Journal of General Internal Medicine

, Volume 28, Issue 6, pp 810–816

Use of an Electronic Health Record Clinical Decision Support Tool to Improve Antibiotic Prescribing for Acute Respiratory Infections: The ABX-TRIP Study

  • Cara B. Litvin
  • Steven M. Ornstein
  • Andrea M. Wessell
  • Lynne S. Nemeth
  • Paul J. Nietert
Original Research

ABSTRACT

BACKGROUND

Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).

OBJECTIVE

To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.

DESIGN

A two-phase, 27-month demonstration project.

SETTING

Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).

PARTICIPANTS

Thirty-nine providers were included in the project.

INTERVENTION

A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.

MAIN OUTCOME MEASURES

1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.

KEY RESULTS

The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57 % [95 % CI, −5.35 %, 8.49 %] in adults and −1.89 % [95 % CI, −9.03 %, 5.26 %] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, −16.30 %, [95 % CI, −24.81 %, −7.79 %] in adults and −16.30 [95%CI, −23.29 %, −9.31 %] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.

CONCLUSIONS

This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.

KEY WORDS

acute respiratory infections antibiotic prescribing electronic health records clinical decision support 

REFERENCES

  1. 1.
    Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302(7):758–66.Google Scholar
  2. 2.
    Linder JA. Editorial commentary: antibiotics for treatment of acute respiratory tract infections: decreasing benefit, increasing risk, and the irrelevance of antimicrobial resistance. Clin Infect Dis. 2008;47(6):744–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096.PubMedCrossRefGoogle Scholar
  4. 4.
    Besser RE. Antimicrobial prescribing in the United States: good news, bad news. Ann Intern Med. 2003;138(7):605–6.Google Scholar
  5. 5.
    Linder JA, Schnipper JL, Tsurikova R, Volk LA, Middleton B. Self-reported familiarity with acute respiratory infection guidelines and antibiotic prescribing in primary care. Int J Qual Health Care. 2010;22(6):469–75.PubMedCrossRefGoogle Scholar
  6. 6.
    Tonkin-Crine S, Yardley L, Little P. Antibiotic prescribing for acute respiratory tract infections in primary care: a systematic review and meta-ethnography. J Antimicrob Chemother. 2011;66(10):2215–23.PubMedCrossRefGoogle Scholar
  7. 7.
    Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005(4):CD003539.Google Scholar
  8. 8.
    Spurling GK, Del Mar CB, Dooley L, Foxlee R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2007(3):CD004417.Google Scholar
  9. 9.
    Linder JA, Schnipper JL, Tsurikova R, et al. Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: a cluster randomised controlled trial. Inform Prim Care. 2009;17(4):231–40.PubMedGoogle Scholar
  10. 10.
    Rubin MA, Bateman K, Donnelly S, et al. Use of a personal digital assistant for managing antibiotic prescribing for outpatient respiratory tract infections in rural communities. J Am Med Inform Assoc. 2006;13(6):627–34.PubMedCrossRefGoogle Scholar
  11. 11.
    Litvin CB, Ornstein SM, Wessell AM, Nemeth LS, Nietert PJ. Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care. Int J Med Inform. 2012;81(8):521–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Mainous AG, 3rd, Lambourne CA, Nietert PJ. Impact of a clinical decision support system on antibiotic prescribing for acute respiratory infections in primary care: quasi-experimental trial. J Am Med Inform Assoc. 2012.Google Scholar
  13. 13.
    CDC: Get Smart - Homepage. http://www.cdc.gov/getsmart/index.html. Accessed 10/10/2012.
  14. 14.
    Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Mak. 1981;1(3):239–46.CrossRefGoogle Scholar
  15. 15.
    Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004(4):CD000245.Google Scholar
  16. 16.
    Ahovuo-Saloranta A, Borisenko OV, Kovanen N, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008(2):CD000243.Google Scholar
  17. 17.
    Phillips TG, Hickner J. Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic use. J Am Board Fam Pract. 2005;18(6):459–63.PubMedCrossRefGoogle Scholar
  18. 18.
    Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003;289(6):719–25.PubMedCrossRefGoogle Scholar
  19. 19.
    Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72.PubMedCrossRefGoogle Scholar
  20. 20.
    Fitzmaurice GM, Laird N, Ware JH. Applied Longitudinal Analysis. Hoboken: John Wiley & Sons, Inc; 2004.Google Scholar
  21. 21.
    Huttner B, Samore M. Outpatient antibiotic use in the United States: time to “get smarter”. Clin Infect Dis. 2011;53(7):640–3.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Cara B. Litvin
    • 1
  • Steven M. Ornstein
    • 2
  • Andrea M. Wessell
    • 2
  • Lynne S. Nemeth
    • 3
  • Paul J. Nietert
    • 4
  1. 1.Division of General Internal Medicine and Geriatrics, Department of MedicineMedical University of South CarolinaCharlestonUSA
  2. 2.Department of Family MedicineMedical University of South CarolinaCharlestonUSA
  3. 3.College of NursingMedical University of South CarolinaCharlestonUSA
  4. 4.Division of Biostatistics and Epidemiology, Department of MedicineMedical University of South CarolinaCharlestonUSA

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