选择明智的干预措施来减少安全网中抗生素的过度使用。

Choosing Wisely interventions to reduce antibiotic overuse in the safety net.

机构信息

Division of General Internal Medicine & Health Services Research, Department of Internal Medicine, David Geffen School of Medicine at UCLA, 1100 Glendon Ave, Ste 726, Los Angeles, CA 90024. Email:

出版信息

Am J Manag Care. 2023 Oct;29(10):488-496. doi: 10.37765/ajmc.2023.89367.

DOI:10.37765/ajmc.2023.89367

PMID:37870542

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10994234/

Abstract

OBJECTIVES

Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs).

STUDY DESIGN

Interrupted time series.

METHODS

A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics.

RESULTS

Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences.

CONCLUSIONS

These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.

摘要

目的

医生薪酬与表现（P4P）计划经常针对不当使用抗生素。然而，对于 P4P 计划对面临因减少医疗而产生不良后果风险的安全网人群的抗生素处方开具的影响，人们知之甚少。我们评估了 P4P 激励干预措施对急性呼吸道感染（ARTI）安全网患者抗生素处方的影响。

研究设计

中断时间序列。

方法

在 2 家大型学术性安全网医院（洛杉矶县+南加州大学[LAC+USC]和奥利弗观-UCLA[OV-UCLA]）进行了一项非随机干预（2015 年 5 月 28 日至 2018 年 2 月 1 日）。为响应加利福尼亚州 2016 年的 P4P 计划，减少急性支气管炎的抗生素使用，我们联合开展了 5 项基于明智选择的干预措施：审核和反馈、临床医生教育、替代方案建议、降钙素原和公开承诺。我们还评估了 5 种意外后果：医疗保健效果数据和信息集（HEDIS）适当处方减少、诊断转移、用类固醇替代抗生素、增加 P4P 计划未处罚的 ARTI 的抗生素使用、以及不适当的抗生素停药。

结果

在 3583 例连续 ARTI 患者中，LAC+USC 的抗生素治疗率从 35.9%降至 22.9%（比值比[OR]，0.60；95%置信区间[CI]，0.39-0.93），OV-UCLA 从 48.7%降至 27.3%（OR，0.81；95% CI，0.70-0.93）。在 LAC+USC，HEDIS 不适当处方率从 28.9%降至 19.7%（OR，0.69；95% CI，0.39-1.21），OV-UCLA 从 40.9%降至 12.5%（OR，0.72；95% CI，0.59-0.88）。没有证据表明存在意外后果。