Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care

https://doi.org/10.1016/j.ijmedinf.2012.03.002Get rights and content

Abstract

Purpose

Overuse of antibiotics for acute respiratory infections (ARIs) in primary care is an established risk factor for worsening antimicrobial resistance. The “Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians” study is assessing the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs using a multimethod intervention to facilitate CDSS adoption. The purpose of this report is to describe use of the CDSS, as well as facilitators and barriers to its adoption, during the first year of the 15-month intervention.

Methods

Between January 1, 2010 and December 31, 2010, 39 providers in 9 practices in US states participated in this study. Quarterly EHR based audit and feedback, practice site visits for academic detailing, performance review and CDSS training, and “best-practice” dissemination during two meetings of study participants were used to facilitate CDSS adoption. Mixed methods were used to evaluate adoption of the CDSS. Using data extracted from the EHR, CDSS use for ARI was calculated. To determine facilitators and barriers of CDSS adoption, semi-structured group interviews were conducted with providers and staff at each practice.

Results

During the first year of implementation, the ABX-TRIP CDSS was used 14,086 times for ARI encounters. Overall, practice use of the CDSS during ARI encounters ranged from 39.4% to 77.2%. Median use of the CDSS for adult patients was 58.2% and 68.6% for pediatric patients. Key factors associated with CDSS adoption include the perception by providers that it assists with decision making and stimulates patient discussions, engagement of non-physician staff and an iterative CDSS development process.

Conclusions

Adoption of a custom designed CDSS in the first year of implementation is promising. Successful implementation of such technology requires a focus not only on the technological solution itself, but on its integration with the entire clinical workplace.

Highlights

Successful implementation of a CDSS within a primary care practice requires: The perception by providers that the CDSS assists with decision making. ► Engagement of non-physician staff. ► An iterative CDSS development process.

Introduction

Antibiotic resistance is a growing problem worldwide and a major public health threat [1]. In primary care, the majority of antibiotic overuse stems from inappropriate prescribing for acute respiratory infections (ARI), leading to increasing antimicrobial resistance. Nearly half of all visits for ARI for which antibiotics are rarely indicated result in a prescription for an antibiotic, with increasing use of broad spectrum antibiotics [2]. In recent years, numerous strategies to increase adherence to clinical practice guidelines for judicious antibiotic prescribing have had varying degrees of success [3], [4], [5]. Multi-faceted interventions combining physician, patient and public education have been most successful in reducing antibiotic prescribing for inappropriate indications [3], although much room for improvement remains [2], [6], [7].

Electronic clinical decision support systems (CDSS) which provide clinicians with patient-specific assessments or recommendations at the time and location of decision making have been increasingly promoted as a means to change physician behavior [8], [9]. Such tools have been shown to be particularly effective for increasing adherence to guideline based care [10]. A few previous studies have piloted the use of CDSS to improve clinician adherence to guidelines for appropriate antibiotic prescribing for ARI. Results of these studies suggest that, when used, these tools may positively impact prescribing, yet low rates of adoption by providers have limited further assessment of their efficacy [11], [12].

The Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians (ABX-TRIP) demonstration project is designed to assess the impact of a CDSS on antibiotic prescribing for ARI in primary care practices using a multi-method intervention to facilitate CDSS adoption. The purpose of this report is to describe use of the CDSS, as well as facilitators and barriers to its adoption, during the first year of the 15-month intervention.

Section snippets

Study practices

The ABX-TRIP study is being conducted in the Practice Partner Research Network (PPRNet), a primary care research network across the United States whose members use a common EHR (Practice Partner® (PP) by McKesson, Inc., San Francisco, CA) and pool data quarterly for quality improvement and research projects. Nine PPRNet practices located in nine US states with 39 health care providers (27 physicians, 6 nurse practitioners and 6 physician's assistants) participated in this study. Practices

Results

During the first year of implementation, the ABX-TRIP CDSS was used 14,086 times for ARI encounters. Table 1 shows CDSS use by practice for encounters with diagnoses of ARIs for all patients. Overall, practice use of the CDSS during ARI encounters ranged from 39.4% to 77.2%. Median use of the CDSS for adult patients was 58.2% and 68.6% for pediatric patients. Percentage of use of the CDSS was highest for diagnoses of streptococcal pharyngitis in adult patients and URIs in pediatric patients.

Discussion

During the first year of the ABX-TRIP study, the CDSS was used by providers for the majority of encounters for ARI, although CDSS adoption varied among practices. In the practice which used the CDSS the least, computers were not located within the exam room, limiting provider and staff's ability to use the CDSS at the point of care. Providers in practices with some of the highest rates of use of the CDSS commonly reported that the CDSS made documentation of ARI visits easier. Key factors which

Author's contributions

C. Litvin, S. Ornstein, A. Wessell, and L. Nemeth contributed to the conception and design of the study, acquisition of data and interpretation of findings. P. Nietert assisted with analysis of data. All authors revised the article critically for important intellectual content, and provided final approval of the version for publication.

Competing interests

None of the authors have any conflicts of interest to declare.

Summary points

What was already known?

  • Antibiotics are overprescribed for acute respiratory infections (ARI).

  • Clinical Decision Support Systems (CDSS) may improve physician adherence to clinical practice guidelines.

  • Previous studies of CDSS to improve adherence to antibiotic prescribing guidelines for ARI have been limited by infrequent provider use.

What this study adds?

  • Successful implementation of a CDSS within a primary care practice

Acknowledgements

This study was conducted under contract by the Agency for Healthcare Research and Quality, Contract No. HHSA290200710015I. The funding agency had no role in the study design; in collection, analysis, and interpretation of data; in writing of the report; and in the decision to submit the paper for publication.

References (17)

  • M.A. Rubin

    Use of a personal digital assistant for managing antibiotic prescribing for outpatient respiratory tract infections in rural communities

    J. Am. Med. Inform. Assoc.

    (2006)
  • B. Spellberg

    The epidemic of antibiotic-resistant infections: a call to action for the medical community from the Infectious Diseases Society of America

    Clin. Infect. Dis.

    (2008)
  • C.G. Grijalva et al.

    Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings

    JAMA

    (2009)
  • S.R. Arnold et al.

    Interventions to improve antibiotic prescribing practices in ambulatory care

    Cochrane Database Syst. Rev.

    (2005)
  • M.A. Steinman

    Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies

    Med. Care

    (2006)
  • A.G. Mainous

    An evaluation of statewide strategies to reduce antibiotic overuse

    Fam. Med.

    (2000)
  • M.A. Steinman et al.

    Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care

    JAMA

    (2003)
  • C.L. Roumie

    Trends in antibiotic prescribing for adults in the United States – 1995 to 2002

    J. Gen. Intern. Med.

    (2005)
There are more references available in the full text version of this article.

Cited by (0)

View full text