Shen XingRong, Lu Manman, Feng Rui, Cheng Jing, Chai Jing, Xie Maomao, Dong Xuemeng, Jiang Tao, Wang Debin
School of Health Service Management, Anhui Medical University, Hefei, China.
Department of Literature Review and Analysis, Library of Anhui Medical University, Hefei, China.
J Med Internet Res. 2018 Feb 14;20(2):e53. doi: 10.2196/jmir.8922.
Excessive use of antibiotics is very common worldwide, especially in rural China; various measures that have been used in curbing the problem have shown only marginal effects.
The objective of this study was to test an innovative intervention that provided just-in-time information and feedback (JITIF) to village doctors on care of common infectious diseases.
The information component of JITIF consisted of a set of theory or evidence-based ingredients, including operation guideline, public commitment, and takeaway information, whereas the feedback component tells each participating doctor about his or her performance scores and percentages of antibiotic prescriptions. These ingredients were incorporated together in a synergetic way via a Web-based aid. Evaluation of JITIF adopted a randomized controlled trial design involving 24 village clinics randomized into equal control and intervention arms. Measures used included changes between baseline and endpoint (1 year after baseline) in terms of: percentages of patients with symptomatic respiratory or gastrointestinal tract infections (RTIs or GTIs) being prescribed antibiotics, delivery of essential service procedures, and patients' beliefs and knowledge about antibiotics and infection prevention. Two researchers worked as a group in collecting the data at each site clinic. One performed nonparticipative observation of the service process, while the other performed structured exit interviews about patients' beliefs and knowledge. Data analysis comprised mainly of: (1) descriptive estimations of beliefs or knowledge, practice of indicative procedures, and use of antibiotics at baseline and endpoint for intervention and control groups and (2) chi-square tests for the differences between these groups.
A total of 1048 patients completed the evaluation, including 532 at baseline (intervention=269, control=263) and 516 at endpoint (intervention=262, control=254). Patients diagnosed with RTIs and GTIs accounted for 76.5% (407/532) and 23.5% (125/352), respectively, at baseline and 80.8% (417/532) and 19.2% (99/532) at endpoint. JITIF resulted in substantial improvement in delivery of essential service procedures (2.6%-24.8% at baseline on both arms and at endpoint on the control arm vs 88.5%-95.0% at endpoint on the intervention arm, P<.001), beliefs favoring rational antibiotics use (11.5%-39.8% at baseline on both arms and at endpoint on the control arm vs 19.8%-62.6% at endpoint on the intervention arm, P<.001) and knowledge about side effects of antibiotics (35.7% on the control arm vs 73.7% on the intervention arm, P<.001), measures for managing or preventing RTIs (39.1% vs 66.7%, P=.02), and measures for managing or preventing GTIs (46.8% vs 69.2%, P<.001). It also reduced antibiotics prescription (from 88.8%-62.3%, P<.001), and this decrease was consistent for RTIs (87.1% vs 64.3%, P<.001) and GTIs (94.7% vs 52.4%, P<.001).
JITIF is effective in controlling antibiotics prescription at least in the short term and may provide a low-cost and sustainable solution to the widespread excessive use of antibiotics in rural China.
抗生素的过度使用在全球范围内非常普遍，在中国农村地区尤为如此；已采取的各种遏制该问题的措施仅显示出微弱的效果。
本研究的目的是测试一种创新干预措施，即向乡村医生提供关于常见传染病护理的即时信息和反馈（JITIF）。
JITIF的信息部分由一组基于理论或证据的要素组成，包括操作指南、公开承诺和关键信息，而反馈部分则告知每位参与的医生其绩效得分以及抗生素处方的百分比。这些要素通过一个基于网络的辅助工具以协同的方式整合在一起。对JITIF的评估采用随机对照试验设计，将24个乡村诊所随机分为相等的对照组和干预组。所使用的测量指标包括基线和终点（基线后1年）之间在以下方面的变化：有症状的呼吸道或胃肠道感染（RTIs或GTIs）患者接受抗生素处方的百分比、基本服务程序的提供情况以及患者对抗生素和感染预防的信念和知识。两名研究人员在每个诊所现场作为一个小组收集数据。一名研究人员对服务过程进行非参与性观察，而另一名研究人员就患者的信念和知识进行结构化的出院访谈。数据分析主要包括：（1）对干预组和对照组在基线和终点时的信念或知识、指示性程序的实施情况以及抗生素使用情况的描述性估计，以及（2）对这些组之间差异的卡方检验。
共有1048名患者完成了评估，其中基线时532名（干预组=269名，对照组=263名），终点时516名（干预组=262名，对照组=254名）。基线时被诊断为RTIs和GTIs的患者分别占76.5%（407/532）和23.5%（125/352），终点时分别占80.8%（417/532）和19.2%（99/532）。JITIF导致基本服务程序的提供有显著改善（基线时两组以及对照组终点时为2.6%-24.8%，干预组终点时为88.5%-95.0%，P<0.001），支持合理使用抗生素的信念（基线时两组以及对照组终点时为11.5%-39.8%，干预组终点时为19.8%-62.6%，P<0.001）以及关于抗生素副作用的知识（对照组为35.7%，干预组为73.7%，P<0.001）、管理或预防RTIs的措施（39.1%对66.7%，P=0.02）以及管理或预防GTIs的措施（46.8%对69.2%，P<0.001）。它还减少了抗生素处方（从88.8%-62.3%，P<0.001），并且这种减少在RTIs（87.1%对64.3%，P<0.001）和GTIs（94.7%对52.4%，P<0.001）方面是一致的。
JITIF至少在短期内有效地控制了抗生素处方，并且可能为中国农村地区广泛存在的抗生素过度使用问题提供一种低成本且可持续的解决方案。
