Acute Respiratory Infections (ARIs) Clinical Trial
Official title:
Use of Behavioral Economics to Improve Treatment of Acute Respiratory Infections (Pilot Study)
Bacteria resistant to antibiotic therapy are a major public health problem. The evolution of
multi-drug resistant pathogens may be encouraged by provider prescribing behavior.
Inappropriate use of antibiotics for nonbacterial infections and overuse of broad spectrum
antibiotics can lead to the development of resistant strains. Though providers are
adequately trained to know when antibiotics are and are not comparatively effective, this
has not been sufficient to affect critical provider practices.
The intent of this study is to apply behavioral economic theory to reduce the rate of
antibiotic prescriptions for acute respiratory diagnoses for which guidelines do not call
for antibiotics. Specifically targeted are infections that are likely to be viral.
The objective of this study is to improve provider decisions around treatment of acute
respiratory infections.
The participants are practicing attending physicians or advanced practice nurses (i.e.
providers) at participating clinics who see acute respiratory infection patients. A maximum
of 550 participants will be recruited for this study.
Providers consenting to participate will fill out a baseline questionnaire online.
Subsequent to baseline data collection and enrollment, participating clinic sites will be
randomized to the study arms, as described below.
There will be a control arm, with clinic sites randomized in a multifactorial design to up
to three interventions that leverage the electronic medical record: Order Sets that are
triggered by EHR workflow containing exclusively guideline concordant choices (SA, for
Suggested Alternatives); Accountable Justification (AJ) triggered by discordant
prescriptions that populate the note with provider's rationale for guideline exceptions ;
and performance feedback that benchmarks providers' own performance to that of their peers
(PC, for Peer Comparison).
The outcomes of interest are antibiotic prescribing patterns, including prescribing rates
and changes in prescribing rates over time.
The intervention period will be over one year, with a one-year follow up period to measure
persistence of the effect after EHR features are returned to the original state and
providers no longer receive email alerts.
Each consented provider will be randomized to 1 of 8 cells in a factorial design with equal
probability. If results of retrospective data analysis imply that design will be improved by
stratification, randomization will be stratified by factors that could influence outcomes.
Data will be collected from Northwestern University's Enterprise Data Warehouse which houses
copies of data recorded in the Epic electronic health record. Data elements from qualifying
office visits will be collected from coded portions of the electronic health record.
An encounter is eligible for intervention if the patient's diagnosis is in the selected
group of acute respiratory infections. The intervention EHR functions will be triggered when
clinicians initiate an antibiotic prescription or enter a diagnosis for an acute respiratory
infection that has a defined Order Set. If an antibiotic from a list of frequently
misprescribed antibiotics is ordered and a diagnosis has not yet been entered, providers
will be prompted to enter a diagnosis. If the diagnosis entered is acute nasopharyngitis;
acute laryngeopharyngitis/acute upper respiratory infection; acute bronchitis; bronchitis
not specified as acute or chronic; or flu; the interventions will be triggered. The
diagnosis-appropriate order set will pop-up for providers in the Suggested Alternatives (SA)
arm, while clinicians randomized to the Accountable Justification (AJ) arm will receive an
alert and be required to enter a brief statement justifying their antibiotic prescription if
antibiotics are not indicated for the diagnosis entered. This note will then be added to the
patient's medical record.
Clinicians randomized to the Peer Comparison (PC) condition will receive monthly updates
about their antibiotic prescribing practices relative to other clinicians in their practice.
;
| Status | Clinical Trial | Phase | |
|---|---|---|---|
| Active, not recruiting |
NCT01767064 -
Nudging Guideline-concordant Antibiotic Prescribing Using Public Commitments
|
N/A | |
| Completed |
NCT01454947 -
Use of Behavioral Economics to Improve Treatment of Acute Respiratory Infections (Main Study)
|
N/A |