IMPLEMENTING ANTIBIOTIC PRACTICE GUIDELINES THROUGH COMPUTER-ASSISTEDDECISION-SUPPORT - CLINICAL AND FINANCIAL OUTCOMES

Objective: To determine the clinical and financial outcomes of antibio tic practice guidelines implemented through computer-assisted decision support. Design: Descriptive epidemiologic study and financial analys is. Setting: 520-bed community teaching hospital in Salt Lake City, Ut ah. Patients: All 162 196 patients discharged from LDS Hospital betwee n 1 January 1988 and 31 December 1994. Intervention: An antibiotic man agement program that used local clinician-derived consensus guidelines embedded in computer-assisted decision support programs. Prescribing guidelines were developed for inpatient prophylactic, empiric, and the rapeutic uses of antibiotics. Measurements: Measures of antibiotic use included timing of preoperative antibiotic administration and duratio n of postoperative antibiotic use. Clinical outcomes included rates of adverse drug events, patterns of antimicrobial resistance, mortality, and length of hospital stay. Financial and use outcomes were expresse d as yearly expenditures for antibiotics and defined daily doses per 1 00 occupied bed-days. Results: During the 7-year study period, 63 759 hospitalized patients (39.3%) received antibiotics. The proportion of the hospitalized patients who received antibiotics increased each year , from 31.8% in 1988 to 53.1% in 1994. Use of broad-spectrum antibioti cs increased from 24% of all antibiotic use in 1988 to 47% in 1994. Th e annual Medicare case-mix index increased from 1.7481 in 1988 to 2.05 20 in 1993. Total acquisition costs of antibiotics (adjusted for infla tion) decreased from 24.8% ($987 547) of the pharmacy drug expenditure budget in 1988 to 12.9% ($612 500) in 1994. Antibiotic costs per trea ted patient (adjusted for inflation) decreased from $122.66 per patien t in 1988 to $51.90 per patient in 1994. Analysis using a standardized method (defined daily doses) to compare antibiotic use showed that an tibiotic use decreased by 22.8% overall. Measures of antibiotic use an d clinical outcomes improved during the study period. The percentage o f patients having surgery who received appropriately timed preoperativ e antibiotics increased from 40% in 1988 to 99.1% in 1994. The average number of antibiotic doses administered for surgical prophylaxis was reduced from 19 doses in the base year to 5.3 doses in 1994. Antibioti c-associated adverse drug events decreased by 30%. During the study, a ntimicrobial resistance patterns were stable, and length of stay remai ned the same. Mortality rates decreased from 3.65% in 1988 to 2.65% in 1994 (P < 0.001). Conclusions: Computer-assisted decision support pro grams that use local clinician-derived practice guidelines can improve antibiotic use, reduce associated costs, and stabilize the emergence of antibiotic-resistant pathogens.