title: Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: a cluster randomised controlled trial.
abstract: OBJECTIVE
  Clinical guidelines discourage antibiotic prescribing for many acute respiratory infections (ARIs), especially for non-antibiotic appropriate diagnoses. Electronic health record (EHR)-based clinical decision support has the potential to improve antibiotic prescribing for ARIs.
  
  
  METHODS
  We randomly assigned 27 primary care clinics to receive an EHR-integrated, documentation-based clinical decision support system for the care of patients with ARIs - the ARI Smart Form - or to offer usual care. The primary outcome was the antibiotic prescribing rate for ARIs in an intent-to-intervene analysis based on administrative diagnoses.
  
  
  RESULTS
  During the intervention period, patients made 21 961 ARI visits to study clinics. Intervention clinicians used the ARI Smart Form in 6% of 11 954 ARI visits. The antibiotic prescribing rate in the intervention clinics was 39% versus 43% in the control clinics (odds ratio (OR), 0.8; 95% confidence interval (CI), 0.6-1.2, adjusted for clustering by clinic). For antibiotic appropriate ARI diagnoses, the antibiotic prescribing rate was 54% in the intervention clinics and 59% in the control clinics (OR, 0.8; 95% CI, 0.5-1.3). For non-antibiotic appropriate diagnoses, the antibiotic prescribing rate was 32% in the intervention clinics and 34% in the control clinics (OR, 0.9; 95% CI, 0.6-1.4). When the ARI Smart Form was used, based on diagnoses entered on the form, the antibiotic prescribing rate was 49% overall, 88% for antibiotic appropriate diagnoses and 27% for non-antibiotic appropriate diagnoses. In an as-used analysis, the ARI Smart Form was associated with a lower antibiotic prescribing rate for acute bronchitis (OR, 0.5; 95% CI, 0.3-0.8).
  
  
  CONCLUSIONS
  The ARI Smart Form neither reduced overall antibiotic prescribing nor significantly improved the appropriateness of antibiotic prescribing for ARIs, but it was not widely used. When used, the ARI Smart Form may improve diagnostic accuracy compared to administrative diagnoses and may reduce antibiotic prescribing for certain diagnoses.
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, BC-3-2X, Boston, MA 02120, USA. jlinder@partners.org
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Linder
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Schnipper
authors.forename: Ruslana
authors.initials: R
authors.lastname: Tsurikova
authors.forename: Tony
authors.initials: T
authors.lastname: Yu
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Volk
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Melnikas
authors.forename: Matvey B
authors.initials: MB
authors.lastname: Palchuk
authors.forename: Maya
authors.initials: M
authors.lastname: Olsha-Yehiav
authors.forename: Blackford
authors.initials: B
authors.lastname: Middleton
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016000:Cluster Analysis; D020000:Decision Support Systems, Clinical; D005260:Female; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D012141:Respiratory Tract Infections / Q000188:drug therapy*; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents