多方面干预措施改善了急诊科和急诊所成人和儿童急性呼吸道感染的处方。
A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings.
机构信息
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA.
Los Angeles Biomedical Research Institute, Torrance, CA.
出版信息
Acad Emerg Med. 2019 Jul;26(7):719-731. doi: 10.1111/acem.13690. Epub 2019 Jun 19.
BACKGROUND
Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.
METHODS
This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).
RESULTS
There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.
CONCLUSION
Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.
背景
在急诊科（ED）和紧急护理中心（UCC）就诊时，抗生素通常用于治疗病毒性急性呼吸道感染（ARI）。我们评估了适应急性护理门诊环境的抗生素管理干预（适应干预）与另外纳入行为提示（增强干预）的管理干预在减少不适当处方方面的比较效果。
方法
这是一项实用的、基于群组的临床试验，在三个学术医疗系统中进行，包括五家成人和儿科 ED 和四家 UCC。对九个地点进行随机分组，按医疗系统分层；每个地点的所有医生都接受适应干预或增强干预。主要结果是每个医生开具的不适当 ARI 诊断就诊的抗生素处方比例。我们使用分层混合效应逻辑回归模型，比较了 2016 年至 2017 年（基线）和 2017 年至 2018 年（干预）流感季节的就诊情况。
结果
在所有九个群组地点的 292 名医生中，共有 44820 例 ARI 就诊。在研究期间，ARI 就诊的抗生素处方率从 6.2%（95%置信区间 [CI]：4.5%至 7.9%）降至 2.4%（95% CI：1.3%至 3.4%）。在调整医疗系统和医生层面的影响后，我们发现不适当处方的比例显著降低，从 2.2%（95% CI：1.0%至 3.4%）降至 1.5%（95% CI：0.7%至 2.3%），优势比为 0.67（95% CI：0.54 至 0.82）。两种干预之间的差异无统计学意义。
结论
在 ED 和 UCC 环境中，实施 ARI 抗生素管理是可行且有效的。在绩效较高的环境中，更强化的行为提示方法并不更有效。
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