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Health Care Use and Access

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Computerized guidelines reduce prescribing by hospital doctors of an expensive and overprescribed antibiotic

Overuse of the broad-spectrum antibiotic vancomycin, which is effective against many types of bacteria, has resulted in vancomycin-resistant bacteria as a major health threat in hospitals throughout North America and Europe. There is no established antimicrobial therapy for vancomycin-resistant enterococci (VRE). Even more alarming is the possibility that vancomycin resistance will emerge among staphylococci, the most common infection-causing pathogen among hospitalized patients. Guidelines for vancomycin use may be a key to reducing physician use of this antibiotic, concludes a study supported by the Agency for Health Care Policy and Research (HS08297).

David W. Bates, M.D., M.Sc., and his colleagues at Brigham and Women's Hospital tested a computerized order-entry system at the hospital to determine whether this approach would reduce vancomycin ordering. The system displayed guidelines for the appropriate use of intravenous vancomycin once a physician keyed in a vancomycin order. The researchers randomly assigned physicians to the vancomycin guidelines (intervention group) and compared their use of the drug with a control group of physicians who were not exposed to the guidelines.

Compared with the control group, intervention physicians reduced their overall use of vancomycin by 30 percent. They wrote 32 percent fewer vancomycin orders (11.3 vs. 16.7 orders per physician), had 28 percent fewer patients for whom they either initiated or renewed an order for vancomycin (7.4 vs. 10.3 orders per physician), and prescribed a 36 percent shorter duration of vancomycin therapy than did control physicians (26.5 vs. 41.2 days). In many instances, a different antibiotic may be chosen instead of the more costly vancomycin, such as first-generation cephalosporins like cefazolin. If cefazolin were substituted for vancomycin in all cases in this study in which physicians chose not to order vancomycin, the projected cost savings from decreased vancomycin use—about $90,000—would be partly offset. At a daily cost of $12 for vancomycin and $9 for cefazolin, the projected savings for this hospital would be about $22,500 per year.

More details are in "Reducing vancomycin use utilizing a computer guideline," by Kaveh G. Shojania, M.D., Deborah Yokoe, M.D., M.P.H., Richard Platt, M.D., M.Sc., and others, in the December 1998 Journal of the American Medical Informatics Association 5(6), pp. 554-562.

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