Samore MH et al. 2005 "Clinical decision support and appropriateness of antimicrobial prescribing - a randomized trial."

Reference
Samore MH, Bateman K, Alder SC, et al. Clinical decision support and appropriateness of antimicrobial prescribing - a randomized trial. JAMA 2005;294(18):2305-2314.
Abstract
"Context: The impact of clinical decision support systems (CDSS) on antimicrobial prescribing in ambulatory settings has not previously been evaluated. Objective: To measure the added value of CDSS when coupled with a community intervention to reduce inappropriate prescribing of antimicrobial drugs for acute respiratory tract infections. Design, Participants and Setting: Cluster randomized trial that included 407,460 inhabitants and 334 primary care clinicians in 12 rural communities in Utah and Idaho (6 with 1 shared characteristic and 6 with another), and a third group of 6 communities that served as nonstudy controls. The preintervention period was January to December 2001 and the postintervention period was January 2002 to September 2003. Acute respiratory tract infection diagnoses were classified into groups based on indication for antimicrobial use. Multilevel regression methods were applied to account for the clustered design. Intervention: Six communities received a community intervention alone and 6 communities received community intervention plus CDSS that were targeted toward primary care clinicians. The CDSS comprised decision support tools on paper and a handheld computer to guide diagnosis and management of acute respiratory tract infection. Main Outcome Measure: Community-wide antimicrobial usage was assessed using retail pharmacy data. Diagnosis-specific antimicrobial use was compared by chart review. Results: Within CDSS communities, 71% of primary care clinicians participated in the use of CDSS. The prescribing rate decreased from 84.1 to 75.3 per 100 person-years in the CDSS arm vs. 84.3 to 85.2 in community intervention alone, and remained stable in the other communities (P=.03). A total of 13 081 acute respiratory tract infection visits were abstracted. The relative decrease in antimicrobial prescribing for visits in the antibiotics "never-indicated" category during the postintervention period was 32% in CDSS communities and 5% in community intervention-alone communities (P=.03). Use of macrolides decreased significantly in CDSS communities but not in community intervention-alone communities. Conclusion: CDSS implemented in rural primary care settings reduced overall antimicrobial use and improved appropriateness of antimicrobial selection for acute respiratory tract infections."
Objective

"To measure the added value of CDSS when coupled with a community intervention to reduce inappropriate prescribing of antimicrobial drugs for acute respiratory tract infections."

Type Clinic
Primary care
Size
Small and/or medium
Geography
Rural
Other Information
The study involved a "[c]luster randomized trial that included...334 primary care clinicians in 12 rural communities in Utah and Idaho (6 with 1 shared characteristic and 6 with another), and a third group of 6 communities that served as nonstudy controls."
Type of Health IT
Decision support system
Type of Health IT Functions
"Three decision support tools were developed to cover a wide variety of acute respiratory tract infections including pharyngitis, otitis media, bronchitis, upper respiratory tract infection, sinusitis, pneumonia, croup, and influenza. Two versions were paper-based and 1 was programmed on a PDA. Three different formats of the tools were made available in order to give clinicians a choice and thereby, enhance their willingness to participate. One paper version was a patient-initiated chart documentation tool on which the patient circled answers to questions about specific symptoms...The other paper version was an easy-to-use graphical flowchart also designed to lead the clinician to the correct diagnosis and treatment options according to precise criteria. The PDA-based CDSS generated diagnostic and therapeutic recommendations on the basis of patient-specific information that was input about the suspected diagnosis, such as the presence or absence of specific symptoms and signs."
Workflow-Related Findings
"Within CDSS communities, clinicians [who used the CDSS most frequently] showed a greater decrease in antimicrobial use than clinicians who did not use the tools (linear trend, P=.034)."
"It was necessary for all patient-specific data to be manually entered into the PDA because the system was not integrated with a practice management system or electronic medical record. This inconvenience was mitigated by the design of the program, in which treatment recommendations were rapidly displayed once minimum criteria for reaching an end node of the decision logic were met."
Study Design
Randomized controlled trial (RCT)
Study Participants
Study participants included "334 primary care clinicians in 12 rural communities in Utah and Idaho [and] 6 communities that served as nonstudy controls." "Primary care clinicians were defined for this study as emergency department clinicians, family practice physicians, internists, pediatricians, nurse practitioners, and physician's assistants."