title: A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis.
abstract: BACKGROUND
  National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis.
  
  
  METHODS
  We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis.
  
  
  RESULTS
  Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites.
  
  
  CONCLUSIONS
  Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00981994.
authors: Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94118, USA. ralphg@medicine.ucsf.edu
authors: Ralph
authors: R
authors: Gonzales
authors: Tammy
authors: T
authors: Anderer
authors: Charles E
authors: CE
authors: McCulloch
authors: Judith H
authors: JH
authors: Maselli
authors: Frederick J
authors: FJ
authors: Bloom
authors: Thomas R
authors: TR
authors: Graf
authors: Melissa
authors: M
authors: Stahl
authors: Michelle
authors: M
authors: Yefko
authors: Julie
authors: J
authors: Molecavage
authors: Joshua P
authors: JP
authors: Metlay
mesh_terms: D000208:Acute Disease / Q000628:therapy; D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001991:Bronchitis / Q000188:drug therapy*; D016000:Cluster Analysis; D003661:Decision Support Techniques; D004363:Drug Utilization / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control*; D008297:Male; D010414:Pennsylvania; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011320:Primary Health Care / Q000379:methods
chemical_list: D000900:Anti-Bacterial Agents