Diagnostic Stewardship as a 'nudge' to reduce inappropriate antibiotic use for urinary tract infections

诊断管理作为“推动”减少尿路感染抗生素的不当使用

• 批准号: 10515632
• 负责人: Daniel J Morgan
• 金额: --
• 依托单位: BALTIMORE VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-10-01 至 2024-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10515632
• 关键词: Acute; Address; Adverse event; Ambulatory Care; American; Antibiotics; Antimicrobial Resistance; Area; Award; Bacterial Antibiotic Resistance; Bladder; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Clostridium difficile; Collaborations; Combating Antibiotic Resistant Bacteria; Communicable Diseases; Computerized Medical Record; Consensus; Data; Diagnosis; Diagnostic; Diagnostic tests; Focus Groups; Funding; Goals; Health system; Healthcare; Healthcare Systems; Hospitals; Infection; Infection prevention; Inflammation; Intervention; Interview; Laboratories; Learning; Life; Literature; Long-Term Care; Maryland; Measures; Medical center; Methods; Nurses; Outcome; Patient Care; Physicians; Pilot Projects; Population; Process; Protocols documentation; Psychology; Quasi-experiment; Reporting; Research; Research Priority; Risk; Safety; Sampling; Technology; Testing; Training; United States Centers for Medicare and Medicaid Services; Universities; Urinary tract infection; Urine; Veterans; Work; acute care; adverse outcome; antimicrobial; behavioral economics; catheter associated UTI; cost; data warehouse; design; effective intervention; effectiveness/implementation study; implementation barriers; implementation facilitators; implementation research; implementation science; implementation strategy; implementation tool; improved; improved outcome; innovation; interest; intervention refinement; novel strategies; prevent; programs; provider behavior; response; tool; uptake; urinary; user centered design

Background: Antibiotic-resistant bacteria are estimated by the Centers for Disease Control and Prevention (CDC) to kill over 23,000 Americans yearly. Overuse of antibiotics is a leading cause, and reducing unnecessary antibiotic use is a national priority. A major factor in antibiotic overuse is inappropriate or unnecessary culturing, particularly unnecessary urine culturing that identifies colonization and leads to overdiagnosis of urinary tract infections (UTI). Significance/ Impact: Diagnostic stewardship is a novel approach to limiting antibiotic use by modifying the ordering, processing, or reporting of a “positive” culture that generally should not be treated. In preliminary work, we found significant reductions in unnecessary urine cultures and associated antibiotic use through diagnostic stewardship. Diagnostic stewardship is synergistic with antimicrobial stewardship by improving the value and accuracy of urine testing before treatment. This proposal addresses gaps including: Defining best UTI diagnostic stewardship methods, informed by experts and clinicians; developing implementation methods for UTI diagnostic stewardship; and, assessing the impact of real life UTI diagnostic stewardship— both benefits and any harms across acute-care, long-term care, and ambulatory care. This meets HSR&D Research priorities of quality/safety, health care value, cross-cutting HSR methods priorities of implementation science/provider behavior and ORD-wide priority of real-world impact of VA research in addition to national priorities from CDC, Centers for Medicare and Medicaid Services (CMS) and the President’s National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB). Innovation: Modifying how tests are ordered, processed, and reported can help improve patient care by using existing technology more effectively. This is a ‘nudge’ approach, developed from psychology and behavioral economics. This work uses the electronic medical record (EMR) in an innovative, mostly behind the scenes fashion to improve appropriateness of ordering and reporting of tests. A pragmatic proof-of- concept study within an existing network of VA health care systems, using automated outcomes from the VA Corporate Data Warehouse (CDW) is efficient and consistent with the VA goal of being a Learning Health System. Our aims are as follows: Aim 1: Define best UTI diagnostic stewardship criteria, based on literature and Delphi method expert panel. Aim 2: Use iterative user-centered design process to develop EMR interface and lab protocols, with clinicians and other stakeholders (nurses, doctors, technicians, and IT representatives). Aim 3: Conduct a pragmatic proof-of-concept hybrid effectiveness implementation study of the UTI diagnostic stewardship interventions in 3 CDC-CREATE Network Healthcare Systems evaluating benefits and any adverse events. Project Methods: Aims 1 and 2 will use expert panels for developing consensus criteria and a user-centered design process, including end-user interviews and focus groups, for creating and refining implementation tools. Aim 3 will conduct a quasi-experimental before-after study in the existing VA CDC-CREATE Network. Next Steps/Implementation: Systematic application of diagnostic stewardship has the potential to limit inappropriate urine culturing; and thereby, reduce unnecessary use of antibiotics for over-diagnosed UTI at a minimal cost and without adverse consequences. If successful, the approaches from this proposal could be readily implemented to reduce antimicrobial resistance across the VA healthcare system and other hospitals; reducing catheter-associated UTI (CAUTI) and C. difficile rates; and improving the care and safety of Veterans.

背景：抗生素耐药细菌是由疾病控制中心估计的 预防（CDC）每年杀死23,000多名美国人。过度使用抗生素是一个主要原因，并且 减少不必要的抗生素使用是国家优先事项。抗生素过度使用的主要因素是 不适当或不必要的文化，尤其是不必要的尿文化 定植并导致尿路感染过度诊断（UTI）。 意义/影响：诊断管理是一种新颖的方法来限制抗生素的使用方法 订购，加工或报告通常不应治疗的“积极”文化。在初步 工作，我们发现通过 诊断管理。诊断管理与抗菌管理是协同的 治疗前尿液测试的价值和准确性。该提案解决了差距，包括：定义最佳 UTI诊断管理方法，由专家和临床医生告知；开发实施 UTI诊断管理的方法；并且，评估现实生活中UTI诊断管理的影响 - 急性护理，长期护理和门诊护理中的福利和任何危害。这遇到了Hsr＆d 质量/安全性，医疗保健价值的研究优先级，交叉切割的HSR方法优先级 实施科学/提供者的行为和va研究实际影响对现实世界的优先级 除了CDC，Medicare和Medicaid Services（CMS）和 总统对抗生素耐药细菌（CARB）打击的国家行动计划。 创新：修改测试的订购，处理和报告的方式可以帮助改善患者护理 更有效地使用现有技术。这是一种从心理学和 行为经济学。这项工作在创新中使用了电子病历（EMR），主要是在后面 场景的时尚，以提高订购和报告测试的适当性。务实的证明 使用VA的自动结果，现有VA医疗保健系统网络中的概念研究 公司数据仓库（CDW）效率高，并且与VA的目标保持一致 系统。 我们的目标如下： AIM 1：根据文献和Delphi方法专家小组定义最佳UTI诊断管理标准。 AIM 2：使用以用户为中心的迭代设计过程来开发EMR接口和实验室协议，并使用 临床医生和其他利益相关者（护士，医生，技术人员以及IT代表）。 AIM 3：进行UTI的务实概念证明混合有效性实施研究 3个CDC创建网络医疗保健系统中的诊断管理干预措施评估福利 和任何不利事件。 项目方法：目标1和2将使用专家面板来制定共识标准和以用户为中心的 设计过程，包括最终用户访谈和焦点小组，用于创建和完善实施 工具。 AIM 3将在现有的VA CDC-CREATE网络中进行准实验前研究。 下一步/实施：系统应用诊断管理有可能限制 不适当的尿液培养；因此，减少不必要的抗生素用于过度诊断的UTI 成本最小，没有不利后果。如果成功的话，该提议的方法可能是 易于实施，以减少VA医疗系统和其他医院的抗菌素耐药性； 降低导管相关的UTI（CAUTI）和艰难梭菌率；并提高护理和安全性 退伍军人。