Abstract
To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents. Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual. 212 residents with suspected UTI, from 16 NHs in the Netherlands. Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level. 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was-0.95 in the intervention group NHs and-0.05 in the control group NHs (P= .02). Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.
Highlights
Rutten et al / JAMDA xxx (2021) 1e7 inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group
The treatment advice generated by this decision tool corresponds to the advice stated in the urinary tract infection (UTI) guideline of the Dutch Association of Elderly Care Physicians (Verenso),[17] which is identical to the advice in the previously mentioned decision tool that was developed in an international Delphi study (Supplementary Material 1).[15]
Sixteen nursing home (NH) located across west, central, and southeast Netherlands participated in the study
Summary
We conducted a cluster randomized controlled trial in 16 NHs in the Netherlands, with NHs as the unit of randomization. Six control group NHs provided care as usual. Ten intervention group NHs were provided a decision tool for the treatment of residents with suspected UTI, integrated in the EHR Ysis (Gerimedica, Amsterdam, the Netherlands). The treatment advice generated by this decision tool corresponds to the advice stated in the UTI guideline of the Dutch Association of Elderly Care Physicians (Verenso),[17] which is identical to the advice in the previously mentioned decision tool that was developed in an international Delphi study (Supplementary Material 1).[15] Box 1 provides a summary of those situations in which antibiotic prescribing is indicated for suspected UTI in NH residents, according to this advice.
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