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BACKGROUND/RATIONALE:
The emergence and rapid rise in antibiotic resistance among common bacteria are adversely affecting the clinical course and health care costs of community-acquired infections. Because antibiotic resistance rates are strongly correlated with antibiotic use patterns, multiple organizations have declared reductions in unnecessary antibiotic use to be critical components of efforts to combat antibiotic resistance. Among humans, the vast majority of unnecessary antibiotic prescriptions are used to treat acute respiratory tract infections (ARIs) that have a viral etiology. Although the rate of antibiotic prescribing for ARIs by office-based physicians in the US has decreased about 16% from its peak in 1997, the rate of antibiotic prescribing in acute care settings (eg, emergency departments and urgent care centers), which account for 1 in 5 ambulatory antibiotic prescriptions in the US, has shown only a modest decline (6%) during this period. Translation of lessons from intervention studies in office-based practices is needed to improve antibiotic use in acute care settings.
OBJECTIVE(S):
Specific Aim 1: To evaluate the impact of a multidimensional (patient, system, clinician) intervention on appropriate antibiotic use for adults with acute respiratory tract infections-- identifying factors that influence successful translation across VA hospital and non-VA hospital acute care. Specific Aim 2: To evaluate the impact of a rapid diagnostic test for c-reactive protein on antibiotic use for adults with acute cough illness when added to a multidimensional intervention.
METHODS:
We conducted a randomized controlled trial of a quality improvement program consisting of physician education (educational seminar, practice guidelines, performance feedback, and decision support tools) and patient education (waiting room print and audiovisual materials) in 8 VA hospital and 8 non-VA hospital emergency departments. Non VA study sites were identified from an existing research network of hospital emergency departments--EMNet. VA hospital sites were selected among academically affiliated hub facilities. Phase one involved a hospital-level randomized trial of a multidimensional intervention to translate existing evidence based guidelines for antibiotic use in ARIs vs. usual care. In phase two we originally planned to involve a second hospital-level randomized trial of antibiotic use guidelines that incorporate a CRP-based diagnostic algorithm vs. the original guidelines. During a pilot study of the CRP-based guidelines at two of the study sites, it was determined that implementing these guidelines on a larger scale would not be beneficial to the end goal of improving appropriate antibiotic prescriptions for adults with acute respiratory tract infections. The results of the pilot study indicated that a CRP guided algorithm did not lead to reductions in antibiotic prescribing for acute respiratory tract infections. In the final phase of the project, we provided educational components to all participating sites and undertook a qualitative evaluation of intervention implementation at all sites. In addition, interviews were conducted with the Site PIs, ED Nurse Managers, Quality Improvement Officers and focus groups were held with ED nursing staff at the sites as part of a process evaluation of the implementation of the interventions.
FINDINGS/RESULTS:
At control sites, adjusted antibiotic prescribing for URI/acute bronchitis remained stable at 47% of visits in both years. At intervention sites, antibiotic prescribing for the same diagnoses declined from 54% in the baseline year to 43% in the intervention year (p=.06 for the comparison of the change in antibiotic prescribing). . There was no difference between intervention and control sites in the change in antibiotic use for antibiotic-responsive ARIs (e.g., sinusitis, pneumonia, and acute exacerbations of chronic bronchitis) (p = 0.42). The effect of the intervention was not significantly different at VA and non-VA hospitals. However, there was substantial site to site variation in the impact of the intervention. An ongoing process evaluation demonstrated that sites with the greatest level of reduction in inappropriate antibiotic prescribing had the strongest local champions for the intervention.
IMPACT:
Results to date have emphasized local organizational effects on the quality of antibiotic prescribing in EDs. The successful intervention trial demonstrates that relatively inexpensive educational interventions can achieve modest reductions in inappropriate antibiotic prescribing. Disseminating results from this study will help individual VA and non-VA hospital emergency departments identify opportunities to improve the quality of antibiotic use in the management of patients with acute respiratory tract infections.
PUBLICATIONS:
None at this time.
DRA:
Acute and Traumatic Injury, Health Services and Systems
DRE:
Quality of Care, Diagnosis and Prognosis
Keywords:
Behavior (provider), Education (patient), Education (provider), Pharmaceuticals
MeSH Terms:
Acute Disease
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