Impact of a computerized template on antibiotic prescribing for acute respiratory infections in children and adolescents

Digital tracking, provider decision support systems, and targeted client communication via mobile devices to improve primary health care

BACKGROUND

Digital tracking on mobile devices, combined with clinical decision support systems and targeted client communication, can facilitate service delivery and potentially improve outcomes.

OBJECTIVES

To assess the effects of using a mobile device to track service use when combined with clinical decision support (Tracking + CDSS), with targeted client communications (Tracking + TCC), or both (Tracking + CDSS + TCC).

SEARCH METHODS

Cochrane CENTRAL, MEDLINE, Embase, Ovid Population Information Online (POPLINE), K4Health and WHO Global Health Library (2000 to November 2022).

SELECTION CRITERIA

Randomised and non-randomised trials in community/primary care settings.

PARTICIPANTS

primary care providers and clients Interventions: 1. Tracking + CDSS 2. Tracking + TCC 3. Tracking + CDSS + TCC Comparators: usual care (without digital tracking) DATA COLLECTION AND ANALYSIS: Two authors independently screened trials, extracted data and assessed risk of bias using the RoB 1 tool. We used a random-effects model to meta-analyse data producing risk differences (RD), risk ratios (RR), or odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Evidence certainty was assessed using GRADE.

MAIN RESULTS

We identified 18 eligible studies (11 randomised, seven non-randomised) conducted in Bangladesh, China, Ethiopia, India, Kenya, Palestine, Uganda, and the USA. All non-randomised studies had a high risk of bias. These results are from randomised studies. 'Probably/may/uncertain' indicates 'moderate/low/very low' certainty evidence. Tracking + CDSS Relating to antenatal/ postnatal care: Providers' adherence to recommendations May slightly increase home visits in the week following delivery (2 studies, 4531 participants; RD 0.10 [0.07, 0.14]) May slightly increase counselling for initiating complementary feeding (2 studies, 4397 participants; RD 0.12 [0.08, 0.15]) May slightly increase the mean number of home visits in the month following delivery (1 study, 3023 participants; MD 0.75 [0.47, 1.03]) Uncertain effect on home visits within 24 hours of delivery Clients' health behaviours May slightly increase skin-to-skin care (1 study, 1544 participants; RD 0.05 [0.00, 0.10]) May slightly increase early breastfeeding (2 studies, 4540 participants; RD 0.08 [0.05, 0.12]) Uncertain effects on applying nothing to the umbilical cord, taking ≥ 90 iron-folate tablets during pregnancy, exclusively breastfeeding for six months, delaying the newborn's bath at least two days and Kangaroo Mother Care. Clients' health status May reduce low birthweight babies (1 study, 3023 participants; RR 0.53 [0.38, 0.73]) May increase infants with pneumonia or fever seeking care (1 study, 3470 participants; RR 1.13 [1.03, 1.24]) Uncertain effects on stillbirths, neonatal and infant deaths, or testing positive for HIV during antenatal testing Tracking + TCC Clients' health status In stroke patients over 12 months: May slightly increase blood pressure (BP) medication adherence (1 study, 1226 participants; RR 1.10 [1.00, 1.21]) May reduce deaths (1 study, 1226 participants; RR 0.52 [0.28, 0.96]) May slightly reduce systolic BP (1 study, 1226 participants; MD -2.80 mmHg [-4.90, -0.70]) May slightly improve EQ-5D scores (1 study, 1226 participants; MD 0.04 [0.02, 0.06]) May reduce stroke hospitalisations (1 study, 1226 participants; RR 0.45 [0.32, 0.64]). Tracking + CDSS + TCC Providers' adherence to recommendations Probably increases guideline adherence for antenatal screening and management of anaemia (1 study, 10,502 participants; OR 1.88 [1.52, 2.32]), diabetes (1 study, 8669 participants; OR 1.45 [1.14, 1.84}), hypertension (1 study, 15,555 participants; OR 1.62 [1.29, 2.04]) and probably leads to lower adherence for abnormal foetal growth (1 study, 1165 participants; OR 0.59 [0.37, 0.95]). May slightly increase nevirapine prophylaxis in infants of HIV+ve mothers (1 study, 609 participants; OR 1.75 [0.73, 4.19]) Data quality In pregnant women (1 study, 6367 participants), tracking + CDSS + TCC: Probably slightly reduces missing data for haemoglobin (RR 0.77 [0.71, 0.84]) but slightly more for BP at delivery (RR 1.16 [1.08, 1.24]) May have little or no effect on missing data on gestational age (RR 0.96 [0.81, 1.14]) or birthweight (RR 0.90 [0.77, 1.04]) Clients' health behaviour May have little or no effect on being on anti-retroviral therapy at delivery (1 study, 438 participants; OR 1.41 [0.81, 2.45]) or exclusive breastfeeding for six months (1 study, 695 participants; OR 1.74 [0.95, 3.17]) in HIV+ve mothers Uncertain effects on physical activity in high cardiovascular-risk adults Clients' health status May reduce the number of deaths in patients with hypertension and diabetes (1 study, 3698 participants; OR 0.61 [0.35, 1.06]) May reduce new cardiovascular events in high-cardiovascular risk adults over 6-18 months (1 study, 8642 participants; OR 0.58 [0.42, 0.80}) May slightly decrease in antenatal women severe hypertension, but the confidence interval includes both a decrease and increase (1 study, 6367 participants; OR 0.61 [0.27, 1.37]) In women receiving antenatal care (1 study, 6367 participants), tracking + CDSS + TCC maymake little or no difference to adverse pregnancy outcomes (OR 0.99 [0.87, 1.12]), moderate or severe anaemia (OR 0.82 [0.51, 1.31]), or large-for-gestational-age babies (OR 1.06 [0.90, 1.25]). In adults with hypertension or diabetes (1 study, 3324 participants), tracking + CDSS + TCC maymake little or no difference to HbA1c (MD 0.08 [-0.27, 0.43]), total cholesterol (MD -2.50 [-7.10, 2.10]), 10-year cardiovascular risk (MD -0.40 [-2.30, 1.50]), tobacco use (MD-0.05 [-0.47, 0.37]), alcohol use (MD 0.70 [-3.70, 5.10]), or PHQ-9 (MD -1.60 [-4.40, 1.20]). Uncertain effects on maternal or infant mortality before the baby reaches 18 months in HIV-positive mothers, patients who achieve optimal BP, BP controlled at five years, diastolic or systolic BP, body mass index, fasting glucose and quality of life in adults with hypertension or diabetes Client service utilisation May have little or no effect on missed early infant diagnosis visits (1 study, 1183 participants; OR 0.92 [0.63, 1.35]). Uncertain effects on linkage to care Client satisfaction Probably increases slightly the number of adults with hypertension or diabetes reporting "slightly/much better" change in the quality of care (1 study, 3324 participants; RR 1.02 [1.00, 1.03]). No studies evaluated time between presentation and appropriate management, timeliness of receiving/accessing care, provider acceptability/satisfaction, resource use, or unintended consequences.

AUTHORS' CONCLUSIONS

Digital tracking may improve primary care workers' ability to follow recommended antenatal and chronic disease practices, quality of patient records, patient health outcomes and service use. However, these interventions led to small or no outcome differences in most studies.

Effectiveness of decision support tools on reducing antibiotic use for respiratory tract infections: a systematic review and meta-analysis

Background: Clinical decision support tools (CDSs) have been demonstrated to enhance the accuracy of antibiotic prescribing among physicians. However, their effectiveness in reducing inappropriate antibiotic use for respiratory tract infections (RTI) is controversial. Methods: A literature search in 3 international databases (Medline, Web of science and Embase) was conducted before 31 May 2023. Relative risk (RR) and corresponding 95% confidence intervals (CI) were pooled to evaluate the effectiveness of intervention. Summary effect sizes were calculated using a random-effects model due to the expected heterogeneity (I 2 over 50%). Results: A total of 11 cluster randomized clinical trials (RCTs) and 5 before-after studies were included in this meta-analysis, involving 900,804 patients met full inclusion criteria. Among these studies, 11 reported positive effects, 1 reported negative results, and 4 reported non-significant findings. Overall, the pooled effect size revealed that CDSs significantly reduced antibiotic use for RTIs (RR = 0.90, 95% CI = 0.85 to 0.95, I 2 = 96.10%). Subgroup analysis indicated that the intervention duration may serve as a potential source of heterogeneity. Studies with interventions duration more than 2 years were found to have non-significant effects (RR = 1.00, 95% CI = 0.96 to 1.04, I 2 = 0.00%). Egger's test results indicated no evidence of potential publication bias (p = 0.287). Conclusion: This study suggests that CDSs effectively reduce inappropriate antibiotic use for RTIs among physicians. However, subgroup analysis revealed that interventions lasting more than 2 years did not yield significant effects. These findings highlight the importance of considering intervention duration when implementing CDSs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023432584, Identifier: PROSPERO (CRD42023432584).

Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

BACKGROUND

Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).

OBJECTIVE

To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED.

DESIGN

Pragmatic randomized clinical trial.

SETTING AND PARTICIPANTS

Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.

INTERVENTION

CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.

MAIN OUTCOME AND MEASURES

The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits.

RESULTS

1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes.

CONCLUSIONS

Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.

The impact of Antimicrobial Stewardship Programmes in paediatric emergency departments and primary care: a systematic review

Background

Antibiotics remain the most prescribed medicine in children worldwide, but half of the prescriptions are unnecessary or inappropriate, leading to an increase in antibiotic resistance. This study aims to systemically review the effects of different Antimicrobial Stewardship Programmes (ASPs) on reducing the rates of both antibiotic prescriptions and changes in antimicrobial resistance, and on the economic impact in paediatric emergency departments (PED) and primary care settings.

Materials and methods

Embase, MEDLINE, and Cochrane Library were systematically searched, combining Medical Subject Heading and free-text terms for 'children' and 'antimicrobial' and 'stewardship'. The search strategy involved restrictions on dates (from 1 January 2007 to 30 December 2020) but not on language. Randomized controlled trials, controlled and non-controlled before and after studies, controlled and non-controlled interrupted time series, and cohort studies were included for review. The review protocol was registered at the PROSPERO International Prospective Register of Systematic Reviews: Registration Number CRD42021270630.

Results

Of the 47,158 articles that remained after removing duplicates, 59 were eligible for inclusion. Most of the studies were published after 2015 (37/59, 62.7%) and in high-income countries (51/59, 86.4%). Almost half of the studies described the implementation of an ASP in the primary care setting (28/59, 47.5%), while 15 manuscripts described the implementation of ASPs in EDs (15/59, 25.4%). More than half of the studies (43/59, 72.9%) described the implementation of multiple interventions, whereas few studies considered the implementation of a single intervention. Antibiotic prescriptions and compliance with guidelines were the most frequent outcomes (47/59, 79.7% and 20/59, 33.9%, respectively). Most of the articles reported an improvement in these outcomes after implementing an ASP. Meanwhile, only very few studies focused on health care costs (6/59, 10.2%) and antimicrobial resistance (3/59 5.1%).

Conclusion

The implementation of ASPs has been proven to be feasible and valuable, even in challenging settings such as Emergency Departments and Primary care.

A roadmap for the development and evaluation of the eHealthResp online course

Background

Inappropriate antibiotic use constitutes one of the most concerning public health issues, being one of the main causes of antibiotic resistance. Hence, to tackle this issue, it is important to encourage the development of educational interventions for health practitioners, namely by using digital health tools. This study focuses on the description of the development and validation process of the eHealthResp online course, a web platform directed to physicians and pharmacists, with the overall goal of improving antibiotic use for respiratory tract infections, along with the assessment of its usability.

Methods

The eHealthResp platform and the courses, developed with a user-centered design and based on Wordpress and MySQL, were based on a previously developed online course. A questionnaire to assess the usability was distributed among physicians (n = 6) and pharmacists (n = 6). Based on the obtained results, statistical analyses were conducted to calculate the usability score and appraise the design of the online course, as well as to compare the overall scores attributed by both groups. Further qualitative comments provided by the participants have also been analyzed.

Results

The eHealthResp contains two online courses directed to physicians and pharmacists aiming to aid in the management of respiratory tract infections. The average usability score of the eHealthResp online courses for physicians and pharmacists was of 78.33 (±11.57, 95%CI), and 83.75 (±15.90, 95%CI), respectively. Qualitative feedback emphasized the usefulness of the course, including overall positive reviews regarding user-friendliness and consistency.

Conclusions

This study led us to conclude that the eHealthResp online course is not recognized as a complex web platform, as both qualitative and quantitative feedback obtained were globally positive.

Effectiveness of interventions aiming to reduce inappropriate drug prescribing: an overview of interventions

Objective

Inappropriate prescribing of drugs is associated with unnecessary harms for patients and healthcare costs. Interventions to reduce these prescriptions are widely studied, yet the effectiveness of different types of interventions remains unclear. Therefore, we provide an overview regarding the effectiveness of intervention types that aim to reduce inappropriate drug prescriptions, unrestricted by target drugs, population or setting.

Methods

For this overview, systematic reviews (SRs) were used as the source for original studies. EMBASE and MEDLINE were searched from inception to August 2018. All SRs aiming to evaluate the effectiveness of interventions to reduce inappropriate prescribing of drugs were eligible for inclusion. The SRs and their original studies were screened for eligibility. Interventions of the original studies were categorized by type of intervention. The percentage of interventions showing a significant reduction of inappropriate prescribing were reported per intervention category.

Key findings

Thirty-two SRs were included, which provided 319 unique interventions. Overall, 61.4% of these interventions showed a significant reduction in inappropriate prescribing of drugs. Strategies that were most frequently effective in reducing inappropriate prescribing were multifaceted interventions (73.2%), followed by interventions containing additional diagnostic tests (antibiotics) (70.4%), computer interventions (69.2%), audit and feedback (66.7%), patient-mediated interventions (62.5%) and multidisciplinary (team) approach (57.1%). The least frequently effective intervention was an education for healthcare professionals (50.0%).

Conclusion

The majority of the interventions were effective in reducing inappropriate prescribing of drugs. Multifaceted interventions most frequently showed a significant reduction of inappropriate prescribing. Education for healthcare professionals is the most frequently included intervention in this overview, yet this category is least frequently effective.

Can evidence-based decision support tools transform antibiotic management? A systematic review and meta-analyses

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.

Information technology interventions to improve antibiotic prescribing for patients with acute respiratory infection: a systematic review

OBJECTIVES

Information technology (IT) interventions provide physicians with easy and quick access to information at the point of care and can play a major role in clinical decision-making for antibiotic prescribing. This study aimed to examine the effects and characteristics of IT interventions on improving antibiotic prescribing for patients with acute respiratory infection (ARI).

METHODS

A comprehensive search was performed in Medline (through PubMed), ISI web of science, Embase, and Cochrane databases from inception to 31 August 2020. Randomized controlled trial (RCT) and cluster RCT (CRCT) studies examining the effectiveness of IT interventions in improving antibiotic prescribing for patients with ARI were included. Participants were patients with ARI. IT interventions were used for improving antibiotic prescribing. Two researchers independently extracted data from studies on methods, characteristics of interventions, and results. The characteristics of interventions were extracted based on three dimensions of IT design, data entry source, and implementation characteristics.

RESULTS

Eighteen studies (15 CRCTs and three RCTs) were included. Most of included studies (n = 11) were conducted in the United States. In 12 studies (66.7%), IT interventions improved the level of antibiotic prescribing, and in eight of the 12 studies the effect was statistically significant. In two studies the intervention had a statistically significant negative effect, and in two studies the level of antibiotic prescribing was not changed. Seventeen studies (94.4%) used clinical decision support systems (CDSSs) for the intervention. In 12 studies (66.7%) CDSSs were integrated with electronic health records (EHRs).

CONCLUSIONS

Information technology interventions have the potential to improve prescription of antibiotics for patients with acute respiratory infection and to change physicians' behaviours in this regard. Factors affecting the acceptance of IT-based interventions to improve prescription of antibiotics should be investigated in future studies.

The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis

Background

Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes.

Methods

This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I² were then used to calculate heterogeneity.

Results

On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs.

Conclusions

Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.

E-Health Tools to Improve Antibiotic Use and Resistances: A Systematic Review

(1) Background: e-Health tools, especially in the form of clinical decision support systems (CDSSs), have been emerging more quickly than ever before. The main objective of this systematic review is to assess the influence of these tools on antibiotic use for respiratory tract infections. (2) Methods: The scientific databases, MEDLINE-PubMed and EMBASE, were searched. The search was conducted by two independent researchers. The search strategy was mainly designed to identify relevant studies on the effectiveness of CDSSs in improving antibiotic use, as a primary outcome, and on the acceptability and usability of CDSSs, as a secondary outcome. (3) Results: After the selection, 22 articles were included. The outcomes were grouped either into antibiotics prescription practices or adherence to guidelines concerning antibiotics prescription. Overall, 15 out of the 22 studies had statistically significant outcomes related to the interventions. (4) Conclusions: Overall, the results show a positive impact on the prescription and conscientious use of antibiotics for respiratory tract infections, both with respect to patients and prescribing healthcare professionals. CDSSs have been shown to have great potential as powerful tools for improving both clinical care and patient outcomes.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Patient-focused outcomes are infrequently reported in pediatric health information technology trials: a systematic review

OBJECTIVES

Billions of dollars have been invested in Health Information Technologies (HITs), and randomized controlled trials (RCTs) have been conducted to identify the effects of these interventions. Our objective was to identify the types of outcomes that were measured and reported in these RCTs.

STUDY DESIGN AND SETTING

We completed a systematic review (Medline, EMBASE, and CENTRAL databases) of RCTs involving children (<18 years) and utilizing HIT interventions.

RESULTS

We identified 45 RCTs involving 323,945 children. Most studies reported process outcomes (n = 40/45 (88.9%)) but did not include patient-focused outcomes such as patient/carer functioning (n = 12/45 (26.7%)), clinical/physiological health (n = 10/45, 22.2%), quality of life (n = 3/45, 6.7%), or mortality (n = 1/45, 2.2%). Only 3 of 45 (6.7%) studies reported an evaluation of adverse events. In only 14 of 45 (31.1%) studies was it clear that all outcomes that were measured were reported.

CONCLUSION

It is difficult to use RCTs to fully evaluate the benefits and risks of using HIT interventions in pediatric health care settings because patient-focused outcomes and adverse events are rarely reported. Measures to improve the quality of future trials may include the publication of study protocols and the development of an outcome reporting framework or core outcome set.

Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures

INTRODUCTION

Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template.

METHODS

The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon.

RESULTS

Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time.

CONCLUSION

Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy.

LEVEL OF EVIDENCE

III.

Computerized Clinical Decision Support Systems and Antibiotic Prescribing: A Systematic Review and Meta-analysis

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.

From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting

Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.

The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

BACKGROUND

Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed. Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully.

METHODS

We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist.

RESULTS

We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy.

CONCLUSIONS

The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed.

The value of participatory development to support antimicrobial stewardship with a clinical decision support system

BACKGROUND

Current clinical decision support systems (CDSSs) for antimicrobial stewardship programs (ASPs) are guideline- or expert-driven. They are focused on (clinical) content, not on supporting real-time workflow. Thus, CDSSs fail to optimally support prudent antimicrobial prescribing in daily practice. Our aim was to demonstrate why and how participatory development (involving end-users and other stakeholders) can contribute to the success of CDSSs in ASPs.

METHODS

A mixed-methods approach was applied, combining scenario-based prototype evaluations (to support verbalization of work processes and out-of-the-box thinking) among 6 medical resident physicians with an online questionnaire (to cross-reference findings of the prototype evaluations) among 54 Dutch physicians.

RESULTS

The prototype evaluations resulted in insight into the end-users and their way of working, as well as their needs and expectations. The online questionnaire that was distributed among a larger group of medical specialists, including lung and infection experts, complemented the findings of the prototype evaluations. It revealed a say/do problem concerning the unrecognized need of support for selecting diagnostic tests.

CONCLUSIONS

Low-fidelity prototypes of a technology allow researchers to get to know the end-users, their way of working, and their work context. Involving experts allows technology developers to continuously check the fit between technology and clinical practice. The combination enables the participatory development of technology to successfully support ASPs.

Antibiotic prescription and food allergy in young children

Background

To assess the relationship between any systemic antibiotic prescription within the first year of life and the presence of an ICD-9-CM diagnosis code for food allergy (FA).

Methods

This was a matched case–control study conducted using South Carolina Medicaid administrative data. FA cases born between 2007 and 2009 were matched to controls without FA on birth month/year, sex, race/ethnicity. Conditional logistic regression was used to model the adjusted odds ratio (aOR) of FA diagnosis. All models were adjusted for presence of asthma, wheeze, or atopic dermatitis.

Results

A total of 1504 cases and 5995 controls were identified. Receipt of an antibiotic prescription within the initial 12 months of life was associated with FA diagnosis in unadjusted and adjusted models (aOR 1.21; 95 % CI 1.06–1.39). Compared to children with no antibiotic prescriptions, a linear increase in the aOR was seen with increasing antibiotic prescriptions. Children receiving five or more (aOR 1.64; 95 % CI 1.31–2.05) antibiotic prescriptions were significantly associated with FA diagnosis. The strongest association was noted among recipients of cephalosporin and sulfonamide antibiotics in both unadjusted and adjusted models.

Conclusions

Receipt of antibiotic prescription in the first year of life is associated with FA diagnosis code in young children after controlling for common covariates. Multiple antibiotic prescriptions are more strongly associated with increases in the odds of FA diagnosis.

What Drives Variation in Antibiotic Prescribing for Acute Respiratory Infections?

BACKGROUND

Acute respiratory infections are the most common symptomatic reason for seeking care among patients in the US, and account for the majority of all antibiotic prescribing, yet a large fraction of antibiotic prescriptions are inappropriate.

OBJECTIVE

We sought to identify the underlying factors driving variation in antibiotic prescribing across clinicians and settings.

DESIGN, PARTICIPANTS

Using electronic health data for adult ambulatory visits for acute respiratory infections to a retail clinic chain and primary care practices from an integrated healthcare system, we identified a random sample of clinicians for survey.

MAIN MEASURES

We evaluated independent predictors of overall prescribing and imperfect antibiotic prescribing, controlling for clinician and site of care. We defined imperfect antibiotic prescribing as prescribing for non-antibiotic-appropriate diagnoses, failure to prescribe for an antibiotic-appropriate diagnosis, or prescribing a non-guideline-concordant antibiotic.

KEY RESULTS

Response rates were 34 % for retail clinics and 24 % for physicians' offices (N = 187). Clinicians in physicians' offices prescribed antibiotics less often than those in retail clinics (53 % versus 67 %; p < 0.01), but had a higher imperfect antibiotic prescribing rate (65 % versus 31 %; p < 0.01). Feeling rushed was associated with higher antibiotic prescribing (OR 1.34; 95 % CI 1.03, 1.75). Antibiotic prescribing was also associated with clinician disagreement that antibiotics are overused (OR 1.60, 95 % CI, 1.16, 2.20). Imperfect antibiotic prescribing was associated with receiving antibiotic prescribing feedback (OR 1.35, 95 % CI 1.04, 1.75) and disagreement that patient demand was a problem (OR 1.66, 95 % CI 1.00, 2.73). Imperfect antibiotic prescribing was less common with clinicians who perceived that they prescribed antibiotics less often than their peers (OR 0.63, 95 % CI 0.46, 0.87).

CONCLUSIONS

Poor-quality antibiotic prescribing was associated with feeling rushed, believing less strongly that antibiotics were overused, and believing that patient demand was not an issue, factors that can be assessed and addressed in future interventions.

Electronic Health Record-Enabled Research in Children Using the Electronic Health Record for Clinical Discovery

Initially described more than 50 years ago, electronic health records (EHRs) are now becoming ubiquitous throughout pediatric health care settings. The confluence of increased EHR implementation and the exponential growth of digital data within them, the development of clinical informatics tools and techniques, and the growing workforce of experienced EHR users presents new opportunities to use EHRs to augment clinical discovery and improve pediatric patient care. This article reviews the basic concepts surrounding EHR-enabled research and clinical discovery, including the types and fidelity of EHR data elements, EHR data validation/corroboration, and the steps involved in analytical interrogation.

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care

BACKGROUND

Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care.

OBJECTIVES

To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care.

SEARCH METHODS

We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available.

MAIN RESULTS

We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms.

AUTHORS' CONCLUSIONS

Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

Impact of a clinical decision model for febrile children at risk for serious bacterial infections at the emergency department: a randomized controlled trial

OBJECTIVES

To assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED).

METHODS

Randomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n = 219) or the control group (usual care; n = 220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for "pneumonia" and "other SBI". Nurses were guided by the intervention to initiate additional tests for high-risk children. The clinical decision model was evaluated by 1) area-under-the-receiver-operating-characteristic-curve (AUC) to indicate discriminative ability and 2) feasibility, to measure nurses' compliance to model recommendations. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs.

RESULTS

The decision model had good discriminative ability for both pneumonia (n = 33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n = 22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination were observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value < 0.05) and more urine-dipstick testing (71% vs. 61%, p-value < 0.05).

CONCLUSIONS

In contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved, however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing.

TRIAL REGISTRATION

Nederlands Trial Register NTR2381.

Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review

OBJECTIVE

To assess the effectiveness of computer-aided clinical decision support systems (CDSS) in improving antibiotic prescribing in primary care.

METHODS

A literature search utilizing Medline (via PubMed) and Embase (via Embase) was conducted up to November 2013. Randomized controlled trials (RCTs) and cluster randomized trials (CRTs) that evaluated the effects of CDSS aiming at improving antibiotic prescribing practice in an ambulatory primary care setting were included for review. Two investigators independently extracted data about study design and quality, participant characteristics, interventions, and outcomes.

RESULTS

Seven studies (4 CRTs, 3 RCTs) met our inclusion criteria. All studies were performed in the USA. Proportions of eligible patient visits that triggered CDSS use varied substantially between intervention arms of studies (range 2.8-62.8%). Five out of seven trials showed marginal to moderate statistically significant effects of CDSS in improving antibiotic prescribing behavior. CDSS that automatically provided decision support were more likely to improve prescribing practice in contrast to systems that had to be actively initiated by healthcare providers.

CONCLUSIONS

CDSS show promising effectiveness in improving antibiotic prescribing behavior in primary care. Magnitude of effects compared to no intervention, appeared to be similar to other moderately effective single interventions directed at primary care providers. Additional research is warranted to determine CDSS characteristics crucial to triggering high adoption by providers as a perquisite of clinically relevant improvement of antibiotic prescribing.

Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review

BACKGROUND

Respiratory tract infections (RTIs) in children are common and often result in antibiotic prescription despite their typically self-limiting course.

AIM

To assess the effectiveness of primary care based interventions to reduce antibiotic prescribing for children with RTIs.

DESIGN AND SETTING

Systematic review.

METHOD

MEDLINE(®), Embase, CINAHL(®), PsycINFO, and the Cochrane library were searched for randomised, cluster randomised, and non-randomised studies testing educational and/or behavioural interventions to change antibiotic prescribing for children (<18 years) with RTIs. Main outcomes included change in proportion of total antibiotic prescribing or change in 'appropriate' prescribing for RTIs. Narrative analysis of included studies was used to identify components of effective interventions.

RESULTS

Of 6301 references identified through database searching, 17 studies were included. Interventions that combined parent education with clinician behaviour change decreased antibiotic prescribing rates by between 6-21%; structuring the parent-clinician interaction during the consultation may further increase the effectiveness of these interventions. Automatic computerised prescribing prompts increased prescribing appropriateness, while passive information, in the form of waiting room educational materials, yielded no benefit.

CONCLUSION

Conflicting evidence from the included studies found that interventions directed towards parents and/or clinicians can reduce rates of antibiotic prescribing. The most effective interventions target both parents and clinicians during consultations, provide automatic prescribing prompts, and promote clinician leadership in the intervention design.

Computerized clinical decision support for medication prescribing and utilization in pediatrics

BACKGROUND AND OBJECTIVE

Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics.

MATERIALS AND METHODS

A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities.

RESULTS AND DISCUSSION

Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use.

CONCLUSION

Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.

A simple approach to improve recording of concerns about child maltreatment in primary care records: developing a quality improvement intervention

BACKGROUND

Information is lacking on how concerns about child maltreatment are recorded in primary care records.

AIM

To determine how the recording of child maltreatment concerns can be improved.

DESIGN AND SETTING

Development of a quality improvement intervention involving: clinical audit, a descriptive survey, telephone interviews, a workshop, database analyses, and consensus development in UK general practice.

METHOD

Descriptive analyses and incidence estimates were carried out based on 11 study practices and 442 practices in The Health Improvement Network (THIN). Telephone interviews, a workshop, and a consensus development meeting were conducted with lead GPs from 11 study practices.

RESULTS

The rate of children with at least one maltreatment-related code was 8.4/1000 child years (11 study practices, 2009-2010), and 8.0/1000 child years (THIN, 2009-2010). Of 25 patients with known maltreatment, six had no maltreatment-related codes recorded, but all had relevant free text, scanned documents, or codes. When stating their reasons for undercoding maltreatment concerns, GPs cited damage to the patient relationship, uncertainty about which codes to use, and having concerns about recording information on other family members in the child's records. Consensus recommendations are to record the code 'child is cause for concern' as a red flag whenever maltreatment is considered, and to use a list of codes arranged around four clinical concepts, with an option for a templated short data entry form.

CONCLUSION

GPs under-record maltreatment-related concerns in children's electronic medical records. As failure to use codes makes it impossible to search or audit these cases, an approach designed to be simple and feasible to implement in UK general practice was recommended.

Development and evaluation of an ontology for guiding appropriate antibiotic prescribing

OBJECTIVES

To develop and apply formal ontology creation methods to the domain of antimicrobial prescribing and to formally evaluate the resulting ontology through intrinsic and extrinsic evaluation studies.

METHODS

We extended existing ontology development methods to create the ontology and implemented the ontology using Protégé-OWL. Correctness of the ontology was assessed using a set of ontology design principles and domain expert review via the laddering technique. We created three artifacts to support the extrinsic evaluation (set of prescribing rules, alerts and an ontology-driven alert module, and a patient database) and evaluated the usefulness of the ontology for performing knowledge management tasks to maintain the ontology and for generating alerts to guide antibiotic prescribing.

RESULTS

The ontology includes 199 classes, 10 properties, and 1636 description logic restrictions. Twenty-three Semantic Web Rule Language rules were written to generate three prescribing alerts: (1) antibiotic-microorganism mismatch alert; (2) medication-allergy alert; and (3) non-recommended empiric antibiotic therapy alert. The evaluation studies confirmed the correctness of the ontology, usefulness of the ontology for representing and maintaining antimicrobial treatment knowledge rules, and usefulness of the ontology for generating alerts to provide feedback to clinicians during antibiotic prescribing.

CONCLUSIONS

This study contributes to the understanding of ontology development and evaluation methods and addresses one knowledge gap related to using ontologies as a clinical decision support system component-a need for formal ontology evaluation methods to measure their quality from the perspective of their intrinsic characteristics and their usefulness for specific tasks.