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Bogale TN, Derseh L, Abraham L, Willems H, Metzger J, Abere B, Tilaye M, Hailegeberel T, Bekele TA. Effect of electronic records on mortality among patients in hospital and primary healthcare settings: a systematic review and meta-analyses. Front Digit Health 2024; 6:1377826. [PMID: 38988733 PMCID: PMC11233798 DOI: 10.3389/fdgth.2024.1377826] [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: 01/28/2024] [Accepted: 06/13/2024] [Indexed: 07/12/2024] Open
Abstract
Background Electronic medical records or electronic health records, collectively called electronic records, have significantly transformed the healthcare system and service provision in our world. Despite a number of primary studies on the subject, reports are inconsistent and contradictory about the effects of electronic records on mortality. Therefore, this review examined the effect of electronic records on mortality. Methods The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline. Six databases: PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and Google Scholar, were searched from February 20 to October 25, 2023. Studies that assessed the effect of electronic records on mortality and were published between 1998 and 2022 were included. Joanna Briggs Institute quality appraisal tool was used to assess the methodological quality of the studies. Narrative synthesis was performed to identify patterns across studies. Meta-analysis was conducted using fixed effect and random-effects models to estimate the pooled effect of electronic records on mortality. Funnel plot and Egger's regression test were used to assess for publication bias. Results Fifty-four papers were found eligible for the systematic review, of which 42 were included in the meta-analyses. Of the 32 studies that assessed the effect of electronic health record on mortality, eight (25.00%) reported a statistically significant reduction in mortality, 22 (68.75%) did not show a statistically significant difference, and two (6.25%) studies reported an increased risk of mortality. Similarly, among the 22 studies that determined the effect of electronic medical record on mortality, 12 (54.55%) reported a statistically significant reduction in mortality, and ten (45.45%) studies didn't show a statistically significant difference. The fixed effect and random effects on mortality were OR = 0.95 (95% CI: 0.93-0.97) and OR = 0.94 (95% CI: 0.89-0.99), respectively. The associated I-squared was 61.5%. Statistical tests indicated that there was no significant publication bias among the studies included in the meta-analysis. Conclusion Despite some heterogeneity among the studies, the review indicated that the implementation of electronic records in inpatient, specialized and intensive care units, and primary healthcare facilities seems to result in a statistically significant reduction in mortality. Maturity level and specific features may have played important roles. Systematic Review Registration PROSPERO (CRD42023437257).
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Affiliation(s)
| | | | - Loko Abraham
- John Snow Research and Training Institute, Inc. (JSI), Addis Ababa, Ethiopia
| | - Herman Willems
- John Snow Research and Training Institute, Inc. (JSI), Boston, MA, United States
| | - Jonathan Metzger
- John Snow Research and Training Institute, Inc. (JSI), Washington, DC, United States
| | - Biruhtesfa Abere
- John Snow Research and Training Institute, Inc. (JSI), Addis Ababa, Ethiopia
| | - Mesfin Tilaye
- United State Agency for International Development, Addis Ababa, Ethiopia
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Abstract
Background Antimicrobial stewardship (AMS) programmes in hospitals support optimal antimicrobial use by utilizing strategies such as restriction policies and education. Several systematic reviews on digital interventions supporting AMS have been conducted but they have focused on specific interventions and outcomes. Objectives To provide a systematic overview and synthesis of evidence on the effectiveness of digital interventions to improve antimicrobial prescribing and monitoring in hospitals. Methods Multiple databases were searched from 2010 onwards. Review papers were eligible if they included studies that examined the effectiveness of AMS digital interventions in an inpatient hospital setting. Papers were excluded if they were not systematic reviews, were limited to a paediatric setting, or were not in English. Results Eight systematic reviews were included for data extraction. A large number of digital interventions were evaluated, with a strong focus on clinical decision support. Due to the heterogeneity of the interventions and outcome measures, a meta-analysis could not be performed. The majority of reviews reported that digital interventions reduced antimicrobial use and improved antimicrobial appropriateness. The impact of digital interventions on clinical outcomes was inconsistent. Conclusions Digital interventions reduce antimicrobial use and improve antimicrobial appropriateness in hospitals, but no firm conclusions can be drawn about the degree to which different types of digital interventions achieve these outcomes. Evaluation of sociotechnical aspects of digital intervention implementation is limited, despite the critical role that user acceptance, uptake and feasibility play in ensuring improvements in AMS are achieved with digital health.
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Affiliation(s)
| | - Jonathan Penm
- The University of Sydney, School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Angus Ritchie
- Health Informatics Unit, Sydney Local Health District, Camperdown, Australia
- The University of Sydney, Faculty of Medicine and Health, Concord Clinical School, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- The University of Sydney, Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, Sydney, New South Wales, Australia
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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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Cordasco KM, Yuan AH, Danz MJ, Jackson L, Yee EF, Tcheung LS, Washington DL. Veterans Health Administration Primary Care Provider Adherence to Prescribing Guidelines for Systemic Hormone Therapy in Menopausal Women. J Healthc Qual 2020; 41:99-109. [PMID: 30839493 DOI: 10.1097/jhq.0000000000000183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Systemic hormone therapy (HT) is effective for treating menopausal symptoms but also confers risks. Therefore, experts have developed clinical guidelines for its use. PURPOSE We assessed primary care guideline adherence in prescribing systemic HT, and associations between adherence and provider characteristics, in four Veterans Health Administration (VA) facilities. METHODS We abstracted medical records associated with new and renewal systemic HT prescriptions examining adherence to guidelines for documenting indications and contraindications; prescribing appropriate dosages; and prescribing progesterone. RESULTS Average guideline adherence was 58%. Among new prescriptions, 74% documented a guideline-adherent indication and 28% documented absence of contraindications. Among renewals, 39% documented a guideline-adherent indication. In prescribing an appropriate dose, 45% of new prescriptions were guideline-adherent. Among renewal prescriptions with conjugated equine estrogen doses ≥0.625 mg or equivalent, 16% documented the dosing rationale. Among 116 prescriptions for systemic estrogen in women with a uterus, progesterone was not prescribed in 8. CONCLUSIONS Guideline adherence in prescribing systemic HT was low among VA primary care providers. Failures to coprescribe progesterone put women at increased risk for endometrial cancer. IMPLICATIONS Intervention development is urgently needed to improve guideline adherence among primary care prescribers of systemic HT for menopause. Similar assessments should be conducted in community settings.
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Akhloufi H, Verhaegh SJC, Jaspers MWM, Melles DC, van der Sijs H, Verbon A. A usability study to improve a clinical decision support system for the prescription of antibiotic drugs. PLoS One 2019; 14:e0223073. [PMID: 31553785 PMCID: PMC6760771 DOI: 10.1371/journal.pone.0223073] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/12/2019] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE A clinical decision support system (CDSS) for empirical antibiotic treatment has the potential to increase appropriate antibiotic use. Before using such a system on a broad scale, it needs to be tailored to the users preferred way of working. We have developed a CDSS for empirical antibiotic treatment in hospitalized adult patients. Here we determined in a usability study if the developed CDSS needed changes. METHODS Four prespecified patient cases, based on real life clinical scenarios, were evaluated by 8 medical residents in the study. The "think-aloud" method was used, and sessions were recorded and analyzed afterwards. Usability was assessed by 3 evaluators using an augmented classification scheme, which combines the User Action Framework with severity rating of the usability problems and the assessment of the potential impact of these problems on the final task outcomes. RESULTS In total 51 usability problems were identified, which could be grouped into 29 different categories. Most (n = 17/29) of the usability problems were cosmetic problems or minor problems. Eighteen (out of 29) of the usability categories could have an ordering error as a result. Classification of the problems showed that some of the problems would get a low priority based on their severity rating, but got a high priority for their impact on the task outcome. This effectively provided information to prioritize system redesign efforts. CONCLUSION Usability studies improve lay-out and functionality of a CDSS for empirical antibiotic treatment, even after development by a multidisciplinary system.
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Affiliation(s)
- H. Akhloufi
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S. J. C. Verhaegh
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M. W. M. Jaspers
- Department of Medical Informatics, Center for Human Factors Engineering of Health Information Technology (HIT-Lab), Academic Medical Center, Amsterdam, the Netherlands
| | - D. C. Melles
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - H. van der Sijs
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A. Verbon
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
- * E-mail:
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Hijazi K, Joshi C, Gould IM. Challenges and opportunities for antimicrobial stewardship in resource-rich and resource-limited countries. Expert Rev Anti Infect Ther 2019; 17:621-634. [PMID: 31282277 DOI: 10.1080/14787210.2019.1640602] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Inappropriate prescription practices, patient and provider knowledge and attitudes, variable availability of diagnostic and surveillance systems, and the unrestricted use of antimicrobials in animals and plants are contributory factors to the global crisis of antimicrobial resistance (AMR). Areas covered: Notwithstanding that interventions to revert AMR should be tailored to the socio-politico-economic landscape, there is a global consensus for the implementation and enhancement of antimicrobial stewardship strategies. Yet the implementation of Antimicrobial Stewardship Programs (ASPs) remains relatively limited within healthcare settings and faces complex challenges in resource-limited countries. The current review summarizes the limitations of current ASPs, translation challenges in resource-limited countries, and potential solutions. Expert opinion: Suboptimal ASP implementation in hospitals is multifactorial. Restriction of antimicrobial use should be informed by risk-benefit analyses, including the potential for substitute prescribing, and displacement of selection pressures. Thresholds in population use of antibiotics above which AMR increases may provide quantitative targets for ASPs. Horizontal and vertical collaborations involving policymakers and the general public are of paramount importance. While impactful prescribing changes require sustained engagement of the public and health-care professionals, we warn against over-estimating the benefits of behavioral interventions. We advocate for population-level stewardship interventions in addition to investment in structural factors that will aid ASP implementation.
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Affiliation(s)
- Karolin Hijazi
- a Institute of Dentistry, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen , Aberdeen , UK
| | - Chaitanya Joshi
- b Department of Medical Microbiology, Aberdeen Royal Infirmary , Aberdeen , UK
| | - Ian M Gould
- b Department of Medical Microbiology, Aberdeen Royal Infirmary , Aberdeen , UK
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El-Lababidi RM, Mooty M, Bonilla MF, Nusair A, Alatoom A, Mohamed S. Implementation and outcomes of an advanced antimicrobial stewardship program at a quaternary care hospital in the United Arab Emirates. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Rania Mohammad El-Lababidi
- Pharmacy Education and Training, Department of Pharmacy Services; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
- Antimicrobial Stewardship Program; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Mohammad Mooty
- Infectious Diseases; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | | | - Ahmad Nusair
- Infectious Diseases; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Adnan Alatoom
- Pathology and Laboratory Medicine Institute, Clinical Microbiology Section; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Shafii Mohamed
- Infection Prevention and Control; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
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Carracedo-Martinez E, Gonzalez-Gonzalez C, Teixeira-Rodrigues A, Prego-Dominguez J, Takkouche B, Herdeiro MT, Figueiras A. Computerized Clinical Decision Support Systems and Antibiotic Prescribing: A Systematic Review and Meta-analysis. Clin Ther 2019; 41:552-581. [PMID: 30826093 DOI: 10.1016/j.clinthera.2019.01.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/16/2019] [Accepted: 01/30/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to perform a systematic review and meta-analysis of studies performed in primary care centers and hospital facilities that evaluated the effectiveness of computerized clinical decision support systems (CDSSs) in decision making on the prescription of any given antibiotic. METHODS We conducted a search of the MEDLINE and EMBASE databases. A meta-analysis was then conducted of all variables with results reported in >2 studies. FINDINGS A total of 42 of the 46 studies included in the review identified a statistically significant advantage for CDSSs in ≥1 study variables. The effect of CDSSs on the percentage accuracy of the antibiotic spectrum prescribed empirically with respect to the microbial agent's susceptibility, which is one of the most frequently studied outcome variables, was examined in 7 studies, all undertaken in hospital settings. In all these studies but one, CDSSs resulted in a statistically significant increase in percentage accuracy. The other study variables present in >2 studies had more inconsistent results. Although the results of the meta-analysis of the variables percentage accuracy, antibiotic prescription rate in hospital, percentage adherence to antibiotic prescription guidelines in primary care or hospital, and percentage of inappropriate prescriptions for antibiotics in primary care were statistically significantly favorable to CDSSs; in the case of hospital length of stay and mortality, they were favorable although not statistically significantly. IMPLICATIONS CDSSs appear to be useful for variables such as the percentage of appropriate empirical treatment in the hospital setting or to induce changes in antibiotics prescription rate. Even so, more better quality studies are required to draw clearer conclusions in respect of morbidity and mortality outcome variables and other settings.
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Affiliation(s)
- Eduardo Carracedo-Martinez
- Santiago de Compostela Health Area, Galician Health Service (Servizo Galego de Saúde-SERGAS), Spanish National Health System, Santiago de Compostela, Spain.
| | - Christian Gonzalez-Gonzalez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Teixeira-Rodrigues
- Department of Medical Sciences and Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Jesus Prego-Dominguez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Bahi Takkouche
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences and Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain; Institute of Health Research of Santiago de Compsotela (IDIS), Spain
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9
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Vassy JL, Brunette CA, Majahalme N, Advani S, MacMullen L, Hau C, Zimolzak AJ, Miller SJ. The Integrating Pharmacogenetics in Clinical Care (I-PICC) Study: Protocol for a point-of-care randomized controlled trial of statin pharmacogenetics in primary care. Contemp Clin Trials 2018; 75:40-50. [PMID: 30367991 PMCID: PMC8119226 DOI: 10.1016/j.cct.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/04/2018] [Accepted: 10/16/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The association between the SLCO1B1 rs4149056 variant and statin-associated muscle symptoms (SAMS) is well validated, but the clinical utility of its implementation in patient care is unknown. DESIGN The Integrating Pharmacogenetics in Clinical Care (I-PICC) Study is a pseudo-cluster randomized controlled trial of SLCO1B1 genotyping among statin-naïve primary care and women's health patients across the Veteran Affairs Boston Healthcare System. Eligible patients of enrolled primary care providers are aged 40-75 and have elevated risk of cardiovascular disease by American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Patients give consent by telephone in advance of an upcoming appointment, but they are enrolled only if and when their provider co-signs an order for SLCO1B1 testing, performed on a blood sample already collected in clinical care. Enrolled patients are randomly allocated to have their providers receive results through the electronic health record at baseline (PGx + arm) versus after 12 months (PGx- arm). The primary outcome is the change in low-density lipoprotein cholesterol (LDL-C) after one year. Secondary outcomes are concordance with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for simvastatin prescribing, concordance with ACC/AHA guidelines for statin use, and incidence of SAMS. With 408 patients, the study has >80% power to exclude a between-group LDL-C difference of 10 mg/dL (non-inferiority design) and to detect between-group differences of 15% in CPIC guideline concordance (superiority design). CONCLUSION The outcomes of the I-PICC Study will inform the clinical utility of preemptive SLCO1B1 testing in the routine practice of medicine, including its proposed benefits and unforeseen risks.
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Affiliation(s)
- Jason L Vassy
- VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | | | | | - Cynthia Hau
- VA Boston Healthcare System, Boston, MA, USA
| | - Andrew J Zimolzak
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
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Hoff BM, Ford DC, Ince D, Ernst EJ, Livorsi DJ, Heintz BH, Masse V, Brownlee MJ, Ford BA. Implementation of a Mobile Clinical Decision Support Application to Augment Local Antimicrobial Stewardship. J Pathol Inform 2018; 9:10. [PMID: 29692947 PMCID: PMC5896164 DOI: 10.4103/jpi.jpi_77_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/15/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Medical applications for mobile devices allow clinicians to leverage microbiological data and standardized guidelines to treat patients with infectious diseases. We report the implementation of a mobile clinical decision support (CDS) application to augment local antimicrobial stewardship. Methods: We detail the implementation of our mobile CDS application over 20 months. Application utilization data were collected and evaluated using descriptive statistics to quantify the impact of our implementation. Results: Project initiation focused on engaging key stakeholders, developing a business case, and selecting a mobile platform. The preimplementation phase included content development, creation of a pathway for content approval within the hospital committee structure, engaging clinical leaders, and formatting the first version of the guide. Implementation involved a media campaign, staff education, and integration within the electronic medical record and hospital mobile devices. The postimplementation phase required ongoing quality improvement, revision of outdated content, and repeated staff education. The evaluation phase included a guide utilization analysis, reporting to hospital leadership, and sustainability and innovation planning. The mobile application was downloaded 3056 times and accessed 9259 times during the study period. The companion web viewer was accessed 8214 times. Conclusions: Successful implementation of a customizable mobile CDS tool enabled our team to expand beyond microbiological data to clinical diagnosis, treatment, and antimicrobial stewardship, broadening our influence on antimicrobial prescribing and incorporating utilization data to inspire new quality and safety initiatives. Further studies are needed to assess the impact on antimicrobial utilization, infection control measures, and patient care outcomes.
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Affiliation(s)
- Brian M Hoff
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Diana C Ford
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Dilek Ince
- Department of Internal Medicine, Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Erika J Ernst
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.,Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - Daniel J Livorsi
- Department of Internal Medicine, Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Brett H Heintz
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA.,Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Vincent Masse
- Department of Microbiology and Infectious Diseases, University of Sherbrooke, QC, Canada
| | - Michael J Brownlee
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.,Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - Bradley A Ford
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:196-201. [PMID: 29417925 PMCID: PMC9793410 DOI: 10.1017/ice.2017.299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antimicrobial stewardship is vital to reducing the spread of antimicrobial resistance. A group of investigators and clinicians within the Veterans Health Administration set forth a research agenda for antimicrobial stewardship, including research targets for inpatient and outpatient stewardship activities, metrics, and antimicrobial dosing and duration.
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12
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Hand KS, Cumming D, Hopkins S, Ewings S, Fox A, Theminimulle S, Porter RJ, Parker N, Munns J, Sheikh A, Keyser T, Puleston R. Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists. J Antimicrob Chemother 2017; 72:1206-1216. [PMID: 27999065 DOI: 10.1093/jac/dkw524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/07/2016] [Indexed: 01/27/2023] Open
Abstract
Background The implementation of electronic prescribing and medication administration (EPMA) systems is a priority for hospitals and a potential component of antimicrobial stewardship (AMS). Objectives To identify software features within EPMA systems that could potentially facilitate AMS and to survey practising UK infection specialist healthcare professionals in order to assign priority to these software features. Methods A questionnaire was developed using nominal group technique and transmitted via email links through professional networks. The questionnaire collected demographic data, information on priority areas and anticipated impact of EPMA. Responses from different respondent groups were compared using the Mann-Whitney U -test. Results Responses were received from 164 individuals (142 analysable). Respondents were predominantly specialist infection pharmacists (48%) or medical microbiologists (37%). Of the pharmacists, 59% had experience of EPMA in their hospitals compared with 35% of microbiologists. Pharmacists assigned higher priority to indication prompt ( P < 0.001), allergy checker ( P = 0.003), treatment protocols ( P = 0.003), drug-indication mismatch alerts ( P = 0.031) and prolonged course alerts ( P = 0.041) and lower priority to a dose checker for adults ( P = 0.02) and an interaction checker ( P < 0.05) than microbiologists. A 'soft stop' functionality was rated essential or high priority by 89% of respondents. Potential EPMA software features were expected to have the greatest impact on stewardship, treatment efficacy and patient safety outcomes with lowest impact on Clostridium difficile infection, antimicrobial resistance and drug expenditure. Conclusions The survey demonstrates key differences in health professionals' opinions of potential healthcare benefits of EPMA, but a consensus of anticipated positive impact on patient safety and AMS.
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Affiliation(s)
- Kieran S Hand
- Southampton Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.,Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Debbie Cumming
- Pharmacy Department, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO31 7QJ, UK
| | - Susan Hopkins
- Department of Infectious Diseases & Microbiology, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Sean Ewings
- Southampton Statistical Sciences Research Institute, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - Andy Fox
- Southampton Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.,Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Sandya Theminimulle
- Microbiology Department, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO31 7QJ, UK
| | - Robert J Porter
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Church Lane, Heavitree, Exeter EX2 5AD, UK
| | - Natalie Parker
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK
| | - Joanne Munns
- Pharmacy Department, Western Sussex Hospitals NHS Foundation Trust, St Richards Hospital, Chichester PO19 6SE, UK
| | - Adel Sheikh
- Pharmacy Department, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth Hospitals' NHS Trust, Portsmouth PO6 3LY, UK
| | - Taryn Keyser
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - Richard Puleston
- City Hospital, Institute of Public Health, Nottingham NG5 1PB, UK
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Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One 2017; 12:e0183062. [PMID: 28837665 PMCID: PMC5570266 DOI: 10.1371/journal.pone.0183062] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background Inappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR. Objectives To evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings. Methods A systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale. Results Eighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p ≤ 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted. Conclusions CDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.
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Affiliation(s)
- Christopher E. Curtis
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Fares Al Bahar
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - John F. Marriott
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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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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Huh K, Chung DR, Park HJ, Kim MJ, Lee NY, Ha YE, Kang CI, Peck KR, Song JH. Impact of monitoring surgical prophylactic antibiotics and a computerized decision support system on antimicrobial use and antimicrobial resistance. Am J Infect Control 2016; 44:e145-52. [PMID: 26975714 DOI: 10.1016/j.ajic.2016.01.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/07/2016] [Accepted: 01/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Monitoring of performance indicators and implementation of a computerized decision support system (CDSS) have been suggested as effective measures to improve quality of care. We conducted this study to evaluate the effect of monitoring of surgical prophylactic antibiotics (SPAs) and the CDSS on the antimicrobial use and resistance rate of major nosocomial pathogens. METHODS An interrupted time series with segmented regression analysis in 3 periods (preintervention, SPAs monitoring, and CDSS) was conducted in a tertiary care hospital. Immediate change and change in trends of antimicrobial use density, resistance rate of nosocomial pathogens, and cost of antibiotics in each intervention period were compared with those of the preintervention period. RESULTS Compared with the preintervention period, the change in the slope of the total use of antibiotics was -8.71 defined daily dose (DDD) per 1,000 patient days per month (95% confidence interval [CI], -11.43 to -5.98; P < .01) in the SPAs monitoring period and -1.95 DDD per 1,000 patient days per month (95% CI, -2.93 to -0.96; P < .01) in the CDSS period. Use of third-generation cephalosporins and aminoglycosides showed change comparable with that of total antibiotics use, but use of vancomycin and carbapenem was unchanged in the CDSS period. Trends of the proportions of extended-spectrum β-lactamase-producing Escherichia coli, meropenem-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus have been reversed or decreased in slope in the CDSS period. Length of hospital stay also showed a negative change in slope in the CDSS period. CONCLUSIONS Monitoring of SPAs and implementation of the CDSS can be effective measures for antimicrobial stewardship.
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Affiliation(s)
- Kyungmin Huh
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hyo Jung Park
- Department of Pharmacy, Samsung Medical Center, Seoul, Republic of Korea
| | - Min-Ji Kim
- Department of Biostatistics, Samsung Biomedical Research Institute, Seoul, Republic of Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Eun Ha
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Cresswell K, Mozaffar H, Shah S, Sheikh A. Approaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:5-17. [DOI: 10.1111/ijpp.12274] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kathrin Cresswell
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | - Hajar Mozaffar
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | | | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
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17
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Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1826] [Impact Index Per Article: 228.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
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Antibiotic prescribing at the transition from hospitalization to discharge: a target for antibiotic stewardship. Infect Control Hosp Epidemiol 2016; 36:474-8. [PMID: 25782905 DOI: 10.1017/ice.2014.85] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Of 300 patients prescribed oral antibiotics at the time of hospital discharge, urinary tract infection, community-acquired pneumonia, and skin infections accounted for 181 of the treatment indications (60%). Half of the prescriptions were antibiotics with broad Gram-negative activity. Discharge prescriptions were inappropriate in 79 of 150 cases reviewed (53%).
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Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis. Crit Care Med 2015; 43:1276-82. [PMID: 25756413 DOI: 10.1097/ccm.0000000000000948] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate effects of health information technology in the inpatient and ICU on mortality, length of stay, and cost. Methodical evaluation of the impact of health information technology on outcomes is essential for institutions to make informed decisions regarding implementation. DATA SOURCES EMBASE, Scopus, Medline, the Cochrane Review database, and Web of Science were searched from database inception through July 2013. Manual review of references of identified articles was also completed. STUDY SELECTION Selection criteria included a health information technology intervention such as computerized physician order entry, clinical decision support systems, and surveillance systems, an inpatient setting, and endpoints of mortality, length of stay, or cost. Studies were screened by three reviewers. Of the 2,803 studies screened, 45 met selection criteria (1.6%). DATA EXTRACTION Data were abstracted on the year, design, intervention type, system used, comparator, sample sizes, and effect on outcomes. Studies were abstracted independently by three reviewers. DATA SYNTHESIS There was a significant effect of surveillance systems on in-hospital mortality (odds ratio, 0.85; 95% CI, 0.76-0.94; I=59%). All other quantitative analyses of health information technology interventions effect on mortality and length of stay were not statistically significant. Cost was unable to be quantitatively evaluated. Qualitative synthesis of studies of each outcome demonstrated significant study heterogeneity and small clinical effects. CONCLUSIONS Electronic interventions were not shown to have a substantial effect on mortality, length of stay, or cost. This may be due to the small number of studies that were able to be aggregately analyzed due to the heterogeneity of study populations, interventions, and endpoints. Better evidence is needed to identify the most meaningful ways to implement and use health information technology and before a statement of the effect of these systems on patient outcomes can be made.
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Abstract
OBJECTIVEWe found previously that inappropriate inpatient antimicrobial use was often attributable to erroneous diagnoses. Here, we detail diagnostic errors and their relationship to inappropriate antimicrobial courses.DESIGNRetrospective cohort studySETTINGVeterans Affairs hospitalPATIENTSA cohort of 500 randomly selected inpatients with an antimicrobial courseMETHODSBlinded reviewers judged the accuracy of the initial provider diagnosis for the condition that led to an antimicrobial course and whether the course was appropriate.RESULTSThe diagnoses were correct in 291 cases (58%), incorrect in 156 cases (31%), and of indeterminate accuracy in 22 cases (4%). In the remaining 31 cases (6%), the diagnosis was a sign or symptom rather than a syndrome or disease. The odds ratio of a correct diagnosis was 4.3 (95% confidence interval [CI], 2.2–8.5) if the index condition was related to the reason for admission. When the diagnosis was correct, 181 of 292 courses (62%) were appropriate, compared with only 10 of 208 (5%) when the diagnosis was incorrect or indeterminate or when providers were treating a sign or symptom rather than a syndrome or disease (P<.001). Among the 309 cases in which antimicrobial courses were not appropriate, reasons varied by diagnostic accuracy; in 81 of 111 cases (73%) with a correct diagnosis, incorrect antimicrobial(s) were selected; in 166 of 198 other cases (84%), antimicrobial therapy was not indicated.CONCLUSIONSDiagnostic accuracy is important for optimal inpatient antimicrobial use. Antimicrobial stewardship strategies should help providers avoid diagnostic errors and know when antimicrobial therapy can be withheld safely.Infect Control Hosp Epidemiol 2015;36(8):949–956
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Wagner B, Filice GA, Drekonja D, Greer N, MacDonald R, Rutks I, Butler M, Wilt TJ. Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/599172] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence ofClostridium difficileinfection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.
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Wagner B, Filice GA, Drekonja D, Greer N, MacDonald R, Rutks I, Butler M, Wilt TJ. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infect Control Hosp Epidemiol 2014; 35:1209-28. [PMID: 25203174 DOI: 10.1086/678057] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes. DESIGN Systematic review. METHODS Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel. RESULTS Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed. CONCLUSIONS Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.
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Affiliation(s)
- Brittin Wagner
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
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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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Friedman ND. Antimicrobial Stewardship: The Need to Cover All Bases. Antibiotics (Basel) 2013; 2:400-18. [PMID: 27029310 PMCID: PMC4790271 DOI: 10.3390/antibiotics2030400] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/18/2013] [Accepted: 08/21/2013] [Indexed: 12/18/2022] Open
Abstract
Increasing antimicrobial resistance has necessitated an approach to guide the use of antibiotics. The necessity to guide antimicrobial use via stewardship has never been more urgent. The decline in anti-infective innovation and the failure of currently available antimicrobials to treat some serious infections forces clinicians to change those behaviors that drive antimicrobial resistance. The majority of antimicrobial stewardship (AMS) programs function in acute-care hospitals, however, hospitals are only one setting where antibiotics are prescribed. Antimicrobial use is also high in residential aged care facilities and in the community. Prescribing in aged care is influenced by the fact that elderly residents have lowered immunity, are susceptible to infection and are frequently colonized with multi-resistant organisms. While in the community, prescribers are faced with public misconceptions about the effectiveness of antibiotics for many upper respiratory tract illnesses. AMS programs in all of these locations must be sustainable over a long period of time in order to be effective. A future with effective antimicrobials to treat bacterial infection will depend on AMS covering all of these bases. This review discusses AMS in acute care hospitals, aged care and the community and emphasizes that AMS is critical to patient safety and relies on government, clinician and community engagement.
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Affiliation(s)
- N Deborah Friedman
- Barwon Health, Bellerine St, Geelong, VIC 3220, Australia.
- Deakin University, Geelong, VIC 3216, Australia .
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