Antibiotics can’t treat the cold or the flu. Prescribed unwisely, they make bacteria harder to kill and make infections harder to treat. Still, about half the antibiotic prescriptions written in doctors’ offices are useless, or worse. But tools that guide doctors’ decisions can reduce excessive use of antibiotics, according to a study published Tuesday in the Journal of the American Medical Association.
The study compared antibiotic prescriptions in eighteen rural communities. In some communities, a public education campaign urged patients not to get unnecessary antibiotics and doctors were given both paper-based and PDA tools to show whether antibiotics are recommended. Other communities received only the public education campaign or no intervention at all. The only significant decrease in antibiotic use occurred in the communities where doctors had the tools. Furthermore, the more doctors used these tools, the more inappropriate use of the antibiotics declined.
Physicians are generally considered to be slow to change their prescribing habits, even in the face of new clinical data and guidelines. But Matthew Samore, the University of Utah informaticist and epidemiologist who led the study, thinks clinical decision support tools could be more effective. (He is quick to point out that the study did not go on long enough to show how long the change would last; antibiotic prescriptions were tracked from January 2002 to September 2003.)
A separate study published last month found that a clinical decision support systems could change behavior. In that study, doctors entered patient prescriptions into a system that generated alerts when a drug could prove dangerous to a particular patient.
But Samore is particularly interested in decision support tools for physician education. Unlike clinical guidelines, support tools make recommendations for specific individuals based on multiple sources of data. “Doctors, or anybody, don’t like things that are annoying or perceived to be unnecessary,” he said. To make the tools more acceptable, he imagines that tool use could be mandatory for a certain number of patient visits and then made optional. Doctors should also be rewarded for participating, perhaps through continuing education credits.
Overall, doctors liked the PDA version of the tool, said Samore, but because it wasn’t integrated with electronic records or prescribing factors, it adds a small amount of time to patient visits and doctors would only use it short-term. He is currently working on a study that combines electronic prescribing with clinical decision support.
The study published this week in JAMA included over 400,000 inhabitants whose communities were randomly selected to receive a public education campaign or an education campaign combined with decision support tools. For situations defined as ones in which antibiotics are never indicated, antibiotic prescription rates fell 32 percent in communities where doctors were given the tools, versus 5 percent for communities that received only the public education campaign.
About 70 percent of doctors given the option of clinical decision support tools used them. Physicians could choose from three decision support tools and were paid $3 more per visit for any inconvenience of using them. Two were paper forms that physicians helped fill out. The third was a PDA programmed with question prompts. About half of the rural doctors used only the PDA; another quarter used both the PDA and paper forms, and another quarter used only the paper forms. The PDA program was created by TheraDoc Inc for research, but is not available for sale.
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