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：抗生素耐药性细菌是由疾病控制中心估计的，并且 预防 (CDC) 每年导致超过 23,000 名美国人死亡，过度使用抗生素是一个主要原因。 减少不必要的抗生素使用是国家的首要任务。抗生素过度使用的一个主要因素是。 不适当或不必要的培养，特别是不必要的尿液培养，以识别 定植并导致尿路感染 (UTI) 的过度诊断。 意义/影响：诊断管理是一种通过修改抗生素使用限制的新方法。 通常不应在初步处理中订购、处理或报告“阳性”培养物。 工作中，我们发现通过以下方式显着减少了不必要的尿培养和相关抗生素的使用 诊断管理与抗菌药物管理具有协同作用，可改善 该提案解决了治疗前尿液检测的价值和准确性： 定义最佳。 尿路感染诊断管理方法，由专家和专家制定实施； UTI 诊断管理的方法；以及评估现实生活中 UTI 诊断管理的影响—— 急性护理、长期护理和门诊护理的益处和危害 这符合 HSR&D 的要求。 质量/安全、医疗保健价值、跨领域 HSR 方法的研究重点 实施科学/提供者行为以及 VA 研究在 ORD 范围内对现实世界影响的优先级 除了 CDC、医疗保险和医疗补助服务中心 (CMS) 以及 总统抗击抗生素耐药性细菌国家行动计划 (CARB)。 创新：修改测试的订购、处理和报告方式有助于改善患者护理 这是一种从心理学和心理学发展而来的“助推”方法。 这项工作利用电子病历（EMR）进行创新，大多落后。 场景时尚以提高测试排序和报告的适当性。 使用 VA 的自动化结果，在 VA 医疗保健系统的现有网络内进行概念研究 企业数据仓库 (CDW) 高效且符合 VA 成为学习健康中心的目标 系统。 我们的目标如下： 目标 1：根据文献和德尔菲法专家小组确定最佳 UTI 诊断管理标准。 目标 2：使用以用户为中心的迭代设计流程来开发 EMR 接口和实验室协议， Fortress 和其他利益相关者（护士、医生、技术人员和 IT 代表）。 目标 3：对 UTI 进行务实的概念验证混合有效性实施研究 3 个 CDC-CREATE 网络医疗保健系统中的诊断管理干预措施评估效益 以及任何不良事件。 项目方法：目标 1 和 2 将利用专家小组制定标准共识和以用户为中心的 设计流程，包括最终用户访谈和焦点小组，用于创建和完善实施 目标 3 将在现有的 VA CDC-CREATE 网络中进行准实验性的前后研究。 后续步骤/实施：诊断管理的系统应用有可能限制 不适当的尿液培养；从而减少因过度诊断的尿路感染而不必要地使用抗生素 如果成功，该提案中的方法可以实现成本最低且不会产生不良后果。 易于实施，以减少整个 VA 医疗系统和其他医院的抗菌药物耐药性； 降低导管相关性尿路感染 (CAUTI) 和艰难梭菌的发生率，并改善患者的护理和安全性； 退伍军人。