User-Centered Design in Pediatric Acute Care Settings Antimicrobial StewardshipFunding This work was supported by NIH K23 HL127130 and NSF 1757644. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health and the National Science Foundation. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Background Antibiotic prescribing in ambulatory care centers is increasing. Previous research suggests that 20 to 50% of antibiotic prescriptions are either unnecessary or inappropriate. Unnecessary antibiotic consumption can harm patients by increasing antibiotic resistance and drug-associated toxicities, and the reasons for such use are multifactorial. Antimicrobial Stewardship Programs (ASP) were developed to guide better use of antibiotics. A core element of ASP is to provide feedback to clinical providers. To create clinically meaningful feedback, user-center design (UCD) is a robust approach to include end-users in the design process to improve systems.
Objective The study aimed to take a UCD approach to developing antibiotic prescribing feedback through input from clinicians in two ambulatory care settings.
Methods We conducted two group prototyping sessions with pediatric clinicians who practice in the emergency department and urgent care settings at a tertiary care children's hospital. Participants received background on the problem of antibiotic prescribing and then were interviewed about their information needs, perceived value, and desired incentives for a prescribing feedback system. Sessions concluded with their response and recommendations to sample sections of an antibiotic feedback report including orienting material, report detail, targeted education, and resources.
Results A UCD approach was found to be highly valuable in the development of a feedback mechanism that is viewed as desirable by clinicians. Clinicians preferred interpreting the data themselves with aids such as diagrams and charts over the researcher concluded statements about the clinician's behavior. Specific feedback that clinicians considered redundant were removed from the model if preexisting alerts were established.
Conclusion Integrating a UCD approach in developing ASP feedback identified desirable report characteristics that substantially modified preliminary wireframes for feedback. Future research will evaluate the clinical effectiveness of our feedback reports in outpatient settings.
Keywordsuser-centered design - ambulatory care - antimicrobial stewardship programs - feedback - pediatrics - requirements analysis and design - qualitative
Protection of Human and Animal Subjects
The study was performed in compliance with the World Medical Association Declaration of Helsinki on ethical principles for medical research involving human subjects and was reviewed by the Vanderbilt University Institutional Review Board.
Received: 29 January 2020
Accepted: 16 September 2020
20 January 2021 (online)
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- 1 Control CDC. Prevention. Antibiotic use in the United States, 2017: progress and opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2017
- 2 Fleming-Dutra KE, Hersh AL, Shapiro DJ. et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016; 315 (17) 1864-1873
- 3 Palms DL, Hicks LA, Bartoces M. et al. Comparison of antibiotic prescribing in retain clinics, urgent care centers, emergency departments, and traditional ambulatory care settings in the United States. JAMA Intern Med 2018; 178 (09) 1267-1269
- 4 Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008; 47 (06) 735-743
- 5 Gerber JS, Prasad PA, Fiks AG. et al. Durability of benefits of an outpatient antimicrobial stewardship intervention after discontinuation of audit and feedback. JAMA 2014; 312 (23) 2569-2570
- 6 Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014; 59 (Suppl. 03) S97-S100
- 7 Agwu AL, Lee CK, Jain SK. et al. A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care pediatric medical center. Clin Infect Dis 2008; 47 (06) 747-753
- 8 Sick AC, Lehmann CU, Tamma PD, Lee CK, Agwu AL. Sustained savings from a longitudinal cost analysis of an internet-based preapproval antimicrobial stewardship program. Infect Control Hosp Epidemiol 2013; 34 (06) 573-580
- 9 Venugopal V, Lehmann CU, Diener-West M, Agwu AL. Longitudinal evaluation of a World Wide Web-based antimicrobial stewardship program: assessing factors associated with approval patterns and trends over time. Am J Infect Control 2014; 42 (02) 100-105
- 10 Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining workflow in a pediatric emergency department to develop a clinical decision support for an Antimicrobial Stewardship Program. Appl Clin Inform 2018; 9 (02) 248-260
- 11 Evans RS, Olson JA, Stenehjem E. et al. Use of computer decision support in an antimicrobial stewardship program (ASP). Appl Clin Inform 2015; 6 (01) 120-135
- 12 Nichols KR, Petschke AL, Webber EC, Knoderer CA. Comparison of antibiotic dosing before and after implementation of an electronic order set. Appl Clin Inform 2019; 10 (02) 229-236
- 13 Dellit TH, Owens RC, McGowan Jr JE. Infectious Diseases Society of America, Society for Healthcare Epidemiology of America. et al; Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44 (02) 159-177
- 14 Ivers N, Jamtvedt G, Flottorp S. et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; (06) CD000259
- 15 Lavoie CF, Plint AC, Clifford TJ, Gaboury I. “I never hear what happens, even if they die”: a survey of emergency physicians about outcome feedback. CJEM 2009; 11 (06) 523-528
- 16 Gerber JS, Prasad PA, Fiks AG. et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013; 309 (22) 2345-2352
- 17 Kramer J, Noronha S, Vergo J. A user-centered design approach to personalization - The key to successful design is grounding the choice of features and tools upon value to the end user. Commun ACM 2000; 43: 45-48
- 18 Constantine LL, Lockwood LA. Usage-centered software engineering: an agile approach to integrating users, user interfaces, and usability into software engineering practice. . Paper presented at: International Conference on Software Engineering. Portland, OR. Available at: https://ieeexplore.ieee.org/document/1201267. Accessed 2003
- 19 Harte R, Glynn L, Rodríguez-Molinero A. et al. A human-centered design methodology to enhance the usability, human factors, and user experience of connected health systems: A three-phase methodology. JMIR Human Factors 2017; 4 (01) e8
- 20 Lyon AR, Koerner K. User-centered design for psychosocial intervention development and implementation. Clin Psychol (New York) 2016; 23 (02) 180-200