Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE Randomized Clinical Trial.

Importance: Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. Objective: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Design, Setting, and Participants: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). Interventions: CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. Main Outcomes and Measures: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Results: Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Conclusions and Relevance: Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. Trial Registration: ClinicalTrials.gov Identifier: NCT03697096.

Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial.

Importance: Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. Objective: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. Design, Setting, and Participants: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. Intervention: CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. Main Outcomes and Measures: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results: Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Conclusions and Relevance: Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. Trial Registration: ClinicalTrials.gov Identifier: NCT03697070.

The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial.

BACKGROUND: Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up. KEY RESULTS: Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03). CONCLUSIONS: Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern. CLINICAL TRIALS IDENTIFIER: NCT01153451.

Accuracy of self-perceived risk for common conditions.

BACKGROUND: Accurate awareness of common disease risk is necessary to promote healthy lifestyles and to prevent unnecessary anxiety and evaluation. Our objective is to identify characteristics of patients who do not accurately perceive their risk of developing coronary heart disease (CHD), diabetes (DM), breast cancer (BC) and colorectal cancer (CRC). METHODS: Using personalized disease risk reports and risk perception surveys, subjects (n = 4703) were classified as high or low/average risk and high or low/average perceived risk for each condition. Models were used to examine factors associated with risk under-estimation by high risk patients and risk over-estimation by low/average risk patients. RESULTS: Patients at high risk for DM, BC and CRC often (60%-75% of the time) under-estimated their risk, while low/average risk patients overestimated their risk 13%-40% of the time. For CHD, under-estimation by high risk individuals approximated over-estimation by low/average individuals. Compared to normal weight patients at high risk for cancer, obese patients were more likely to under-estimate their risk for BC (OR 3.1, CI 1.9-5.0) and CRC (2.6, 1.5-4.5) as were overweight patients. Overweight and obese patients at low/average risk of DM or CHD were more likely than normal weight patients to over-estimate their risk. Low/average risk women were more likely than men to over-estimate their risk of DM (1.3, 1.1-1.5) and CHD (1.8, 1.5-2.1). CONCLUSIONS: Our data show that body mass index is the factor most consistently associated with incorrect risk perceptions for several common conditions.

A Cluster Randomized Trial of a Personalized Multi-Condition Risk Assessment in Primary Care.

INTRODUCTION: Personal risk for multiple conditions should be assessed in primary care. This study evaluated whether collection of risk factors to generate electronic health record (EHR)-linked health risk appraisal (HRA) for coronary heart disease, diabetes, breast cancer, and colorectal cancer was associated with improved patient-provider communication, risk assessment, and plans for breast cancer screening. METHODS: This pragmatic trial recruited adults with upcoming visits to 11 primary care practices during 2013-2014 (N=3,703). Pre-visit, intervention patients completed a risk factor and perception assessment and received an HRA; coded risk factor data were sent to the EHR. Post-visit, intervention patients reported risk perception. Pre-visit, control patients only completed the risk perception assessment; post-visit they also completed the risk factor assessment and received the HRA. No data were sent to the EHR for controls. Accuracy/improvement of self-perceived risk was assessed by comparing self-perceived to calculated risk. RESULTS: The intervention was associated with improvement of patient-provider communication of changes to improve health (78.5% vs 74.1%, AOR=1.67, 99% CI=1.07, 2.60). There was a similar trend for discussion of risk (54.1% vs 45.5%, AOR=1.34, 95% CI=0.97, 1.85). The intervention was associated with greater improvement in accuracy of self-perceived risk for diabetes (16.0% vs 12.6%, p=0.006) and colorectal cancer (27.9% vs 17.2%, p<0.001) with a similar trend for coronary heart disease and breast cancer. There were no changes in plans for breast cancer screening. CONCLUSIONS: Patient-reported risk factors and EHR-linked multi-condition HRAs in primary care can modestly improve communication and promote accuracy of self-perceived risk.

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.

Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment functionality to ensure follow-up of nonurgent CSTRs.