Evaluation of an antibiotic prescribing protocol for treatment of acute exacerbations of chronic obstructive airways disease in a hospital respiratory unit

Abstract

A prescribing protocol for infective exacerbations of chronic obstructive airways disease (COAD), specifying the use of oral amoxycillin 500 mg tid (or erythromycin 500 mg qid if allergic) as first line therapy, and oral ciprofloxacin 500 mg bd as second line treatment, was introduced in 1991. Every third sequential admission was screened for the year preceding (1990) and the year after (1991) the protocol was implemented. Only those patients with a discharge diagnosis of infective exacerbation of COAD, but without pneumonia, were included in the analysis. The two groups (1990 and 1991) were matched in terms of age, sex and pre-treatment given by their General Practitioner (GP), but differed with respect to severity score, with 1991 being more severe. The outcome measures showed that duration of hospital stay was comparable as was duration of treatment. Response to first line therapy was 68% and 67% for 1990 and 1991, respectively. Of those who had received antibiotics from their GP, 67% responded to first line therapy, while of those who had not received antibiotics from their GP 75% responded. Duration of therapy was shorter in first line responders (mean and 95% CI: 7.3 (6.3-8.3) days vs 12.7 (10.1-15.3) days). The mean cost per day antibiotic treatment was reduced by 54.6% (95% CI 52.3-56.9%) from 3.77 pounds to 1.71 pounds. In conclusion, the introduction of antibiotic prescribing guidelines for treatment of infective exacerbations of COAD showed no detrimental effect on outcome measures, but was associated with a significant reduction in the cost of antibiotic therapy.

Do clinical guidelines reduce clinician dependent costs?

“…Interventions included: introduction of integrated management of childhood illness (IMCI)[11] clinical guidelines, a multifaceted intervention to improve preventive care delivered by nurses[24], a multidisciplinary clinical pathway for oxygen management[22], a multifaceted intervention to promote early switching from intravenous to oral acetaminophen for post-operative pain[17], introduction of new antibiotic protocols is the treatment of pneumonia[19], an educational intervention to decrease use of selected expensive medications[20], use of clinical pathway designed to manage community acquired pneumonia more efficiently than with conventional therapy[25], use of commercially available prescribing system with integrated clinical decision support and evidence based message capability[23], clinical pathways for patients undergoing total laryngectomy[18], inpatient diabetes management program[16] and evaluation of educational outreach visits by community pharmacists[26] on the effectiveness of guidelines. These interventions aimed at changing clinician behaviour either through training, prompts, feedback, supervision or a combination of this process.…”

“…Several studies have reported the degree of financial savings arising from certain interventions aimed at improving clinicians' prescribing behavior[11-15,17,19,20,22,24-26]. The studies which modeled the effect of changing health worker behavior present degrees of financial savings on CDC's limited to drug costs ranging from 26 to 80 percent.…”

“…There is a possibility that studies are only conducted and reported in areas where they already feel that costs are unreasonably high[11,17,19,20,24,25], hence making it more likely that their intervention will work. This bias serves to show that clinical guidelines will always reduce costs, whereas there are many other reasons why guidelines may be helpful in improving quality of care.…”

The Influence of Case Mix, Site Selection, and Methods Biases on Costs of Hospitalization For Acute Exacerbations of Chronic Obstructive Airways Disease and Lower Respiratory Tract Infections

“…Patients who are hospitalized with lower respiratory tract infections caused by beta‐lactamase–producing organisms are more likely to have received antibiotics before admission [21]. Our local hospital antibiotic policy follows national guidelines and recommends amoxycillin alone for acute exacerbations of COAD and amoxycillin plus erythromycin for pneumonia, with or without COAD [22]. We have previously shown that patients with acute exacerbations of COAD have a lower rate of response to amoxycillin if they have received antibiotics before admission [22].…”

“…Our local hospital antibiotic policy follows national guidelines and recommends amoxycillin alone for acute exacerbations of COAD and amoxycillin plus erythromycin for pneumonia, with or without COAD [22]. We have previously shown that patients with acute exacerbations of COAD have a lower rate of response to amoxycillin if they have received antibiotics before admission [22]. Thus, antibiotic treatment before hospitalization could be associated with a longer duration of hospitalization if it is associated with a higher probability of infection with antibiotic resistant organisms, and hence of failure to respond to first line antibiotic treatment.…”