始、延长和药物种类选择。
方法
我们对 2014 年 1 月 1 日至 12 月 31 日期间在安大略省长期护理机构开处方的所有医生进行了回顾性队列研究。我们检查了医生在以下 3 个方面的抗生素处方差异：抗生素治疗开始时间、使用超过 7 天的延长疗程和氟喹诺酮类药物的选择。使用带有控制限的漏斗图来确定变异程度，并根据每个倾向将医生分为极端低、低、平均、高和极高的处方者。多变量逻辑回归用于评估临床医生前一年的处方倾向是否能预测当前的处方模式，同时考虑到居民的人口统计学、合并症、功能状态和内置设备。
结果
在 1695 名长期护理医生中，有 93132 名居民接受了治疗，抗生素治疗的起始（中位数 45%，四分位距 [IQR] 32%-55%）、延长治疗持续时间（中位数 30%，IQR 19%-46%）和氟喹诺酮类药物的选择（中位数 27%，IQR 18%-37%）存在广泛的差异。2014 年医生开抗生素处方的倾向与前一年的倾向密切相关。在控制了个别居民的特征后，先前的处方倾向是当前实践的一个显著预测因素。
结论
开抗生素处方的医生表现出了个体、可衡量的和历史上的抗生素治疗起始、延长治疗时间和药物种类选择的倾向。医生审核和反馈可能是优化长期护理机构抗生素使用的一种有前途的工具。
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