Research Activities, March 2014
Decision support tools improve antibiotic prescribing for respiratory infections
Health Information Technology
Primary care providers often inappropriately prescribe antibiotics for acute respiratory infections (ARIs), which are typically caused by viruses rather than bacteria that antibiotics target. Adding interactive clinical decision support system (CDSS) tools to electronic health records (EHRs) can change antibiotic prescribing and testing patterns for ARIs in primary care practices, concludes two studies.
The study by Cara B. Litvin, M.D., M.S., of the Medical University of South Carolina, and coinvestigators focused on the ABX–TRIP CDSS system implementation of the Center for Disease Control and Prevention "Get Smart" diagnosis and treatment recommendations. The second study by Thomas G. McGinn, M.D., M.P.H., of Hofstra North Shore–Long Island Jewish School of Medicine, and colleagues investigated the implementation of clinical prediction rules for streptococcal pharyngitis and for pneumonia. Both AHRQ-supported studies (Contract No. 290-07-00151, grant HS18491) are briefly summarized here.
Litvin, C.B., Ornstein, S.M., Wessell, A.M., and others (2013). "Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: The ABX–TRIP study." Journal of General Internal Medicine 28(6), pp. 810-816.
This 27-month study involved nine primary care practices (totaling 27 physicians, 6 nurse practitioners, and 6 physician assistants) in nine States from a practice-based research network using the Practice Partner® EHR. The CDSS intervention included a sophisticated progress note template embedded within the EHR designed to help providers properly diagnose and treat ARIs based on CDC recommendations.
The researchers found that the CDSS was used 38,592 times over the study period. While it did not significantly decrease inappropriate use of antibiotics generally in adult or pediatric patients, the use of broad-spectrum antibiotics fell by about 16 percent in both adults and children. Although antibiotic prescribing for bronchitis did not change significantly over the 27 months, the use of broad-spectrum antibiotics for sinus infections fell by nearly 20 percent.
McGinn, T.G., McCullagh, L., Kannry, J., and others (2013). "Efficacy of an evidence-based clinical decision support in primary care practices: A randomized clinical trial." JAMA Internal Medicine 173(17), pp. 1584-1591.
This study focused on implementing two clinical prediction rules (the Walsh rule for streptococcal pharyngitis and the Heckerling rule for pneumonia) as part of a CDSS. The researchers implemented the rules in two large urban ambulatory primary care practices at Mount Sinai Medical Center in New York City. A total of 168 primary care providers enrolled in the study and were randomly assigned to either training using journal articles on the two rules (controls) or training in the use of the CDSS with integrated clinical prediction rules to make treatment and testing decisions for 40,003 patient visits.
The intervention group had an overall adoption rate of nearly 63 percent, which is higher than typically observed in the past. Patients with pharyngitis or pneumonia who were seen by an intervention provider were 26 percent less likely to receive an antibiotic, the prescribed antibiotics were more appropriate (i.e., narrow spectrum), and patients were 25 percent less likely to undergo a rapid streptococcal test for pharyngitis.