Improving antibiotic prescribing for adults with community acquired pneumonia: Does a computerised decision support system achieve more than academic detailing alone?--A time series analysis.

Kirsty L Buising,James F Black,Alan C Street,Karin A Thursky,Graham V Brown,Lachlan Macgregor,Marcus P Kennedy

doi:10.1186/1472-6947-8-35

Abstract

BackgroundThe ideal method to encourage uptake of clinical guidelines in hospitals is not known. Several strategies have been suggested. This study evaluates the impact of academic detailing and a computerised decision support system (CDSS) on clinicians' prescribing behaviour for patients with community acquired pneumonia (CAP).MethodsThe management of all patients presenting to the emergency department over three successive time periods was evaluated; the baseline, academic detailing and CDSS periods. The rate of empiric antibiotic prescribing that was concordant with recommendations was studied over time comparing pre and post periods and using an interrupted time series analysis.ResultsThe odds ratio for concordant therapy in the academic detailing period, after adjustment for age, illness severity and suspicion of aspiration, compared with the baseline period was OR = 2.79 [1.88, 4.14], p < 0.01, and for the computerised decision support period compared to the academic detailing period was OR = 1.99 [1.07, 3.69], p = 0.02. During the first months of the computerised decision support period an improvement in the appropriateness of antibiotic prescribing was demonstrated, which was greater than that expected to have occurred with time and academic detailing alone, based on predictions from a binary logistic model.ConclusionDeployment of a computerised decision support system was associated with an early improvement in antibiotic prescribing practices which was greater than the changes seen with academic detailing. The sustainability of this intervention requires further evaluation.

Highlights

The ideal method to encourage uptake of clinical guidelines in hospitals is not known
The observed death rate during the computerised decision support system (CDSS) period appeared to be higher than for the other two periods, but this was largely explained by differences in the proportion of patients aged over 85 years, and differences in the number of patients who died in the emergency department (ED) for whom supportive therapy was not thought appropriate
The odds ratio for having received the recommended empiric antibiotic therapy to cover both typical and atypical pathogens ('concordant therapy') in the ED for the academic detailing period compared to the baseline period was 2.58 [1.78, 3.73], p < 0.01, and after adjustment for age, severity (PSI class) and suspicion of aspiration, OR = 2.79 [1.88, 4.14], p < 0.01

Summary

Introduction

The ideal method to encourage uptake of clinical guidelines in hospitals is not known. This study evaluates the impact of academic detailing and a computerised decision support system (CDSS) on clinicians' prescribing behaviour for patients with community acquired pneumonia (CAP). [12] We chose in the first instance to deploy a guideline for the management of patients with community acquired pneumonia (CAP) as this is one of the most common conditions presenting to hospital emergency departments. The general aim of this study was to describe the impact of different methods of guideline promotion on clinician prescribing behaviour. A comparison of the impact of both academic detailing (AD) and a computerised decision support system (CDSS) on the management of patients with CAP in an emergency department (ED) was examined. The outcomes of interest included the prescription of antibiotics that were concordant with guideline recommendations, the early identification of the severely ill patients and adjustment of antibiotics to meet recommendations for prescribing in the severely ill group, and adjustment of antibiotics to accommodate known patient allergies

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Discussion

Conclusion