Guideline-concordant Prescribing Research Articles

Using intervention mapping to design and implement a multicomponent intervention to improve antibiotic and NSAID prescribing.

Successfully changing prescribing behavior to reduce inappropriate antibiotic and nonsteroidal anti-inflammatory drug (NSAID) prescriptions often requires combining components into a multicomponent intervention. However, multicomponent interventions often fail because of development and implementation complexity. To increase the likelihood of successfully changing prescribing behavior, we applied a systematic process to design and implement a multicomponent intervention. We used Intervention Mapping to create a roadmap for a multicomponent intervention in unscheduled outpatient care settings in the Veterans Health Administration. Intervention Mapping is a systematic process consisting of six steps that we grouped into three phases: (i) understand behavioral determinants and barriers to implementation, (ii) develop the intervention, and (iii) define evaluation plan and implementation strategies. A targeted literature review, combined with 25 prescriber and 25 stakeholder interviews, helped identify key behavioral determinants to inappropriate prescribing (e.g. perceived social pressure from patients to prescribe). We targeted three desired prescriber behaviors: (i) review guideline-concordant prescribing and patient outcomes, (ii) manage diagnostic and treatment uncertainty, and (iii) educate patients and caregivers. The intervention consisted of components for academic detailing, prescribing feedback, and alternative prescription order sets. Implementation strategies consisted of preparing clinical champions, conducting readiness assessments, and incentivizing use of the intervention. We chose a mixed-method study design with a commonly used evaluation framework to assess effectiveness and implementation outcomes in a subsequent trial. This study furthers knowledge about causes of inappropriate antibiotic and NSAID prescribing and demonstrates how theoretical, empirical, and practical information can be systematically applied to develop a multicomponent intervention to help address these causes.

Factors Affecting Prescribing of Type 2 Diabetes Medications in Older Adults within an Integrated Healthcare System.

Despite type 2 diabetes guidelines recommending against the use of sulfonylureas in older adults and for the use of sodium-glucose cotransporter-2 inhibitors (SGLT2) and glucagon-like peptide-1 agonists (GLP1s) in patients with atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure (HF), real-world guideline-concordant prescribing remains low. While some factors such as cost have been suggested, an in-depth analysis of the factors associated with guideline-concordant prescribing is warranted. To quantify the extent of guideline-concordant prescribing in an integrated health care delivery system and examine provider and patient level factors that influence guideline-concordant prescribing. We performed a cross-sectional study. Participants were included if they had a diagnosis of type 2 diabetes, were prescribed a second-line diabetes medication between January 1, 2018 and December 31, 2020 and were at least 65 years old at the time of this second-line prescription. Our outcome of interest was guideline-concordant prescribing. The definition of guideline-concordant prescribing was based on American Diabetes Association and American Geriatric Society recommendations as well as expert consensus. Factors affecting guideline concordant prescribing included patient demographics and provider characteristics among others. We included 1,693 patients of which only 50% were prescribed guideline-concordant medications. In a subgroup of 843 patients with cardiorenal conditions, only 30% of prescriptions were guideline concordant. Prescribing of guideline-concordant prescriptions was more likely among pharmacists than physicians (RR 1.34, 95% CI 1.19-1.51, p<0.001) and in endocrinology practices compared to primary care practices (RR 1.41 95% CI 1.16-1.72, p=0.007). Additionally, guideline concordant prescribing increased over time (42% in 2018 vs 53% in 2019 vs 53% in 2020, p<0.001). Guideline-concordant prescribing remains low in older adults, especially among those with cardiorenal conditions. Future studies should examine barriers to prescribing guideline-concordant medications and interventions to improve guideline-concordant prescribing.

Guideline-concordant use of olanzapine as part of a 4-drug antiemetic regimen for high emetic risk chemotherapy across the state of Michigan.

6519 Background: Chemotherapy-induced nausea and vomiting (CINV) is a feared side effect of cancer treatment. If not adequately controlled, CINV can negatively affect both quality of life and increase the costs of care. Clinical practice guidelines from both ASCO and NCCN recommend inclusion of olanzapine as part of a 4-drug antiemetic regimen in patients receiving high emetic risk chemotherapy (HEC). Uptake of olanzapine has been low, however, in part due to oncologists’ lack of familiarity with the medication, lack of awareness or agreement with the guidelines, and lack of olanzapine inclusion on prepopulated order sets. Current labeling of olanzapine as an antipsychotic poses an additional barrier. The purpose of this project was to increase guideline-concordant prescribing of olanzapine as part of a 4-drug antiemetic regimen in patients receiving HEC in practices that are part of the Michigan Oncology Quality Consortium (MOQC), a physician-led consortium of nearly 90% of oncologists in Michigan. Methods: In 2019, MOQC began measuring guideline-concordant HEC prophylaxis with a 4-drug regimen of olanzapine added to corticosteroids, a 5HT3RA, and an NK1RA as part of its measure set. A quality improvement intervention was initiated that consisted of 1) dissemination of baseline measure performance and regular reporting of practice and state-level performance to MOQC practices, 2) information support through sharing of guidelines at biannual meetings (2019, 2022) and state-wide CINV education to improve prescriber knowledge and beliefs and support the practices in updating prepopulated antiemetic order sets, and 3) addition of value-based reimbursement in 2021 to encourage practice change. Measure performance was assessed using ASCO’s Quality Oncology Practice Initiative (QOPI) program. Results: The patient sample included 5,703 patients. MOQC practices increased the guideline-concordant prescribing of olanzapine as part of a 4-drug antiemetic regimen in patients receiving HEC round over round from R1 2019 to R1 2022 (p&lt;0.0001). Conclusions: MOQC has facilitated increased use of olanzapine as part of a 4-drug antiemetic regimen in patients receiving HEC through practice education, reporting, and value-based reimbursement. Ongoing work will focus on practices with low uptake and on demonstrating the impact of this important practice change on patient outcomes. [Table: see text]

Going local: Evaluating guideline adherence and appropriateness of antibiotic prescribing in patients with febrile neutropenia at an academic teaching hospital.

Febrile neutropenia (FN) is a medical emergency with significant morbidity and mortality for oncology patients, requiring comprehensive workup and timely antibiotic administration. We evaluated concordance with locally developed FN guidelines and outcomes of cancer patients admitted to general internal medicine at an academic teaching hospital. We conducted a retrospective observational cohort study of patients admitted between July 1, 2016, and June 30, 2017, for FN. Patients were classified as having low-risk or high-risk FN according to their malignancy and chemotherapy. Primary outcome was the proportion of patients receiving guideline-concordant antibiotics within 48 hours of admission to general internal medicine. Secondary outcomes were the proportion of patients in whom empirical antibiotics were active against pathogens isolated, rate of antibiotic-associated adverse events, and in-hospital mortality. We used logistic regression to model relationship between FN risk and guideline-concordant antibiotics. Among 100 patients included, 34 (34%) were low-risk FN and 66 (66%) were high-risk. Proportion of guideline-concordant empirical antibiotics was significantly lower among low-risk FN patients than high-risk patients: 12 (35%) of 34 versus 47 (71%) of 66 (P = .001). Empirical antibiotics were active against 17 (94%) of 18 isolated pathogens. The mortality rate was 3%, and 16% of patients experienced antibiotic-associated adverse events. Hematological malignancy and infectious diseases-trained physician involvement were associated with guideline-concordant prescribing, with adjusted odds ratios of 3.76 (95% CI, 1.46-9.70; P = .006) and 3.71 (95% CI, 1.49-9.23; P = .005), respectively. Guideline concordance was low compared to published reports. Factors influencing appropriate antimicrobial prescribing in patients with FN warrant further exploration.

914. Implementation and User Experience with a Mobile Stewardship App: Phase One of a Study on Guideline Concordant Prescribing

Abstract Background The development of facility-specific antibiotic guides to promote the appropriate use of antibiotics is strongly encouraged; however, the inability to access these resources quickly and easily can be a barrier to optimal antimicrobial prescribing. This study phase aims to determine whether providing guidelines in an easy-to-use mobile app increases access to and awareness of these resources available to providers. Methods In phase one of this study, our team: migrated facility guidelines over to the Sanford Guide Stewardship AssistTM application, provided education, launched the app (March 14, 2022), and sent out a voluntary pre- and one-month post-implementation REDcap provider survey. Phase two of this study will evaluate antibiotic prescribing for limited indications pre-post app implementation and will include a six-month follow-up survey to assess continued trends in guideline awareness and accessibility. The primary endpoint for phase one is to evaluate the usefulness and effect of the app on provider guideline awareness. Results As of May 3, 2022, 409 downloads of the app occurred since launch, with the facility-specific antibiogram being the most viewed page. Thirty-five participants completed the pre-implementation survey, and twenty-three completed the one-month follow-up survey. Respondents included medicine residents (54.3%), hospitalists (17.1%), primary care (11.4%), infectious disease (8.6%), internal medicine (5.7%), and others (2.9%). Statistically significant increases pre-post app implementation for strongly agree/agree responses were seen for the statements, “I feel confident in using an antibiogram” (71.4% vs. 95.7%, p=0.02) and “I can easily access our facility-specific antibiotic guidelines when needed” (68.6% vs. 95.7%, p=0.01). At one month, 73.9% and 91.3% of providers agreed with the statements “I would consider myself a better steward of antibiotics because of the app implementation” and “The app is useful to my practice,” respectively. Pre-implementation Survey Responses One-month Post-survey Responses: General One-month Post-survey Responses: App-specific Conclusion Implementing an antimicrobial stewardship app at a large, non-academic health system promoted accessibility to facility-specific guidelines, reinforced antimicrobial stewardship ideals, and was a valuable resource for prescribers. Disclosures All Authors: No reported disclosures.

1743. Antimicrobial and Diagnostic Stewardship Targeting Urinary Tract Infections in the Emergency Department: A Pharmacist-driven Quality Improvement Project at a Tertiary Military Treatment Facility

Abstract Background With the increasing interest in ambulatory stewardship, we designed a quality improvement project to enhance guideline concordant antimicrobial and diagnostic stewardship practices targeting urinary tract infections (UTI) in the ED of a Military Treatment Facility. Between two data collection phases (P1, P2), we provided education on national guidelines, local protocols and antibiograms, modified order-sets, and implemented enhancements targeting urine collection. The primary outcome was a change in guideline-concordant practices between P1 and P2. Methods This prospective pharmacist-driven study had two 3-month data collection periods including ED encounters that resulted in a urinalysis (UA), urine culture (UCx) and antibiotics for UTI upon discharge. We collected data on participant demographics, clinical course and therapy details via chart review. Culture callback and corresponding interventions were made within 72 hours. Based on P1 results, we broadened our scope in P2 to include a diagnostic stewardship arm (Figure 1). This project was IRB approved under a non-research determination. Results There were no significant changes in guideline-concordant prescribing or diagnostic practices between P1 and P2 (Figure 2). Inappropriate antibiotic selection was primarily due to use of cephalosporins and FQs as first line agents (Table 1). The primary pharmacy intervention was discontinuation of therapy (P1 29.1%, P2 39.8%). One-third of patients receiving antibiotics were asymptomatic, a majority of which had a positive UA (P1 68.4%, P2 73.3%). There was a high rate of UCx contamination which improved in P3 but did not reach statistical significance (P1 25.6%, P2 17.2%, p=0.19). Across all P2 encounters, 51.4% of UCx were deemed inappropriate. Conclusion Significant guideline-discordant prescribing persisted despite interventions. An overreliance on UA findings results in treatment of asymptomatic bacteriuria. Education and order-set modification alone are insufficient for a lasting impact on prescribing practices especially where there is a high rate of provider turnover. An EMR with embedded clinical and alert-based decision support capabilities are likely to make a sustained impact in curbing inappropriate treatment of asymptomatic bacteriuria. Disclosures All Authors: No reported disclosures.

Long-term impact of fluoroquinolone-sparing strategies for empirical treatment of acute uncomplicated cystitis among ambulatory patients.

Background:Acute uncomplicated cystitis is common among outpatients and frequently leads to antibiotic prescriptions, making urinary tract infections (UTIs) an important area for antimicrobial stewardship initiatives. Infectious Disease Society of America (IDSA) guidelines promote alternative agents in place of fluoroquinolones for acute uncomplicated cystitis. Despite IDSA guidance, adherence to the guideline remains low in the United States (US). Several studies have described interventions to improve guideline-concordant prescribing for UTIs. However, the long-term sustainability and impact of fluoroquinolone (FLQ)-sparing strategies on community antimicrobial resistance and treatment outcomes are unknown. The objectives of this study were to characterize current antibiotic prescribing patterns, treatment failures and Escherichia coli resistance rates in a setting which instituted FLQ sparing strategies for UTIs in 2007.Methods:Retrospective cohort study of women aged ⩾ 18 diagnosed with acute uncomplicated cystitis based on International Classification of Diseases, 10th Revision (ICD-10) codes were included. Data were abstracted for ambulatory visits over a 6-month period, January 2018 to June 2018, at a large urban health care system. Treatment decisions were made by individual providers, and data were analyzed retrospectively. Nitrofurantoin (NFT) resistance was obtained from the institutional antibiogram and patient-level data. Treatment failure was defined as the need for a different antibiotic for UTI within 28 days of the original prescription.Results:NFT was the most frequently prescribed antibiotic (n = 386, 71.6%) of empiric antibiotic prescriptions for UTIs. FLQs comprised 4.6% of all antibiotic prescriptions (n = 25). Treatment failure rate was 2.3% in patients treated with NFT. Urine culture was ordered for only 26.8% of patients. Among the small group of patients with cultures ordered, E. coli remained 98.5% susceptible to NFT.Conclusions:This study is the first to report significantly low rates (4.6%) of FLQ prescribing for acute uncomplicated cystitis. Treatment failure rate was low with empiric NFT. Increased NFT resistance among E. coli was not observed at the institution or among the subset of patients with E. coli positive urine cultures. These findings support current IDSA treatment guidance for uncomplicated cystitis.

Addressing an epidemic: Improving guideline-concordant opioid prescribing in surgical patients

BackgroundExcess postoperative opioid prescribing increases the risk of opioid abuse, diversion, and addiction. Clinicians receive variable training for opioid prescribing, and despite the availability of guidelines, wide variations in prescribing practices persist. This quality improvement initiative aimed to assess and improve institutional adherence to published guidelines. MethodsThis study represented a quality improvement initiative at an academic medical center implemented over a 6-month period with data captured 1 year before and after implementation. The quality improvement initiative focused on prescribing education and monthly feedback reports for clinicians. All opioid-naïve, adult patients undergoing a reviewed procedure were included. Demographics, surgical details, hospital course, and opioid prescriptions were reviewed. Opioids prescribed on discharge were evaluated for concordance with recommendations based on published guidelines. Pre- and postimplementation cohorts were compared. ResultsThere were 4,905 patients included: 2,343 preimplementation and 2,562 postimplementation. There were similar distributions in patient demographics between the 2 cohorts. Guideline-concordant discharge prescriptions improved from 50.3% to 72.2% after the quality improvement initiative was implemented (P < .001). Adjusted analysis controlling for sex, age, discharge clinician, length of stay, outpatient surgery, and procedure demonstrated a 190% increase in odds of receiving a guideline-concordant opioid prescription on discharge in the postimplementation cohort (adjusted odds ratio 2.90; 95% confidence interval = 2.55–3.30). ConclusionThis study represented a successful quality improvement initiative improving guideline-concordant opioid discharges and decreasing overprescribing. This study suggested published guidelines are insufficient without close attention to elements of effective change management including the critical importance of locally targeting educational efforts and suggested that real-time, data-driven feedback amplifies impact on prescribing behavior.

Provider and patient sex disparities in opioid prescribing and patient outcomes.

To assess sex disparities in opioid prescribing practices and patient outcomes. A retrospective cross-sectional study. Thirty-three primary care clinics in an academic health system. 2,738 adults prescribed 10+ outpatient opioid prescriptions within 12 months. Patient and primary care provider (PCP) sexbased differences in clinical outcomes, opioid prescribing, and rates of adherence to guideline-concordant opioid prescribing practices. Female PCPs were more likely (p < 0.001) to prescribe lower morphineequivalent daily dose (MEDD) of opioids and complete risk assessment for opioid misuse than male PCPs. PCPs did not differ by sex in adherence rates to controlled substance agreements, urine drug, depression screening, or opioid-benzodiazepine coprescribing. Female patients were more likely (all p ≤ 0.01) to be screened for opioid misuse, treated with lower MEDD, receive opioid-benzodiazepine coprescriptions, have higher pain interference, anxiety and depression diagnoses, and have an overdose diagnosis; they were less likely (all p < 0.001) to report alcohol use or have an alcohol use disorder diagnosis and utilized health care at higher rates than male patients. Sex differences were found in clinician opioid-prescribing practices and adherence to opioid prescribing guidelines and patient characteristics associated with long-term opioid therapy. Strategies to identify sex-related disparities and enhance guideline-concordant opioid prescribing and monitoring could contribute to improved patient care, and clinical and safety outcomes.

Research and Scholarly Methods: Implementation Science Studies.

Traditional research focuses on efficacy or effectiveness of interventions but lacks evaluation of strategies needed for equitable uptake, scalable implementation, and sustainable evidence-based practice transformation. The purpose of this introductory review is to describe key implementation science (IS) concepts as they apply to medication management and pharmacy practice, and to provide guidance on literature review with an IS lens. There are five key ingredients of IS, including: (1) evidence-based intervention; (2) implementation strategies; (3) IS theory, model, or framework; (4) IS outcomes and measures; and (5) stakeholder engagement, which is key to a successful implementation. These key ingredients apply across the three stages of IS research: (1) pre-implementation; (2) implementation; and (3) sustainment. A case example using a combination of IS models, PRISM (Practical, Robust Implementation and Sustainability model) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance), is included to describe how an IS study is designed and conducted. This case is a cluster randomized trial comparing two clinical decision support tools to improve guideline-concordant prescribing for patients with heart failure and reduced ejection fraction. The review also includes information on the Standards for Reporting Implementation Studies (StaRI), which is used for literature review and reporting of IS studies,as well as IS-related learning resources.

Increasing the use of olanzapine in patients receiving chemotherapy in a community oncology practice.

12123 Background: The addition of olanzapine to high emetic risk chemotherapy regimens substantially improves nausea and vomiting within 24 hours and is recommended in the guidelines of both the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN). However, the uptake of olanzapine has been low in national and institutional settings. The purpose of this project was to increase guideline-concordant prescribing of olanzapine in eligible patients in a community oncology practice. Methods: We developed a multiphase program to address the barriers to the use of olanzapine in a community oncology practice. Patients’ medical records (N = 423) were reviewed to collect baseline data. Motivational interviewing with prescribing clinicians elicited barriers to prescribing, reinforced clinical guidelines, and elicited and reinforced language that suggested a willingness to change prescribing patterns. Chemotherapy protocols were subsequently updated to include olanzapine for high emetic chemotherapy regimens, and prescriber and nurse education was provided by our pharmacists regarding the most recent ASCO and NCCN guidelines. A fellow-led educational session was provided to the infusion nursing team and care managers. At the end of a seven-month period, prescribing information was identified through a system-generated report followed by a medical record review for validation (N = 136) and was shared monthly with prescribing clinicians. Results: At baseline, the use of olanzapine was zero. Multiple barriers were identified regarding the use of olanzapine during motivational interviewing with clinicians, including lack of knowledge of the guidelines, belief that most patients do not require olanzapine, concerns about sedation with the previously recommended dose of 10 mg, and order sets that did not include olanzapine. After the interventions, there was a statistically significant increase in the use of olanzapine from 0% to 56% (p-value &lt; 0.001). Conclusions: A combination of motivational interviewing, prescriber and nurse information support, and changes to the pre-populated order sets for chemotherapy antiemetics was highly successful in improving the uptake of guideline-concordant prescribing of antiemetics. This model of quality improvement, including motivation interview, may support quality improvement efforts across oncology.[Table: see text]

Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention

BackgroundVenous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action—here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers.MethodsAll admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach).ResultsData from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90–95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis.DiscussionAn EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8–5% despite this mandated system. Further research is needed to assess the potential reasons for this.

Increasing Guideline-Concordant Durations of Antibiotic Therapy for Acute Otitis Media

To compare the effectiveness of 2 interventions in improving prescribing of guideline-concordant durations of therapy for acute otitis media (AOM). This was a quasi-experimental mixed methods analysis that compared a bundled quality improvement intervention consisting of individualized audit and feedback, education, and electronic health record (EHR) changes to an EHR-only intervention. The bundle was implemented in 3 pediatric clinics from January to August 2020 and an EHR-only intervention was implemented in 6 family medicine clinics. The primary outcome measure was prescription of an institutional guideline-concordant 5-day duration of therapy for children ≥2years of age with uncomplicated AOM. Propensity score matching and differences-in-differences analysis weighted with inverse probability of treatment were completed. Implementation outcomes were assessed using the Reach, Effectiveness, Adoption, Implementation, MaintenanceFramework. Balance measures included treatment failure and recurrence. In total, 1017 encounters for AOM were included from February 2019 to August 2020. Guideline-concordant prescribing increased from 14.4% to 63.8% (difference=49.4%) in clinics that received the EHR-only intervention and from 10.6% to 85.2% (difference=74.6%) in clinics that received the bundled intervention. In the adjusted analysis, the bundled intervention improved guideline-concordant durations by an additional 26.4% (P<.01) compared with the EHR-only intervention. Providers identified EHR-prescription field changes as the most helpful components. There were no differences in treatment failure or recurrence rates between baseline and either intervention. Both interventions resulted in improved prescribing of guideline-concordant durations of antibiotics. The bundled intervention improved prescribing more than an EHR-only intervention and was acceptable to providers.

Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting.

BackgroundUrinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed.MethodsWe conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach.ResultsData were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use.ConclusionsClinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.

Electronic Prescribing Systems as Tools to Improve Patient Care: A Learning Health Systems Approach to Increase Guideline Concordant Prescribing for Venous Thromboembolism Prevention

Background: Venous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. In England, reporting the percentage of patients with a VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance (defined as an assessment and an appropriate action) is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that EPS-based interventions would increase full VTE guideline compliance more than other interventions. Methods: All admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011-2020. The proportion of patients who received a fully compliant risk assessment with the recommended action (prophylaxis or not, depending on the risk score) was assessed over time. Interventions included face-to-face feedback based on measured performance (an individual approach) and mandatory risk assessment and prescribing rules into an EPS (a systems approach). Findings: Data from all 235,005 admissions and all 5503 prescribers were included in the analysis. Face-to-face feedback gradually improved full VTE guideline concordance from 70% to 77% (p=<0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p=<0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p<0.001), but this was then maintained during two changes to the low molecular weight heparin drug used for VTE prophylaxis. Interpretation: While both feedback and a rules-based EPS intervention improved guideline-compliant VTE management, a systems approach was more effective and benefits were sustained even during changes to formulary drugs. Non-compliance (an assessment without appropriate action or no assessment) was not eradicated despite this mandated system. Further work is needed to understand this and to ensure software changes enhance full guideline compliance. Funding Statement: This work was supported by PIONEER, the Health Data Research Hub in acute care and the HDR-UK Better Care programme. Declaration of Interests: S Gallier, P Nightingale, T Pankhurst, I Woolhouse, MA Berry, M Garrick report no conflicts of interest. S Ball reports funding support from the HDRUK. E Sapey reports funding support from HDRUK, MRC, Wellcome Trust, NIHR, Alpha 1 Foundation, EPSRC and British Lung Foundation. All other authors have nothing to declare. Ethics Approval Statement: This research was conducted under the ethical approvals of PIONEER, a Health data research hub in acute care (East Midlands – Derby Research ethics committee, reference 20/EM/0158).

Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review.

BackgroundThere has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed.ObjectiveThis study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing.MethodsSearches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases’ inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations).ResultsIn total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations.ConclusionsThere is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.

Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial

BackgroundThough the knowledge base on implementation strategies is growing, much remains unknown about how to most effectively operationalize these strategies in diverse contexts. For example, while evidence shows that champions can effectively support implementation efforts in some circumstances, little has been reported on how to operationalize this role optimally in different settings, or on the specific pathways through which champions enact change.MethodsThis is a secondary analysis of data from a pragmatic trial comparing implementation strategies supporting the adoption of guideline-concordant cardioprotective prescribing in community health centers in the USA. Quantitative data came from the community health centers’ shared electronic health record; qualitative data sources included community health center staff interviews over 3 years. Using a convergent mixed-methods design, data were collected concurrently and merged for interpretation to identify factors associated with improved outcomes. Qualitative analysis was guided by the constant comparative method. As results from the quantitative and initial qualitative analyses indicated the essential role that champions played in promoting guideline-concordant prescribing, we conducted multiple immersion-crystallization cycles to better understand this finding.ResultsFive community health centers demonstrated statistically significant increases in guideline-concordant cardioprotective prescribing. A combination of factors appeared key to their successful practice change: (1) A clinician champion who demonstrated a sustained commitment to implementation activities and exhibited engagement, influence, credibility, and capacity; and (2) organizational support for the intervention. In contrast, the seven community health centers that did not show improved outcomes lacked a champion with the necessary characteristics, and/or organizational support. Case studies illustrate the diverse, context-specific pathways that enabled or prevented study implementers from advancing practice change.ConclusionThis analysis confirms the important role of champions in implementation efforts and offers insight into the context-specific mechanisms through which champions enact practice change. The results also highlight the potential impact of misaligned implementation support and key modifiable barriers and facilitators on implementation outcomes. Here, unexamined assumptions and a lack of evidence-based guidance on how best to identify and prepare effective champions led to implementation support that failed to address important barriers to intervention success.Trial registrationClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

Impact of a Pharmacist-Driven Protocol to Improve Guideline-Concordant Prescribing of Diabetes Medications in Patients With Atherosclerotic Cardiovascular Disease: A Pilot Study

Purpose: To determine whether a pharmacist-driven protocol improves guideline-concordant prescribing of diabetes medications in patients with atherosclerotic cardiovascular disease (ASCVD). Methods: A retrospective pre- and post-intervention study was conducted at a university-based family medicine clinic. A pharmacist-driven protocol was implemented which involved the creation of an algorithm recommending specific diabetes medications in patients with ASCVD. An in-service presentation reviewing the algorithm and process for referral of eligible patients to an appointment with a clinical pharmacist was delivered to providers. Clinical pharmacist appointments focus was on improving diabetes management and initiating cardiovascular risk-reducing medications if appropriate. Results: A total of 234 patients were screened, and 108 met inclusion criteria. Upon completion of patient outreach, 34% were scheduled with a pharmacist. Forty-three percent of patients (16 of 37) attended the appointment. Of those, 31% were initiated on an evidence-based regimen indicated for diabetes and ASCVD. In comparing pre- to post-implementation of the pharmacist-driven protocol, the rate of guideline-concordant prescribing increased by 48% (3.8% to 5.6%). Conclusion: Implementation of a pharmacist-driven protocol can increase guideline-concordant prescribing. However, further exploration of patient- and system-level barriers is necessary to implement such a program more broadly.

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

BackgroundRates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.Methods/designThe study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study’s primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study’s primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics.DiscussionSystems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices.Trial registrationNCT 04044521 (ClinicalTrials.gov). Registered 05 August 2019.

Does increased implementation support improve community clinics\u2019 guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial

BackgroundDisseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs).MethodsThis pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs’ EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes.ResultsOutcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes.ConclusionsEfforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics’ ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs.Trial registrationClinicalTrials.gov, NCT02325531. Registered 15 December 2014.