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Leuchter RK, Sarkisian CA, Trotzky-Sirr R, Wei EK, Carrillo CA, Vangala S, Coffey C, Spellberg B, Melamed O, Jeng AC, Mafi JN. Choosing Wisely interventions to reduce antibiotic overuse in the safety net. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:488-496. [PMID: 37870542 PMCID: PMC10994234 DOI: 10.37765/ajmc.2023.89367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
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.
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Affiliation(s)
- Richard K Leuchter
- 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.
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Xu R, Wu L, Wu L, Xu C, Mu T. Effectiveness of decision support tools on reducing antibiotic use for respiratory tract infections: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1253520. [PMID: 37745052 PMCID: PMC10512864 DOI: 10.3389/fphar.2023.1253520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background: Clinical decision support tools (CDSs) have been demonstrated to enhance the accuracy of antibiotic prescribing among physicians. However, their effectiveness in reducing inappropriate antibiotic use for respiratory tract infections (RTI) is controversial. Methods: A literature search in 3 international databases (Medline, Web of science and Embase) was conducted before 31 May 2023. Relative risk (RR) and corresponding 95% confidence intervals (CI) were pooled to evaluate the effectiveness of intervention. Summary effect sizes were calculated using a random-effects model due to the expected heterogeneity (I 2 over 50%). Results: A total of 11 cluster randomized clinical trials (RCTs) and 5 before-after studies were included in this meta-analysis, involving 900,804 patients met full inclusion criteria. Among these studies, 11 reported positive effects, 1 reported negative results, and 4 reported non-significant findings. Overall, the pooled effect size revealed that CDSs significantly reduced antibiotic use for RTIs (RR = 0.90, 95% CI = 0.85 to 0.95, I 2 = 96.10%). Subgroup analysis indicated that the intervention duration may serve as a potential source of heterogeneity. Studies with interventions duration more than 2 years were found to have non-significant effects (RR = 1.00, 95% CI = 0.96 to 1.04, I 2 = 0.00%). Egger's test results indicated no evidence of potential publication bias (p = 0.287). Conclusion: This study suggests that CDSs effectively reduce inappropriate antibiotic use for RTIs among physicians. However, subgroup analysis revealed that interventions lasting more than 2 years did not yield significant effects. These findings highlight the importance of considering intervention duration when implementing CDSs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023432584, Identifier: PROSPERO (CRD42023432584).
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Affiliation(s)
- Rixiang Xu
- School of Humanities and Management, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Lang Wu
- School of Humanities and Management, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Lingyun Wu
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Caiming Xu
- School of Law, Hangzhou City University, Hangzhou, Zhejiang, China
| | - Tingyu Mu
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
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Ramanathan S, Evans CT, Hershow RC, Calip GS, Rowan S, Hubbard C, Suda KJ. Comparison of guideline concordant antibiotic prophylaxis in Veterans Affairs and non-Veterans Affairs dental settings among those with cardiac conditions or prosthetic joints. BMC Infect Dis 2023; 23:427. [PMID: 37353757 DOI: 10.1186/s12879-023-08400-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND No research has been conducted to assess whether antibiotic prophylaxis prescribing differs by dental setting. Therefore, the goal of this study was to compare the prescribing of antibiotic prophylaxis in Veterans Affairs (VA) and non-Veterans Affairs settings. METHODS This was a retrospective study of veteran and non-veteran dental patients with cardiac conditions or prosthetic joints between 2015-2017. Multivariable log binomial regression analysis was conducted to compare concordant prescribing by setting with a sub-analysis for errors of dosing based on antibiotic duration (i.e., days prescribed). RESULTS A total of 61,124 dental visits that received a prophylactic antibiotic were included. Most were male (61.0%), and 55 years of age or older (76.2%). Nearly a third (32.7%) received guideline concordant prophylaxis. VA dental settings had a lower prevalence of guideline concordant prescribing compared to non-VA settings in unadjusted results (unadjusted prevalence ratio [uPR] = 0.92, 95% CI: 0.90-0.95). After adjustment, prevalence of guideline concordant prescribing was higher in those with prosthetic joints in the VA setting (adjusted prevalence ratio [aPR] = 1.73, 95% CI: 1.59-1.88), with no difference identified in those without a prosthetic joint (aPR = 0.99, 95% CI: 0.96-1.01). Concordance of dosing was higher in VA compared to non-VA settings (aPR = 1.11, 95% CI: 1.07-1.15). CONCLUSIONS VA has a higher prevalence of guideline concordant prescribing among those with prosthetic joints and when assessing dosing errors. Though the presence of an integrated electronic health record (EHR) may be contributing to these differences, other system or prescriber-related factors may be responsible. Future studies should focus on to what extent the integrated EHR may be responsible for increased guideline concordant prescribing in the VA setting.
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Affiliation(s)
- Swetha Ramanathan
- School of Public Heath, University of Illinois at Chicago, Chicago, IL, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ronald C Hershow
- School of Public Heath, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S Calip
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Susan Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA
| | - Colin Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 3609 Forbes Ave. Suite 2, Pittsburgh, PA, USA.
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Csonka P, Korppi M. Electronic health record databases provide a platform for intervention studies. Acta Paediatr 2022; 111:1104-1106. [PMID: 35332573 DOI: 10.1111/apa.16329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/25/2022] [Accepted: 03/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research Faculty of Medicine and Health Technology Tampere University and Tampere University Hospital Tampere Finland
- Terveystalo Healthcare Tampere Finland
| | - Matti Korppi
- Tampere Center for Child, Adolescent and Maternal Health Research Faculty of Medicine and Health Technology Tampere University and Tampere University Hospital Tampere Finland
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Clinical Decision Support Systems for Antibiotic Prescribing: An Inventory of Current French Language Tools. Antibiotics (Basel) 2022; 11:antibiotics11030384. [PMID: 35326847 PMCID: PMC8944435 DOI: 10.3390/antibiotics11030384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Clinical decision support systems (CDSSs) are increasingly being used by clinicians to support antibiotic decision making in infection management. However, coexisting CDSSs often target different types of physicians, infectious situations, and patient profiles. The objective of this study was to perform an up-to-date inventory of French language CDSSs currently used in community and hospital settings for antimicrobial prescribing and to describe their main characteristics. A literature search, a search among smartphone application stores, and an open discussion with antimicrobial stewardship (AMS) experts were conducted in order to identify available French language CDSSs. Any clinical decision support tool that provides a personalized recommendation based on a clinical situation and/or a patient was included. Eleven CDSSs were identified through the search strategy. Of the 11 CDSSs, only 2 had been the subject of published studies, while 9 CDSSs were identified through smartphone application stores and expert knowledge. The majority of CDSSs were available free of charge (n = 8/11, 73%). Most CDSSs were accessible via smartphone applications (n = 9/11, 82%) and online websites (n = 8/11, 73%). Recommendations for antibiotic prescribing in urinary tract infections, upper and lower respiratory tract infections, and digestive tract infections were provided by over 90% of the CDSSs. More than 90% of the CDSSs displayed recommendations for antibiotic selection, prioritization, dosage, duration, route of administration, and alternative antibiotics in case of allergy. Information about antibiotic side effects, prescription recommendations for specific patient profiles and adaptation to local epidemiology were often missing or incomplete. There is a significant but heterogeneous offer for antibiotic prescribing decision support in French language. Standardized evaluation of these systems is needed to assess their impact on antimicrobial prescribing and antimicrobial resistance.
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Estrela M, Magalhães Silva T, Pisco Almeida AM, Regueira C, Zapata-Cachafeiro M, Figueiras A, Roque F, Herdeiro MT. A roadmap for the development and evaluation of the eHealthResp online course. Digit Health 2022; 8:20552076221089088. [PMID: 35360007 PMCID: PMC8961349 DOI: 10.1177/20552076221089088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background Inappropriate antibiotic use constitutes one of the most concerning public
health issues, being one of the main causes of antibiotic resistance. Hence,
to tackle this issue, it is important to encourage the development of
educational interventions for health practitioners, namely by using digital
health tools. This study focuses on the description of the development and
validation process of the eHealthResp online course, a web platform directed
to physicians and pharmacists, with the overall goal of improving antibiotic
use for respiratory tract infections, along with the assessment of its
usability. Methods The eHealthResp platform and the courses, developed with a user-centered
design and based on Wordpress and MySQL, were based on a previously
developed online course. A questionnaire to assess the usability was
distributed among physicians (n = 6) and pharmacists (n = 6). Based on the
obtained results, statistical analyses were conducted to calculate the
usability score and appraise the design of the online course, as well as to
compare the overall scores attributed by both groups. Further qualitative
comments provided by the participants have also been analyzed. Results The eHealthResp contains two online courses directed to physicians and
pharmacists aiming to aid in the management of respiratory tract infections.
The average usability score of the eHealthResp online courses for physicians
and pharmacists was of 78.33 (±11.57, 95%CI), and 83.75 (±15.90, 95%CI),
respectively. Qualitative feedback emphasized the usefulness of the course,
including overall positive reviews regarding user-friendliness and
consistency. Conclusions This study led us to conclude that the eHealthResp online course is not
recognized as a complex web platform, as both qualitative and quantitative
feedback obtained were globally positive.
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Affiliation(s)
- Marta Estrela
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Tânia Magalhães Silva
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | | | - Carlos Regueira
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Santiago de Compostela, Spain
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Santiago de Compostela, Spain.,Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Santiago de Compostela, Spain.,Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Guarda Polytechnic Institute (UDI-IPG), Guarda, Portugal.,Health Sciences Research Center, University of Beira Interior (CICS-UBI), Covilhã, Portugal
| | - Maria Teresa Herdeiro
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
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Agarwal S, Glenton C, Tamrat T, Henschke N, Maayan N, Fønhus MS, Mehl GL, Lewin S. Decision-support tools via mobile devices to improve quality of care in primary healthcare settings. Cochrane Database Syst Rev 2021; 7:CD012944. [PMID: 34314020 PMCID: PMC8406991 DOI: 10.1002/14651858.cd012944.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ubiquity of mobile devices has made it possible for clinical decision-support systems (CDSS) to become available to healthcare providers on handheld devices at the point-of-care, including in low- and middle-income countries. The use of CDSS by providers can potentially improve adherence to treatment protocols and patient outcomes. However, the evidence on the effect of the use of CDSS on mobile devices needs to be synthesized. This review was carried out to support a World Health Organization (WHO) guideline that aimed to inform investments on the use of decision-support tools on digital devices to strengthen primary healthcare. OBJECTIVES To assess the effects of digital clinical decision-support systems (CDSS) accessible via mobile devices by primary healthcare providers in the context of primary care settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Global Index Medicus, POPLINE, and two trial registries from 1 January 2000 to 9 October 2020. We conducted a grey literature search using mHealthevidence.org and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies. SELECTION CRITERIA Study design: we included randomized trials, including full-text studies, conference abstracts, and unpublished data irrespective of publication status or language of publication. Types of participants: we included studies of all cadres of healthcare providers, including lay health workers and other individuals (administrative, managerial, and supervisory staff) involved in the delivery of primary healthcare services using clinical decision-support tools; and studies of clients or patients receiving care from primary healthcare providers using digital decision-support tools. Types of interventions: we included studies comparing digital CDSS accessible via mobile devices with non-digital CDSS or no intervention, in the context of primary care. CDSS could include clinical protocols, checklists, and other job-aids which supported risk prioritization of patients. Mobile devices included mobile phones of any type (but not analogue landline telephones), as well as tablets, personal digital assistants, and smartphones. We excluded studies where digital CDSS were used on laptops or integrated with electronic medical records or other types of longitudinal tracking of clients. DATA COLLECTION AND ANALYSIS A machine learning classifier that gave each record a probability score of being a randomized trial screened all search results. Two review authors screened titles and abstracts of studies with more than 10% probability of being a randomized trial, and one review author screened those with less than 10% probability of being a randomized trial. We followed standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. We used the GRADE approach to assess the certainty of the evidence for the most important outcomes. MAIN RESULTS Eight randomized trials across varying healthcare contexts in the USA,. India, China, Guatemala, Ghana, and Kenya, met our inclusion criteria. A range of healthcare providers (facility and community-based, formally trained, and lay workers) used digital CDSS. Care was provided for the management of specific conditions such as cardiovascular disease, gastrointestinal risk assessment, and maternal and child health. The certainty of evidence ranged from very low to moderate, and we often downgraded evidence for risk of bias and imprecision. We are uncertain of the effect of this intervention on providers' adherence to recommended practice due to the very low certainty evidence (2 studies, 185 participants). The effect of the intervention on patients' and clients' health behaviours such as smoking and treatment adherence is mixed, with substantial variation across outcomes for similar types of behaviour (2 studies, 2262 participants). The intervention probably makes little or no difference to smoking rates among people at risk of cardiovascular disease but probably increases other types of desired behaviour among patients, such as adherence to treatment. The effect of the intervention on patients'/clients' health status and well-being is also mixed (5 studies, 69,767 participants). It probably makes little or no difference to some types of health outcomes, but we are uncertain about other health outcomes, including maternal and neonatal deaths, due to very low-certainty evidence. The intervention may slightly improve patient or client acceptability and satisfaction (1 study, 187 participants). We found no studies that reported the time between the presentation of an illness and appropriate management, provider acceptability or satisfaction, resource use, or unintended consequences. AUTHORS' CONCLUSIONS We are uncertain about the effectiveness of mobile phone-based decision-support tools on several outcomes, including adherence to recommended practice. None of the studies had a quality of care framework and focused only on specific health areas. We need well-designed research that takes a systems lens to assess these issues.
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Affiliation(s)
- Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Maryland (MD), USA
| | | | - Tigest Tamrat
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | | | | | | | - Garrett L Mehl
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Laka M, Milazzo A, Merlin T. Can evidence-based decision support tools transform antibiotic management? A systematic review and meta-analyses. J Antimicrob Chemother 2021; 75:1099-1111. [PMID: 31960021 DOI: 10.1093/jac/dkz543] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/17/2019] [Accepted: 12/06/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To assess the effectiveness of clinical decision support systems (CDSSs) at reducing unnecessary and suboptimal antibiotic prescribing within different healthcare settings. METHODS A systematic review of published studies was undertaken with seven databases from database inception to November 2018. A protocol was developed using the PRISMA-P checklist and study selection criteria were determined prior to performing the search. Critical appraisal of studies was undertaken using relevant tools. Meta-analyses were performed using a random-effects model to determine whether CDSS use affected optimal antibiotic management. RESULTS Fifty-seven studies were identified that reported on CDSS effectiveness. Most were non-randomized studies with low methodological quality. However, randomized controlled trials of moderate methodological quality were available and assessed separately. The meta-analyses indicated that appropriate antibiotic therapy was twice as likely to occur following the implementation of CDSSs (OR 2.28, 95% CI 1.82-2.86, k = 20). The use of CDSSs was also associated with a relative decrease (18%) in mortality (OR 0.82, 95% CI 0.73-0.91, k = 18). CDSS implementation also decreased the overall volume of antibiotic use, length of hospital stay, duration and cost of therapy. The magnitude of the effect did vary by study design, but the direction of the effect was consistent in favouring CDSSs. CONCLUSIONS Decision support tools can be effective to improve antibiotic prescribing, although there is limited evidence available on use in primary care. Our findings suggest that a focus on system requirements and implementation processes would improve CDSS uptake and provide more definitive benefits for antibiotic stewardship.
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Affiliation(s)
- Mah Laka
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Adriana Milazzo
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Tracy Merlin
- Adelaide Health Technology (AHTA), School of Public Health, University of Adelaide, Adelaide, Australia
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Estrela M, Roque F, Silva TM, Zapata-Cachafeiro M, Figueiras A, Herdeiro MT. Validation of the eHealthResp online course for pharmacists and physicians: A Delphi method approach. Biomed Pharmacother 2021; 140:111739. [PMID: 34020245 DOI: 10.1016/j.biopha.2021.111739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022] Open
Abstract
FRAMEWORK The inappropriate use of antibiotics for respiratory tract infections is dispersed worldwide, thus being a strong contributor to antibiotic resistances. As the use of educational interventions among health practitioners is shown to have an impact on judicious antibiotic use, an online course (eHealthResp) has been developed, especially targeted to pharmacists and physicians. Thus, the main goal of this study is to validate the contents of the online course eHealthResp. METHODS This two-round Delphi study involved the recruitment of a multidisciplinary panel (n = 19), to which the questionnaires of the first round were sent. After the first round, a report summing up the results has been forwarded to the panel, along with a new, reformulated version of the questionnaire. RESULTS After the two rounds of the Delphi process, consensus was evaluated. Six clinical cases and fifty-one treatments obtained minor consensus [60-75%] or full consensus (≥75%). The question on antibiotic practice has obtained a consensus >90% on both rounds. CONCLUSIONS The validation of the contents based on experts' consensus has been an essential approach to improve eHealthResp's online course, as valuable feedback has been provided by the panel on both rounds.
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Affiliation(s)
- Marta Estrela
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal.
| | - Fátima Roque
- Research Unit for Inland Development, Guarda Polytechnic Institute (UDI-IPG), Guarda, Portugal; Health Sciences Research Center, University of Beira Interior (CICS-UBI), Covilhã, Portugal
| | - Tânia Magalhães Silva
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Maruxa Zapata-Cachafeiro
- Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Spain; Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Madrid, Spain
| | - Adolfo Figueiras
- Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Spain; Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health - CIBERESP), Madrid, Spain
| | - Maria Teresa Herdeiro
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
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Figueiras A, López-Vázquez P, Gonzalez-Gonzalez C, Vázquez-Lago JM, Piñeiro-Lamas M, López-Durán A, Sánchez C, Herdeiro MT, Zapata-Cachafeiro M. Impact of a multifaceted intervention to improve antibiotic prescribing: a pragmatic cluster-randomised controlled trial. Antimicrob Resist Infect Control 2020; 9:195. [PMID: 33287881 PMCID: PMC7722452 DOI: 10.1186/s13756-020-00857-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 11/18/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study sought to assess the effectiveness and return on investment (ROI) of a multifaceted intervention aimed at improving antibiotic prescribing for acute respiratory infections in primary care. DESIGN Large-sized, two-arm, open-label, pragmatic, cluster-randomised controlled trial. SETTING All primary care physicians working for the Spanish National Health Service (NHS) in Galicia (region in north-west Spain). PARTICIPANTS The seven spatial clusters were distributed by unequal randomisation (3:4) of the intervention and control groups. A total of 1217 physicians (1.30 million patients) were recruited from intervention clusters and 1393 physicians (1.46 million patients) from control clusters. INTERVENTIONS One-hour educational outreach visits tailored to training needs identified in a previous study; an online course integrated in practice accreditation; and a clinical decision support system. MAIN OUTCOME MEASURES Changes in the ESAC (European Surveillance of Antimicrobial Consumption) quality indicators for outpatient antibiotic use. We used generalised linear mixed and conducted a ROI analysis to ascertain the overall cost savings. RESULTS Median follow-up was 19 months. The adjusted effect on overall antibiotic prescribing attributable to the intervention was - 4.2% (95% CI: - 5.3% to - 3.2%), with this being more pronounced for penicillins - 6.5 (95% CI: - 7.9% to - 5.2%) and for the ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides - 9.0% (95% CI: - 14.0 to - 4.1%). The cost of the intervention was €87 per physician. Direct savings per physician attributable to the reduction in antibiotic prescriptions was €311 for the NHS and €573 for patient contributions, with an ROI of €2.57 and €5.59 respectively. CONCLUSIONS Interventions designed on the basis of gaps in physicians' knowledge of and attitudes to misprescription can improve antibiotic prescribing and yield important direct cost savings. TRIAL REGISTRATION Current Controlled Trials ISRCTN24158380 . Registered 5 February 2009.
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Affiliation(s)
- Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública- CIBERESP), Santiago de Compostela, Spain.
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
| | - Paula López-Vázquez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
| | - Cristian Gonzalez-Gonzalez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
| | - Juan Manuel Vázquez-Lago
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
| | - María Piñeiro-Lamas
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública- CIBERESP), Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Ana López-Durán
- Department of Clinical Psychology and Psychobiology, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Coro Sánchez
- Pontevedra Primary Care Service, SERGAS Eoxi Pontevedra-Salnés, Pontevedra, Spain
| | - María Teresa Herdeiro
- Department of Medical Sciences & Institute for Biomedicine - iBiMED, University of Aveiro, Aveiro, Portugal
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública- CIBERESP), Santiago de Compostela, Spain
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11
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Mann D, Hess R, McGinn T, Richardson S, Jones S, Palmisano J, Chokshi SK, Mishuris R, McCullagh L, Park L, Dinh-Le C, Smith P, Feldstein D. Impact of Clinical Decision Support on Antibiotic Prescribing for Acute Respiratory Infections: a Cluster Randomized Implementation Trial. J Gen Intern Med 2020; 35:788-795. [PMID: 32875505 PMCID: PMC7652959 DOI: 10.1007/s11606-020-06096-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clinical decision support (CDS) is a promising tool for reducing antibiotic prescribing for acute respiratory infections (ARIs). OBJECTIVE To assess the impact of previously effective CDS on antibiotic-prescribing rates for ARIs when adapted and implemented in diverse primary care settings. DESIGN Cluster randomized clinical trial (RCT) implementing a CDS tool designed to guide evidence-based evaluation and treatment of streptococcal pharyngitis and pneumonia. SETTING Two large academic health system primary care networks with a mix of providers. PARTICIPANTS All primary care practices within each health system were invited. All providers within participating clinic were considered a participant. Practices were randomized selection to a control or intervention group. INTERVENTIONS Intervention practice providers had access to an integrated clinical prediction rule (iCPR) system designed to determine the risk of bacterial infection from reason for visit of sore throat, cough, or upper respiratory infection and guide evidence-based evaluation and treatment. MAIN OUTCOME(S) Change in overall antibiotic prescription rates. MEASURE(S) Frequency, rates, and type of antibiotics prescribed in intervention and controls groups. RESULTS 33 primary care practices participated with 541 providers and 100,573 patient visits. Intervention providers completed the tool in 6.9% of eligible visits. Antibiotics were prescribed in 35% and 36% of intervention and control visits, respectively, showing no statistically significant difference. There were also no differences in rates of orders for rapid streptococcal tests (RR, 0.94; P = 0.11) or chest X-rays (RR, 1.01; P = 0.999) between groups. CONCLUSIONS The iCPR tool was not effective in reducing antibiotic prescription rates for upper respiratory infections in diverse primary care settings. This has implications for the generalizability of CDS tools as they are adapted to heterogeneous clinical contexts. TRIAL REGISTRATION Clinicaltrials.gov (NCT02534987). Registered August 26, 2015 at https://clinicaltrials.gov.
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Affiliation(s)
- Devin Mann
- New York University School of Medicine, New York, NY, USA.
| | - Rachel Hess
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas McGinn
- Hofstra Northwell School of Medicine, New York, NY, USA
| | | | - Simon Jones
- New York University School of Medicine, New York, NY, USA
| | | | | | | | | | - Linda Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Paul Smith
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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12
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Carvalho É, Estrela M, Zapata-Cachafeiro M, Figueiras A, Roque F, Herdeiro MT. E-Health Tools to Improve Antibiotic Use and Resistances: A Systematic Review. Antibiotics (Basel) 2020; 9:antibiotics9080505. [PMID: 32806583 PMCID: PMC7460242 DOI: 10.3390/antibiotics9080505] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/04/2022] Open
Abstract
(1) Background: e-Health tools, especially in the form of clinical decision support systems (CDSSs), have been emerging more quickly than ever before. The main objective of this systematic review is to assess the influence of these tools on antibiotic use for respiratory tract infections. (2) Methods: The scientific databases, MEDLINE-PubMed and EMBASE, were searched. The search was conducted by two independent researchers. The search strategy was mainly designed to identify relevant studies on the effectiveness of CDSSs in improving antibiotic use, as a primary outcome, and on the acceptability and usability of CDSSs, as a secondary outcome. (3) Results: After the selection, 22 articles were included. The outcomes were grouped either into antibiotics prescription practices or adherence to guidelines concerning antibiotics prescription. Overall, 15 out of the 22 studies had statistically significant outcomes related to the interventions. (4) Conclusions: Overall, the results show a positive impact on the prescription and conscientious use of antibiotics for respiratory tract infections, both with respect to patients and prescribing healthcare professionals. CDSSs have been shown to have great potential as powerful tools for improving both clinical care and patient outcomes.
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Affiliation(s)
- Érico Carvalho
- iBiMED–Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, 3800 Aveiro, Portugal; (É.C.); (M.E.)
| | - Marta Estrela
- iBiMED–Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, 3800 Aveiro, Portugal; (É.C.); (M.E.)
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; (M.Z.-C.); (A.F.)
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health-CIBERESP), 28001 Madrid, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; (M.Z.-C.); (A.F.)
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health-CIBERESP), 28001 Madrid, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development-Polytechnic of Guarda (UDI-IPG), 6300 Guarda, Portugal;
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
| | - Maria Teresa Herdeiro
- iBiMED–Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, 3800 Aveiro, Portugal; (É.C.); (M.E.)
- Correspondence:
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13
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Ciprut SE, Kelly MD, Walter D, Hoffman R, Becker DJ, Loeb S, Sedlander E, Tenner CT, Sherman SE, Zeliadt SB, Makarov DV. A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study. Urology 2020; 145:113-119. [PMID: 32721517 DOI: 10.1016/j.urology.2020.05.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/19/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS FIFTY SEVEN PERCENT: (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. CONCLUSION While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.
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Affiliation(s)
- Shannon E Ciprut
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY
| | - Matthew D Kelly
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY.
| | - Dawn Walter
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY
| | | | - Daniel J Becker
- VA New York Harbor Healthcare System, New York, NY; Department of Oncology, New York University, New York, NY; Perlmutter Cancer Center, New York University, New York, NY
| | - Stacy Loeb
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY
| | - Erica Sedlander
- Department of Prevention and Community Health, George Washington University, Milken Institute School of Public Health, Washington, DC
| | - Craig T Tenner
- VA New York Harbor Healthcare System, New York, NY; Department of Medicine - General Internal Medicine, New York University, New York, NY
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, NY; Department of Population Health, New York University, New York, NY
| | - Steven B Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Danil V Makarov
- VA New York Harbor Healthcare System, New York, NY; Department of Urology, New York University, New York, NY; Department of Population Health, New York University, New York, NY; Perlmutter Cancer Center, New York University, New York, NY; Robert F. Wagner Graduate School of Public Service, New York University, New York, NY
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14
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Reducing Antibiotic Prescription Errors in the Emergency Department: A Quality Improvement Initiative. Pediatr Qual Saf 2020; 5:e314. [PMID: 32766489 PMCID: PMC7339249 DOI: 10.1097/pq9.0000000000000314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 05/21/2020] [Indexed: 11/25/2022] Open
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15
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Salazar A, Karmiy SJ, Forsythe KJ, Amato MG, Wright A, Lai KH, Lambert BL, Liebovitz DM, Eguale T, Volk LA, Schiff GD. How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. Am J Health Syst Pharm 2020; 76:970-979. [PMID: 31361884 DOI: 10.1093/ajhp/zxz082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To examine the extent to which outpatient clinicians currently document drug indications in prescription instructions. METHODS Free-text sigs were extracted from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. Natural language processing was used to identify drug indications. The data set was analyzed to determine the rates at which prescribers included indications. It was stratified by provider specialty, drug class, and specific medications, to determine how often these indications were in prescriptions for as-needed (PRN) versus non-PRN medications. RESULTS During the study period, 4,356,086 prescriptions were ordered. Indications were included in 322,961 orders (7.41%). From these orders, 249,262 indications (77.18%) were written for PRN orders. Although internal medicine prescribers generated the highest number of medication orders, they included indications in only 6.26% of their prescriptions, whereas orthopedic surgery providers had the highest rate of documenting indications (33.41%). Pain was the most common indication, accounting for 30.35% of all documented indications. The drug class with the highest number of sigs-containing indications was narcotic analgesics. Non-PRN chronic medication prescriptions rarely included the indication. CONCLUSION Prescribers rarely included drug indications in electronic free-text prescription instructions, and, when they did, it was mostly for PRN uses such as pain.
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Affiliation(s)
- Alejandra Salazar
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston Medical Center, Boston, MA
| | | | | | - Mary G Amato
- Division of General Internal Medicine, Brigham and Women's Hospital, MCPHS University, Boston, MA
| | - Adam Wright
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kenneth H Lai
- Partners HealthCare, Somerville, MA, and Brandeis University, Waltham, MA
| | | | | | - Tewodros Eguale
- Division of General Internal Medicine, Brigham and Women's Hospital, MCPHS University, Boston, MA
| | | | - Gordon D Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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16
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Impact of an electronic best-practice advisory in combination with prescriber education on antibiotic prescribing for ambulatory adults with acute, uncomplicated bronchitis within a large integrated health system. Infect Control Hosp Epidemiol 2019; 40:1348-1355. [PMID: 31631834 DOI: 10.1017/ice.2019.295] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system. DESIGN This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017. SETTING Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics. PARTICIPANTS All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included. INTERVENTIONS A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis. RESULTS The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments. CONCLUSIONS An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.
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17
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Cole KA, Rivard KR, Dumkow LE. Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies. Curr Infect Dis Rep 2019; 21:33. [PMID: 31473861 DOI: 10.1007/s11908-019-0689-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Overutilization of antimicrobials is a known contributor to the development of antimicrobial resistance, which is a threat to global health. The goal of antimicrobial stewardship programs (ASPs) is to implement targeted interventions to reduce inappropriate antimicrobial prescribing and prevent development of antimicrobial resistance. We aim to review recently published literature focused on five categories of ASP interventions that have demonstrated success in optimizing appropriate antimicrobial use, improving patient outcomes, and fighting antimicrobial resistance. RECENT FINDINGS In the past year, ASP interventions in the published literature have focused on minimizing duration of antimicrobial therapy for infectious syndromes, implementing novel methods for performing prospective audit and feedback, utilizing microbiology laboratory or rapid diagnostic tests to expedite diagnosis, leveraging clinical decision support and electronic medical record tools, and performing penicillin allergy assessment. While the majority of studies assessing ASP interventions do not assess changes in antimicrobial resistance, outcomes demonstrating improved appropriate antibiotic use have been used as a surrogate. Successful ASPs should seek to implement and evaluate novel interventions targeting improvement in antimicrobial prescribing. Such interventions are of critical importance to prevent further growth of antimicrobial resistance.
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Affiliation(s)
- Kelli A Cole
- Department of Pharmacy Services, University of Toledo Medical Center, 3000 Arlington Ave. MS 1013, Toledo, OH, 43614, USA.
| | - Kaitlyn R Rivard
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Lisa E Dumkow
- Department of Pharmacy Services, Mercy Health Saint Mary's, 200 Jefferson SE, Grand Rapids, MI, 49503, USA.
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18
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Ayadurai S, Sunderland B, Tee LB, Hattingh HL. A training program incorporating a diabetes tool to facilitate delivery of quality diabetes care by community pharmacists in Malaysia and Australia. Pharm Pract (Granada) 2019; 17:1457. [PMID: 31275501 PMCID: PMC6594426 DOI: 10.18549/pharmpract.2019.2.1457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 06/02/2019] [Indexed: 11/24/2022] Open
Abstract
Objectives: To assess a clinical training program on management of Type 2 Diabetes Mellitus (T2DM) incorporating a diabetes tool, the Simpler™ tool. Subsequently pharmacists’ experience utilising the tool to deliver structured, consistent, evidence-based T2DM care was explored. Methods: Full-time non-credentialed diabetes pharmacists providing diabetes medication management services in community settings were purposively recruited. Participants had either face-to-face or online training on diabetes management using the tool which took about two hours and 20 minutes to complete. Their diabetes management knowledge was assessed pre- and post-training using quantitative methodology. They were then required to apply the tool in daily practice for one month. Feedback on both the training sessions and tool utilisation were obtained through semi-structured interviews and analysed using a qualitative approach. Results: Twelve pharmacists participated: Six from Australia and six from Malaysia. Before attending the training session, their median test score was 6.5/27, IQR 1.4 (1st marker) and 5.3/27, IQR 2.0 (2nd marker). After training, the scores doubled to 14.3/27, IQR 4.5 (1st marker) and 11.3/27, IQR 3.1 (2nd marker), showing significant improvements (p=0.002). Interview data identified perceived effectiveness factor through use of the tool. Participants found the content relevant, structured, concise and easy to understand; enabled comprehensive medication reviews; focused on achieving glycaemic improvement; facilitated documentation processes and pharmacists’ role in T2DM management; and as a specific aid for diabetes management. Barriers included lack of accessibility to patients’ laboratory data in Australia. Conclusions: The targeted training improved pharmacists’ knowledge on diabetes management and supported the Simpler™ tool use in practice as a structured and beneficial method to deliver evidence-based T2DM care.
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Affiliation(s)
- Shamala Ayadurai
- School of Pharmacy and Biomedical Sciences, Curtin University. Perth, WA (Australia).
| | - Bruce Sunderland
- School of Pharmacy and Biomedical Sciences, Curtin University. Perth, WA (Australia).
| | - Lisa B Tee
- School of Pharmacy and Biomedical Sciences, Curtin University. Perth, WA (Australia).
| | - H Laetitia Hattingh
- School of Pharmacy and Pharmacology, Griffith University. Gold Coast, QLD (Australia).
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19
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Keyworth C, Hart J, Armitage CJ, Tully MP. What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review. BMC Med Inform Decis Mak 2018; 18:93. [PMID: 30404638 PMCID: PMC6223001 DOI: 10.1186/s12911-018-0661-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023] Open
Abstract
Background Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation. Methods A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation. Results Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions. Conclusions Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Keyworth
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.
| | - J Hart
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK
| | - C J Armitage
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - M P Tully
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PL, UK
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20
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From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting. Curr Probl Pediatr Adolesc Health Care 2018; 48:289-305. [PMID: 30322711 DOI: 10.1016/j.cppeds.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.
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21
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Knowledge discovery and visualization in antimicrobial resistance surveillance systems: a scoping review. Artif Intell Rev 2018. [DOI: 10.1007/s10462-018-9659-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Ginzburg R, Conway JJ, Waltermaurer E, Song W, Jellinek-Cohen SP. Using Clinical Decision Support Within the Electronic Health Record to Reduce Incorrect Prescribing for Acute Sinusitis. J Patient Cent Res Rev 2018; 5:196-203. [PMID: 31414004 DOI: 10.17294/2330-0698.1619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose Acute sinusitis has viral etiology in more than 90% of cases, but antibiotics are prescribed for more than 80% of adults in the United States. While applications of computer-assisted guidelines have been found effective in reducing inaccurate prescribing for acute respiratory infections, there is a paucity of research focused specifically on the utilization of electronic best practice alerts (BPA) in improving treatment for acute sinusitis. Methods This observational cohort study examined prescribing behavior for sinusitis at a single Federally Qualified Health Center 1 year prior and during the first year of implementation of a BPA in the electronic health record (EHR) reminding providers of the recommended treatment of sinusitis. The advisory included a link to national guidelines and a note template was installed to assist providers in documentation. The BPA appeared on the providers' screen when an ICD-9 code of acute or bacterial sinusitis was entered during the patient visit. Results After adjusting for select patient and provider factors, the computer-assisted guidelines effectively reduced the overall antibiotic prescribing among these patients by 31% (relative risk: 0.69, 95% confidence interval: 0.51-0.95) and reduced incorrect prescribing from 88.5% to 78.7% (P=0.02). Conclusions Clinical reminders within the EHR can be an effective tool to reduce inappropriate antibiotic use and improve providers' decisions regarding the correct antibiotic choices for patients with acute sinusitis.
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Affiliation(s)
- Regina Ginzburg
- St. John's University, Queens, NY.,Institute for Family Health, New York, NY
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McDonagh MS, Peterson K, Winthrop K, Cantor A, Lazur BH, Buckley DI. Interventions to reduce inappropriate prescribing of antibiotics for acute respiratory tract infections: summary and update of a systematic review. J Int Med Res 2018; 46:3337-3357. [PMID: 29962311 PMCID: PMC6134646 DOI: 10.1177/0300060518782519] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective Antibiotic overuse contributes to antibiotic resistance and adverse
consequences. Acute respiratory tract infections (RTIs) are the most common
reason for antibiotic prescribing in primary care, but such infections often
do not require antibiotics. We summarized and updated a previously performed
systematic review of interventions to reduce inappropriate use of
antibiotics for acute RTIs. Methods To update the review, we searched MEDLINE®, the Cochrane Library (until
January 2018), and reference lists. Two reviewers selected the studies,
extracted the study data, and assessed the quality and strength of
evidence. Results Twenty-six interventions were evaluated in 95 mostly fair-quality studies.
The following four interventions had moderate-strength evidence of
improved/reduced antibiotic prescribing and low-strength evidence of no
adverse consequences: parent education (21% reduction, no increase return
visits), combined patient/clinician education (7% reduction, no change in
complications/satisfaction), procalcitonin testing for adults with RTIs of
the lower respiratory tract (12%–72% reduction, no increased adverse
consequences), and electronic decision support systems (24%–47% improvement
in appropriate prescribing, 5%–9% reduction, no increased
complications). Conclusions The best evidence supports use of specific educational interventions,
procalcitonin testing in adults, and electronic decision support to reduce
inappropriate antibiotic prescribing for acute RTIs without causing adverse
consequences.
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Affiliation(s)
- Marian S McDonagh
- 1 The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Kim Peterson
- 1 The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,6 Evidence-based Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Kevin Winthrop
- 2 Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, USA.,3 Department of Ophthalmology, Casey Eye Institute, Portland, OR, USA.,5 Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amy Cantor
- 1 The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,4 Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brittany H Lazur
- 1 The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - David I Buckley
- 1 The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,4 Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,5 Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA
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Nelson SD, Woodroof T, Liu W, Lehmann CU. Link between prescriptions and the electronic health record. Am J Health Syst Pharm 2018; 75:S29-S34. [DOI: 10.2146/ajhp170455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Scott D. Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Wing Liu
- HealthIT, Vanderbilt University Medical Center, Nashville, TN
| | - Christoph U. Lehmann
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
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25
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Kron K, Myers S, Volk L, Nathan A, Neri P, Salazar A, Amato MG, Wright A, Karmiy S, McCord S, Seoane-Vazquez E, Eguale T, Rodriguez-Monguio R, Bates DW, Schiff G. Incorporating medication indications into the prescribing process. Am J Health Syst Pharm 2018; 75:774-783. [DOI: 10.2146/ajhp170346] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Sara Myers
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | | | - Aaron Nathan
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Pamela Neri
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, and Partners Healthcare, Somerville, MA
| | - Alejandra Salazar
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Mary G. Amato
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, and MCPHS University, Boston, MA
| | - Adam Wright
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | | | - Tewodros Eguale
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
- MCPHS University, Boston, MA
| | | | - David W. Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Gordon Schiff
- Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Gifford J, Vaeth E, Richards K, Siddiqui T, Gill C, Wilson L, DeLisle S. Decision support during electronic prescription to stem antibiotic overuse for acute respiratory infections: a long-term, quasi-experimental study. BMC Infect Dis 2017; 17:528. [PMID: 28760143 PMCID: PMC5537944 DOI: 10.1186/s12879-017-2602-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 07/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to support decision-making can reduce inappropriate antibiotic use for acute respiratory infections (ARI), but they may not be sustainable. The objective of the study is to evaluate the long-term effectiveness of a clinical decision-support system (CDSS) interposed at the time of electronic (e-) prescriptions for selected antibiotics. METHODS This is a retrospective, observational intervention study, conducted within a large, statewide Veterans Affairs health system. Participants are outpatients with an initial visit for ARI. A CDSS was deployed upon e-prescription of selected antibiotics during the study period. From 01/2004 to 05/2006 (pre-withdrawal period), the CDSS targeted azithromycin and the fluoroquinolone gatifloxacin. From 05/2006 to 12/2011 (post-withdrawal period), the CDSS was retained for azithromycin but withdrawn for the fluoroquinolone. A manual record review was conducted to determine concordance of antibiotic prescription with ARI treatment guidelines. RESULTS Of 1131 included ARI visits, 380 (33.6%) were guideline-concordant. For azithromycin, concordance did not change between the pre- and post-withdrawal periods, and adjusted odds of concordance was 8.8 for the full study period, compared to unrestricted antibiotics. For fluoroquinolones, guideline concordance decreased from 88.6% (39 of 44 visits) to 51.3% (59 of 115 visits), pre- vs. post-withdrawal periods (p < 0.005). The adjusted odds of concordance compared to "All Other Antibiotics" visits decreased from 24.4 (95% CI 9.0-66.3) pre-withdrawal to 5.5 (95% CI 3.5-8.8) post-withdrawal (p = .008). Concordance did not change between those same time periods for antibiotics that were never subjected to the intervention ("All Other Antibiotics"). CONCLUSIONS A CDSS interposed at the time of e-prescription of selected antibiotics can shift their use toward ARI treatment guidelines, and this effect can be maintained over the long term as long as the CDSS remains in place. Removal of the CDSS after 3.5 years of implementation resulted in a rise in guideline-discordant antibiotic use.
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Affiliation(s)
- Jeneen Gifford
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.,School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Elisabeth Vaeth
- Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | | | - Tariq Siddiqui
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.,School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Christine Gill
- School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | - Sylvain DeLisle
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA. .,School of Medicine, University of Maryland, Baltimore, MD, USA. .,Professor of Medicine and Clinical Sciences, University of Texas Southwestern, 8B, Building 2, Dallas VA Medical Center, 4500 S Lancaster Rd, Dallas, TX, 75216, USA.
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27
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Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc (2003) 2017; 57:464-473. [DOI: 10.1016/j.japh.2017.03.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/07/2017] [Accepted: 03/31/2017] [Indexed: 01/10/2023]
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Henry NL, Braun TM, Breslin TM, Gorski DH, Silver SM, Griggs JJ. Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry. Cancer 2017; 123:2975-2983. [PMID: 28301680 DOI: 10.1002/cncr.30674] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/14/2017] [Accepted: 02/18/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care. METHODS Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record. RESULTS Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease. CONCLUSION Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.
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Affiliation(s)
- N Lynn Henry
- Huntsman Cancer Institute, Salt Lake City, Utah.,University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas M Braun
- University of Michigan School of Public Health, Ann Arbor, Michigan
| | | | - David H Gorski
- Wayne State University School of Medicine, Detroit, Michigan.,Barbara Ann Karmanos Cancer Institute, Detroit, Michigan
| | | | - Jennifer J Griggs
- University of Michigan School of Public Health, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
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29
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Rawson TM, Moore LSP, Hernandez B, Charani E, Castro-Sanchez E, Herrero P, Hayhoe B, Hope W, Georgiou P, Holmes AH. A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately? Clin Microbiol Infect 2017; 23:524-532. [PMID: 28268133 DOI: 10.1016/j.cmi.2017.02.028] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. METHOD PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. RESULTS Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. CONCLUSION Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.
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Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - B Hernandez
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - E Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - E Castro-Sanchez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - B Hayhoe
- School of Public Health, Imperial College, London, UK
| | - W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
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31
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Foraker RE, Shoben AB, Kelley MM, Lai AM, Lopetegui MA, Jackson RD, Langan MA, Payne PR. Electronic health record-based assessment of cardiovascular health: The stroke prevention in healthcare delivery environments (SPHERE) study. Prev Med Rep 2016; 4:303-8. [PMID: 27486559 PMCID: PMC4959947 DOI: 10.1016/j.pmedr.2016.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/21/2016] [Accepted: 07/08/2016] [Indexed: 12/30/2022] Open
Abstract
< 3% of Americans have ideal cardiovascular health (CVH). The primary care encounter provides a setting in which to conduct patient-provider discussions of CVH. We implemented a CVH risk assessment, visualization, and decision-making tool that automatically populates with electronic health record (EHR) data during the encounter in order to encourage patient-centered CVH discussions among at-risk, yet under-treated, populations. We quantified five of the seven CVH behaviors and factors that were available in The Ohio State University Wexner Medical Center's EHR at baseline (May–July 2013) and compared values to those ascertained at one-year (May–July 2014) among intervention (n = 109) and control (n = 42) patients. The CVH of women in the intervention clinic improved relative to the metrics of body mass index (16% to 21% ideal) and diabetes (62% to 68% ideal), but not for smoking, total cholesterol, or blood pressure. Meanwhile, the CVH of women in the control clinic either held constant or worsened slightly as measured using those same metrics. Providers need easy-to-use tools at the point-of-care to help patients improve CVH. We demonstrated that the EHR could deliver such a tool using an existing American Heart Association framework, and we noted small improvements in CVH in our patient population. Future work is needed to assess how to best harness the potential of such tools in order to have the greatest impact on the CVH of a larger patient population. Use and adoption of health information technology advances quality in patient care. Healthcare systems need tools to enhance primary prevention at the point-of-care. Providers and patients have shared accountability for population health metrics.
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Key Words
- 95% CI, 95% confidence interval
- ACC, American College of Cardiology
- AHA, American Heart Association
- CDS, clinical decision support
- CVH, cardiovascular health
- Disease management
- EHR, electronic health record
- GEE, generalized estimation equation
- Health outcomes
- Medical informatics
- OSUWMC, Ohio State University Wexner Medical Center
- Prevention
- Primary care
- SD, standard deviation
- SPHERE, stroke prevention in healthcare delivery environments
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Affiliation(s)
- Randi E. Foraker
- The Ohio State University College of Public Health, Columbus, OH 43210, United States
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
- Corresponding author at: The Ohio State University College of Public Health, 1841 Neil Avenue, Columbus, OH 43210, United States.The Ohio State University College of Public Health1841 Neil AvenueColumbusOH43210United States
| | - Abigail B. Shoben
- The Ohio State University College of Public Health, Columbus, OH 43210, United States
| | - Marjorie M. Kelley
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
| | - Albert M. Lai
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
| | - Marcelo A. Lopetegui
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Rebecca D. Jackson
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
| | - Michael A. Langan
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
| | - Philip R.O. Payne
- The Ohio State University College of Public Health, Columbus, OH 43210, United States
- The Ohio State University College of Medicine, Columbus, OH 43210, United States
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Zou G, Wei X, Hicks JP, Hu Y, Walley J, Zeng J, Elsey H, King R, Zhang Z, Deng S, Huang Y, Blacklock C, Yin J, Sun Q, Lin M. Protocol for a pragmatic cluster randomised controlled trial for reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China. BMJ Open 2016; 6:e010544. [PMID: 27235297 PMCID: PMC4885273 DOI: 10.1136/bmjopen-2015-010544] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Irrational use of antibiotics is a serious issue within China and internationally. In 2012, the Chinese Ministry of Health issued a regulation for antibiotic prescriptions limiting them to <20% of all prescriptions for outpatients, but no operational details have been issued regarding policy implementation. This study aims to test the effectiveness of a multidimensional intervention designed to reduce the use of antibiotics among children (aged 2-14 years old) with acute upper respiratory infections in rural primary care settings in China, through changing doctors' prescribing behaviours and educating parents/caregivers. METHODS AND ANALYSIS This is a pragmatic, parallel-group, controlled, cluster-randomised superiority trial, with blinded evaluation of outcomes and data analysis, and un-blinded treatment. From two counties in Guangxi Province, 12 township hospitals will be randomised to the intervention arm and 13 to the control arm. In the control arm, the management of antibiotics prescriptions will continue through usual care via clinical consultations. In the intervention arm, a provider and patient/caregiver focused intervention will be embedded within routine primary care practice. The provider intervention includes operational guidelines, systematic training, peer review of antibiotic prescribing and provision of health education to patient caregivers. We will also provide printed educational materials and educational videos to patients' caregivers. The primary outcome is the proportion of all prescriptions issued by providers for upper respiratory infections in children aged 2-14 years old, which include at least one antibiotic. ETHICS AND DISSEMINATION The trial has received ethical approval from the Ethics Committee of Guangxi Provincial Centre for Disease Control and Prevention, China. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION NUMBER ISRCTN14340536; Pre-results.
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Affiliation(s)
- Guanyang Zou
- China Global Health Research and Development, Shenzhen, China
| | - Xiaolin Wei
- China Global Health Research and Development, Shenzhen, China
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Yanhong Hu
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Helen Elsey
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Yuanyuan Huang
- China Global Health Research and Development, Shenzhen, China
| | - Claire Blacklock
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jia Yin
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Qiang Sun
- Centre for Health Management and Policy, Shandong University, Jinan, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
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McGinn T. Putting Meaning into Meaningful Use: A Roadmap to Successful Integration of Evidence at the Point of Care. JMIR Med Inform 2016; 4:e16. [PMID: 27199223 PMCID: PMC4891572 DOI: 10.2196/medinform.4553] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 08/26/2015] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
Pressures to contain health care costs, personalize patient care, use big data, and to enhance health care quality have highlighted the need for integration of evidence at the point of care. The application of evidence-based medicine (EBM) has great promise in the era of electronic health records (EHRs) and health technology. The most successful integration of evidence into EHRs has been complex decision tools that trigger at a critical point of the clinical visit and include patient specific recommendations.
The objective of this viewpoint paper is to investigate why the incorporation of complex CDS tools into the EMR is equally complex and continues to challenge health service researchers and implementation scientists. Poor adoption and sustainability of EBM guidelines and CDS tools at the point of care have persisted and continue to document low rates of usage. The barriers cited by physicians include efficiency, perception of usefulness, information content, user interface, and over-triggering.
Building on the traditional EHR implementation frameworks, we review keys strategies for successful CDSs: (1) the quality of the evidence, (2) the potential to reduce unnecessary care, (3) ease of integrating evidence at the point of care, (4) the evidence’s consistency with clinician perceptions and preferences, (5) incorporating bundled sets or automated documentation, and (6) shared decision making tools.
As EHRs become commonplace and insurers demand higher quality and evidence-based care, better methods for integrating evidence into everyday care are warranted. We have outlined basic criteria that should be considered before attempting to integrate evidenced-based decision support tools into the EHR.
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Affiliation(s)
- Thomas McGinn
- Hofstra North Shore LII School of Medicine, Manhasset, NY, United States.
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Hwang AY, Gums JG. The emergence and evolution of antimicrobial resistance: Impact on a global scale. Bioorg Med Chem 2016; 24:6440-6445. [PMID: 27117692 DOI: 10.1016/j.bmc.2016.04.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
The evolution of antimicrobial resistance is a multifaceted issue that is influenced by numerous factors. This growing healthcare problem has significantly impacted the public welfare and has substantially burdened the economic system on a global scale. In an effort to combat this rising problem, several strategies have been implemented in the recent years to stall the progression and decrease the emergence of antimicrobial resistance. The aim of this review article is to describe the various factors that have contributed to the current state of antimicrobial resistance and to evaluate potential strategies developed to reduce the burden of antimicrobial resistance.
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Affiliation(s)
- Andrew Y Hwang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609, USA.
| | - John G Gums
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609, USA
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35
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Initial Experience of the American Society of Regional Anesthesia and Pain Medicine Coags Regional Smartphone Application. Reg Anesth Pain Med 2016; 41:334-8. [DOI: 10.1097/aap.0000000000000391] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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The Value of Imaging Part II: Value beyond Image Interpretation. Acad Radiol 2016; 23:23-9. [PMID: 26683509 DOI: 10.1016/j.acra.2015.09.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/09/2015] [Accepted: 09/20/2015] [Indexed: 12/21/2022]
Abstract
Although image interpretation is an essential part of radiologists' value, there are other ways in which we contribute to patient care. Part II of the value of imaging series reviews current initiatives that demonstrate value beyond the image interpretation. Standardizing processes, reducing the radiation dose of our examinations, clarifying written reports, improving communications with patients and providers, and promoting appropriate imaging through decision support are all ways we can provide safer, more consistent, and higher quality care. As payers and policy makers push to drive value, research that demonstrates the value of these endeavors, or lack thereof, will become increasingly sought after and supported.
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Dragan IF, Newman M, Stark P, Steffensen B, Karimbux N. Using a Simulated Infobutton Linked to an Evidence-Based Resource to Research Drug-Drug Interactions: A Pilot Study with Third-Year Dental Students. J Dent Educ 2015. [DOI: 10.1002/j.0022-0337.2015.79.11.tb06032.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Irina F. Dragan
- Department of Periodontology; Tufts University School of Dental Medicine
| | - Michael Newman
- University of California; Los Angeles School of Dentistry
| | - Paul Stark
- Tufts University School of Dental Medicine
| | - Bjorn Steffensen
- Department of Periodontology; Tufts University School of Dental Medicine
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Foraker RE, Kite B, Kelley MM, Lai AM, Roth C, Lopetegui MA, Shoben AB, Langan M, Rutledge NL, Payne PRO. EHR-based Visualization Tool: Adoption Rates, Satisfaction, and Patient Outcomes. EGEMS (WASHINGTON, DC) 2015; 3:1159. [PMID: 26290891 PMCID: PMC4537147 DOI: 10.13063/2327-9214.1159] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Electronic health records (EHRs) have the potential to enhance patient-provider communication and improve patient outcomes. However, in order to impact patient care, clinical decision support (CDS) and communication tools targeting such needs must be integrated into clinical workflow and be flexible with regard to the changing health care landscape. DESIGN The Stroke Prevention in Healthcare Delivery Environments (SPHERE) team developed and implemented the SPHERE tool, an EHR-based CDS visualization, to enhance patient-provider communication around cardiovascular health (CVH) within an outpatient primary care setting of a large academic medical center. IMPLEMENTATION We describe our successful CDS alert implementation strategy and report adoption rates. We also present results of a provider satisfaction survey showing that the SPHERE tool delivers appropriate content in a timely manner. Patient outcomes following implementation of the tool indicate one-year improvements in some CVH metrics, such as body mass index and diabetes. DISCUSSION Clinical decision-making and practices change rapidly and in parallel to simultaneous changes in the health care landscape and EHR usage. Based on these observations and our preliminary results, we have found that an integrated, extensible, and workflow-aware CDS tool is critical to enhancing patient-provider communications and influencing patient outcomes.
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Forrest GN, Van Schooneveld TC, Kullar R, Schulz LT, Duong P, Postelnick M. Use of electronic health records and clinical decision support systems for antimicrobial stewardship. Clin Infect Dis 2015; 59 Suppl 3:S122-33. [PMID: 25261539 DOI: 10.1093/cid/ciu565] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Electronic health records (EHRs) and clinical decision support systems (CDSSs) have the potential to enhance antimicrobial stewardship. Numerous EHRs and CDSSs are available and have the potential to enable all clinicians and antimicrobial stewardship programs (ASPs) to more efficiently review pharmacy, microbiology, and clinical data. Literature evaluating the impact of EHRs and CDSSs on patient outcomes is lacking, although EHRs with integrated CDSSs have demonstrated improvements in clinical and economic outcomes. Both technologies can be used to enhance existing ASPs and their implementation of core ASP strategies. Resolution of administrative, legal, and technical issues will enhance the acceptance and impact of these systems. EHR systems will increase in value when manufacturers include integrated ASP tools and CDSSs that do not require extensive commitment of information technology resources. Further research is needed to determine the true impact of current systems on ASP and the ultimate goal of improved patient outcomes through optimized antimicrobial use.
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Affiliation(s)
- Graeme N Forrest
- Division of Infectious Diseases, Portland Veterans Affairs Medical Center, Portland, Oregon
| | | | - Ravina Kullar
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | | | - Phu Duong
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
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Rush J, Postelnick M, Schulz L. Use of Electronic Health Record Clinical Decision Support Tools in Antimicrobial Stewardship Activities. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0042-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Clinical decision support system in medical knowledge literature review. INFORMATION TECHNOLOGY & MANAGEMENT 2015. [DOI: 10.1007/s10799-015-0216-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Dempsey PP, Businger AC, Whaley LE, Gagne JJ, Linder JA. Primary care clinicians' perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC FAMILY PRACTICE 2014; 15:194. [PMID: 25495918 PMCID: PMC4275949 DOI: 10.1186/s12875-014-0194-5] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Abstract
Background Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated. Methods To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis. Results All the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians’ misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits. Conclusions Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients’ expectations. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0194-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick P Dempsey
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | - Alexandra C Businger
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | - Lauren E Whaley
- Bureau of Infectious Diseases, Massachusetts Department of Public Health, Boston, MA, USA.
| | - Joshua J Gagne
- Survey and Data Management Core, Dana Farber Cancer Institute, Boston, MA, USA.
| | - Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA.
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McCullagh L, Mann D, Rosen L, Kannry J, McGinn T. Longitudinal adoption rates of complex decision support tools in primary care. ACTA ACUST UNITED AC 2014; 19:204-9. [PMID: 25238769 DOI: 10.1136/ebmed-2014-110054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Translating research findings into practice promises to standardise care. Translation includes the integration of evidence-based guidelines at the point of care, discerning the best methods to disseminate research findings and models to sustain the implementation of best practices.By applying usability testing to clinical decision support(CDS) design, overall adoption rates of 60% can be realised.What has not been examined is how long adoption rates are sustained and the characteristics associated with long-term use. We conducted secondary analysis to decipher the factors impacting sustained use of CD Stools. This study was a secondary data analysis from a clinical trial conducted at an academic institution in New York City. Study data was identified patients electronic health records (EHR). The trial was to test the implementation of an integrated clinical prediction rule(iCPR) into the EHR. The primary outcome variable was iCPR tool acceptance of the tool. iCPR tool completion and iCPR smartest completion were additional outcome variables of interest. The secondary aim was to examine user characteristics associated with iCPR tool use in later time periods. Characteristics of interest included age, resident year, use of electronic health records (yes/no) and use of best practice alerts (BPA) (yes/no). Generalised linear mixed models (GLiMM) were used to compare iCPR use over time for each outcome of interest: namely, iCPR acceptance, iCPR completion and iCPR smartset completion.GLiMM was also used to examine resident characteristics associated with iCPR tool use in later time periods; specifically, intermediate and long-term (ie, 90+days). The tool was accepted, on average, 82.18% in the first 90 days (short-term period). The use decreases to 56.07% and 45.61% in intermediate and long-term time periods, respectively. There was a significant association between iCPR tool completion and time periods(p<0.0001). There was no significant difference in iCPR tool completion between resident encounters in the intermediate and long-term periods (p<0.6627). There was a significant association between iCPR smartset completion and time periods (p<0.0021). There were no significant associations between iCPR smartest completion and any of the four predictors of interest. We examined the frequencies of components of the iCPR tool being accepted over time by individual clinicians. Rates of adoption of the different components of the tool decreased substantially over time. The data suggest that over time and prolonged exposure to CDS tools, providers are less likely to utilise the tool. It is not clear if it is fatigue with the CDS tool, acquired knowledge of the clinical prediction rule, or gained clinical experience and gestalt that are influencing adoption rates. Further analysis of individual adoption rates over time and the impact it has on clinical outcomes should be conducted.
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Affiliation(s)
- Lauren McCullagh
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York, USA
| | - Devin Mann
- Department of Medicine, Section of Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lisa Rosen
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York, USA
| | - Joseph Kannry
- Department of Medicine, Division of General Internal Medicine, Mount Sinai School of Medicine, New York, New York, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York, USA
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Mann D, Knaus M, McCullagh L, Sofianou A, Rosen L, McGinn T, Kannry J. Measures of user experience in a streptococcal pharyngitis and pneumonia clinical decision support tools. Appl Clin Inform 2014; 5:824-35. [PMID: 25298820 PMCID: PMC4187097 DOI: 10.4338/aci-2014-04-ra-0043] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 08/09/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To understand clinician adoption of CDS tools as this may provide important insights for the implementation and dissemination of future CDS tools. MATERIALS AND METHODS Clinicians (n=168) at a large academic center were randomized into intervention and control arms to assess the impact of strep and pneumonia CDS tools. Intervention arm data were analyzed to examine provider adoption and clinical workflow. Electronic health record data were collected on trigger location, the use of each component and whether an antibiotic, other medication or test was ordered. Frequencies were tabulated and regression analyses were used to determine the association of tool component use and physician orders. RESULTS The CDS tool was triggered 586 times over the study period. Diagnosis was the most frequent workflow trigger of the CDS tool (57%) as compared to chief complaint (30%) and diagnosis/antibiotic combinations (13%). Conversely, chief complaint was associated with the highest rate (83%) of triggers leading to an initiation of the CDS tool (opening the risk prediction calculator). Similar patterns were noted for initiation of the CDS bundled ordered set and completion of the entire CDS tool pathway. Completion of risk prediction and bundled order set components were associated with lower rates of antibiotic prescribing (OR 0.5; CI 0.2-1.2 and OR 0.5; CI 0.3-0.9, respectively). DISCUSSION Different CDS trigger points in the clinician user workflow lead to substantial variation in downstream use of the CDS tool components. These variations were important as they were associated with significant differences in antibiotic ordering. CONCLUSIONS These results highlight the importance of workflow integration and flexibility for CDS success.
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Affiliation(s)
- D. Mann
- Department of Medicine, Section of Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, MA, USA
| | - M. Knaus
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - L. McCullagh
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - A. Sofianou
- Department of Medicine, Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - L. Rosen
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - T. McGinn
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - J. Kannry
- Department of Medicine, Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY, USA
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Kullar R, Goff DA. Transformation of antimicrobial stewardship programs through technology and informatics. Infect Dis Clin North Am 2014; 28:291-300. [PMID: 24857394 DOI: 10.1016/j.idc.2014.01.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The successful integration of technology in antimicrobial stewardship programs has made it possible for clinicians to function more efficiently. With government endorsement of electronic health records (EHRs), EHRs and clinical decision support systems (CDSSs) are being used as decision support tools to aid clinicians in efforts to improve antibiotic use. Likewise, medical applications (apps) have provided educational tools easily accessible to clinicians through their mobile devices. In this article, the impact that informatics and technology have had on promoting antibiotic stewardship is described, focusing on EHRs and CDSSs, apps, electronic resources, and social media.
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Affiliation(s)
- Ravina Kullar
- Cubist Pharmaceuticals, Department of Medical Affairs, 55 Hayden Avenue, Lexington, MA 02421, USA.
| | - Debra A Goff
- Infectious Diseases, Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Room 368, Doan Hall, Columbus, OH 43210, USA
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Alweis R, Greco M, Wasser T, Wenderoth S. An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis. J Community Hosp Intern Med Perspect 2014; 4:22958. [PMID: 24596644 PMCID: PMC3937558 DOI: 10.3402/jchimp.v4.22958] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/31/2013] [Accepted: 01/03/2014] [Indexed: 11/27/2022] Open
Abstract
Background Upper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues. Methods The primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines. Results After the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7–57.58% (p=0.086) and 24.0–25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed. Conclusions Passive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.
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Affiliation(s)
- Richard Alweis
- Department of Medicine, The Reading Hospital and Medical Center, West Reading, PA, USA ; Department of Medicine, Jefferson Medical College, Philadelphia, PA, USA
| | | | - Thomas Wasser
- Consult-Stat: Complete Statistical Services, Macungie, PA, USA
| | - Suzanne Wenderoth
- Department of Medicine, The Reading Hospital and Medical Center, West Reading, PA, USA
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Palmay L, Walker SAN, Leis JA, Taggart LR, Lee C, Daneman N. Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014. [DOI: 10.1007/s40506-013-0008-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bright TJ. Transforming user needs into functional requirements for an antibiotic clinical decision support system: explicating content analysis for system design. Appl Clin Inform 2013; 4:618-35. [PMID: 24454586 DOI: 10.4338/aci-2013-08-ra-0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 11/11/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many informatics studies use content analysis to generate functional requirements for system development. Explication of this translational process from qualitative data to functional requirements can strengthen the understanding and scientific rigor when applying content analysis in informatics studies. OBJECTIVE To describe a user-centered approach transforming emergent themes derived from focus group data into functional requirements for informatics solutions and to illustrate these methods to the development of an antibiotic clinical decision support system (CDS). METHODS THE APPROACH CONSISTED OF FIVE STEPS: 1) identify unmet therapeutic planning information needs via Focus Group Study-I, 2) develop a coding framework of therapeutic planning themes to refine the domain scope to antibiotic therapeutic planning, 3) identify functional requirements of an antibiotic CDS system via Focus Group Study-II, 4) discover informatics solutions and functional requirements from coded data, and 5) determine the types of information needed to support the antibiotic CDS system and link with the identified informatics solutions and functional requirements. RESULTS The coding framework for Focus Group Study-I revealed unmet therapeutic planning needs. Twelve subthemes emerged and were clustered into four themes; analysis indicated a need for an antibiotic CDS intervention. Focus Group Study-II included five types of information needs. Comments from the Barrier/Challenge to information access and Function/Feature themes produced three informatics solutions and 13 functional requirements of an antibiotic CDS system. Comments from the Patient, Institution, and Domain themes generated required data elements for each informatics solution. CONCLUSION This study presents one example explicating content analysis of focus group data and the analysis process to functional requirements from narrative data. Illustration of this 5-step method was used to develop an antibiotic CDS system, resolving unmet antibiotic prescribing needs. As a reusable approach, these techniques can be refined and applied to resolve unmet information needs with informatics interventions in additional domains.
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Affiliation(s)
- T J Bright
- Columbia University, Biomedical Informatics, New York , New York, United States
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Ackerman SL, Gonzales R, Stahl MS, Metlay JP. One size does not fit all: evaluating an intervention to reduce antibiotic prescribing for acute bronchitis. BMC Health Serv Res 2013; 13:462. [PMID: 24188573 PMCID: PMC4228248 DOI: 10.1186/1472-6963-13-462] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 10/22/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians. METHODS Clinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29). RESULTS Compared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions-including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components' effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy. CONCLUSIONS Future efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA.
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Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest. Resuscitation 2013; 85:138-42. [PMID: 24056391 DOI: 10.1016/j.resuscitation.2013.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 08/09/2013] [Accepted: 09/04/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Adherence to advanced cardiac life support (ACLS) guidelines during in-hospital cardiac arrest (IHCA) is associated with improved outcomes, but current evidence shows that sub-optimal care is common. Successful execution of such protocols during IHCA requires rapid patient assessment and the performance of a number of ordered, time-sensitive interventions. Accordingly, we sought to determine whether the use of an electronic decision support tool (DST) improves performance during high-fidelity simulations of IHCA. METHODS After IRB approval and written informed consent was obtained, 47 senior medical students were enrolled. All participants were ACLS certified and within one month of graduation. Each participant was issued an iPod Touch device with a DST installed that contained all ACLS management algorithms. Participants managed two scenarios of IHCA and were allowed to use the DST in one scenario and prohibited from using it in the other. All participants managed the same scenarios. Simulation sessions were video recorded and graded by trained raters according to previously validated checklists. RESULTS Performance of correct protocol steps was significantly greater with the DST than without (84.7% v 73.8%, p<0.001) and participants committed significantly fewer additional errors when using the DST (2.5 errors vs. 3.8 errors, p<0.012). CONCLUSION Use of an electronic DST provided a significant improvement in the management of simulated IHCA by senior medical students as measured by adherence to published guidelines.
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