Peer Comparison Research Articles

Antimicrobial stewardship to reduce overtreatment of asymptomatic bacteriuria in critical access hospitals: measuring a quality improvement intervention.

Asymptomatic bacteriuria (ASB) treatment is a common form of antibiotic overuse and diagnostic error. Antibiotic stewardship using the inappropriate diagnosis of urinary tract infection (ID-UTI) measure has reduced ASB treatment in diverse hospitals. However, critical access hospitals (CAHs) have differing resources that could impede stewardship. We aimed to determine if stewardship including the ID-UTI measure could reduce ASB treatment in CAHs. From October 2022 to July 2023, ten CAHs participated in an Intensive Quality Improvement Cohort (IQIC) program including 3 interventions to reduce ASB treatment: 1) learning labs (ie, didactics with shared learning), 2) mentoring, and 3) data-driven performance reports including hospital peer comparison based on the ID-UTI measure. To assess effectiveness of the IQIC program, change in the ID-UTI measure (ie, percentage of patients treated for a UTI who had ASB) was compared to two non-equivalent control outcomes (antibiotic duration and unjustified fluoroquinolone use). Ten CAHs abstracted a total of 608 positive urine culture cases. Over the cohort period, the percentage of patients treated for a UTI who had ASB declined (aOR per month = 0.935, 95% CI: 0.873, 1.001, P = 0.055) from 28.4% (range across hospitals, 0%-63%) in the first to 18.6% (range, 0%-33%) in the final month. In contrast, antibiotic duration and unjustified fluoroquinolone use were unchanged (P = 0.768 and 0.567, respectively). The IQIC intervention, including learning labs, mentoring, and performance reports using the ID-UTI measure, was associated with a non-significant decrease in treatment of ASB, while control outcomes (duration and unjustified fluoroquinolone use) did not change.

Strategies to Limit Benzodiazepine Use in Anesthesia for Older Adults

Despite guidelines recommending avoidance of benzodiazepine administration to older patients, many of them now receive benzodiazepines as a part of anesthesia care. The effectiveness of clinician- and patient-facing interventions to discourage such use remains insufficiently characterized. To evaluate the effect of clinician peer comparison, patient informational mail, or a combination of these interventions compared with usual care on the rate of perioperative benzodiazepine administration to older patients. This 2 × 2 factorial, stepped-wedge, cluster randomized clinical trial of a corporate quality improvement initiative was conducted between August 8, 2022, and May 28, 2023, across 415 hospitals, surgery centers, and physician offices in 8 US states served by anesthesia clinicians from a national anesthesia practice. Participants were adults aged 65 years or older who underwent an elective surgical or endoscopic procedure with general anesthesia. Data analyses followed the intention-to-treat principle. Patients were randomly assigned to 1 of 4 groups-clinician peer comparison (wherein clinicians received feedback regarding their performance compared with other clinicians in the practice), patient informational mail (wherein patients received an informational letter encouraging them to have a discussion regarding medication selection with their clinician on the day of surgery), both interventions, or usual care (no intervention). Rate of benzodiazepine administration during anesthesia care and patient satisfaction with anesthesia care (measured by the Anesthesia Patient Satisfaction Questionnaire, version 2). Among the 509 269 enrolled participants (255 871 females [50.2%]; mean [SD] age, 74 [7] years), 81 363 (16.0%) were assigned to clinician peer comparison, 98 520 (19.3%) to patient informational mail, 169 712 (33.3%) to both interventions, and 159 674 (31.4%) to usual care. Among patients who received benzodiazepine during anesthesia care, 24.5% were in the usual care group compared with 19.7% in the clinician peer comparison group, 20.0% in the patient informational mail group, and 19.7% in the combination group. After adjustment for time, none of the study interventions were associated with lower odds of benzodiazepine administration compared with usual care (odds ratio [OR], 1.02 [95% CI, 0.98-1.07]; P = .35 for clinician peer comparison; OR, 1.01 [95% CI, 0.96-1.05]; P = .81 for patient informational mail; and OR, 1.11 [95% CI, 1.05-1.16]; P < .001 for combined interventions). Satisfaction scores were high in all groups and did not vary by treatment assignment. This randomized clinical trial found that clinician peer comparison, patient informational mail, or a combination of both interventions did not reduce benzodiazepine administration to older patients compared with usual care; patient satisfaction remained high throughout the study. Overall, the findings suggest a need to explore other patient-targeted interventions to improve anesthesia care. Clinicaltrials.gov Identifier: NCT05436392.

Pragmatic randomised trial assessing the impact of peer comparison and therapeutic recommendations, including repetition, on antibiotic prescribing patterns of family physicians across British Columbia for uncomplicated lower urinary tract infections

ObjectiveTo evaluate the impact of a personalised audit and feedback prescribing report (AF) and brief educational summary (ES) on empiric treatment of uncomplicated lower urinary tract infections (UTIs) by family...

The Impact of Tele-Stewardship on Rural Antibiotic Prescribing Practices

Abstract Background Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. There has been limited research on the effectiveness of tele-stewardship in the outpatient setting. In this study, we address the need for better AS in rural areas by developing, implementing, and evaluating AS interventions using tele-stewardship. Methods We employed bundled outpatient AS implementation strategies in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center (VUMC) using tele-stewardship. The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls on common pediatric infections, communication skills training (DART modules), app-based microlearning modules (QuizTime), and implicit/explicit bias education and (4) quarterly audit and feedback with peer comparison on guideline-concordant antibiotic use. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children &amp;lt;18 years collected during the “baseline” period (Jan-Dec 2022) to the intervention period (Jan-Sept 2023). Two academic urban primary care clinics and one academic urban ED at which the interventions were not implemented were included as “control” sites. The primary outcome is percent of all encounters that result in an antibiotic prescription. Pre- and post-intervention data were analyzed in aggregate (not at the provider-level). Significance was determined via calculating a 95% confidence interval (CI) for the difference of proportions. Results To date, there have been 140,077 PC patient encounters (98,409 baseline and 41,065 intervention) and 94,205 ED encounters (61759 baseline and 32,446 intervention) across all sites. Change from baseline to intervention periods in academic PC sites was 0.9 percentage points (95% CI 0.556 to 1.243; 6.6% baseline, 7.5% intervention) while change in rural intervention sites was -1.05 percentage points (95% CI -0.409 to -1.667; 11.8% baseline, 10.75% intervention; Figure 1a). Only 1 of 3 rural EDs had a decrease in percent of encounters with an antibiotic prescription (Figure 1b). Overall the academic ED showed a 3.1 percentage point increase (95% CI 2.430 to 3.769; 18.0% baseline, 21.1% intervention) while the rural sites showed a 1.0 percentage point increase (95% CI -0.817 to 2.817; 24.2% baseline, 25.2% intervention). Conclusion Interim analysis shows that bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural primary care clinics compared to urban academic control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

Distributive fairness during the transition to adolescence: The role of peer comparison and social value orientation.

Combining the dictator game (DG) and the ultimatum game (UG), this study recruited 546 Chinese children (321 boys, aged 9-12 years) as distributors, and found that both peer comparison and social value orientation (SVO) significantly influenced children's distributive fairness from late childhood to early adolescence. Results showed that as the unfairness of peer proposals increased, participants decreased the amount of gold coins distributed to the receiver in both tasks, revealing a peer comparison effect. This effect was more pronounced for adolescents than for children in both tasks. In addition, participants' fair distribution behaviors in the DG showed a three-way interaction effect of SVO, grade, and peer comparison. Specifically, for proselfs, children were not influenced by peers and consistently proposed self-interested distributions, whereas adolescents exhibited a peer comparison effect; for prosocials, both children and adolescents were influenced by peers, but children decreased the amount of their distributions only when they saw peers make extremely unfair distributions, whereas adolescents decreased the amount of their distributions when they saw peers make both mildly and extremely unfair distributions. This study highlights the importance of social environment and personal trait in shaping children's fair distribution behavior during the transition from late childhood to early adolescence.

Design and Implementation of an Opioid Scorecard for Hospital System-Wide Peer Comparison of Opioid Prescribing Habits: Observational Study.

Reductions in opioid prescribing by health care providers can lead to a decreased risk of opioid dependence in patients. Peer comparison has been demonstrated to impact providers' prescribing habits, though its effect on opioid prescribing has predominantly been studied in the emergency department setting. The purpose of this study is to describe the development of an enterprise-wide opioid scorecard, the architecture of its implementation, and plans for future research on its effects. Using data generated by the author's enterprise vendor-based electronic health record, the enterprise analytics software, and expertise from a dedicated group of informaticists, physicians, and analysts, the authors developed an opioid scorecard that was released on a quarterly basis via email to all opioid prescribers at our institution. These scorecards compare providers' opioid prescribing habits on the basis of established metrics to those of their peers within their specialty throughout the enterprise. At the time of this study's completion, 2034 providers have received at least 1 scorecard over a 5-quarter period ending in September 2021. Poisson regression demonstrated a 1.6% quarterly reduction in opioid prescribing, and chi-square analysis demonstrated pre-post reductions in the proportion of prescriptions longer than 5 days' duration and a morphine equivalent daily dose of >50. To our knowledge, this is the first peer comparison effort with high-quality evidence-based metrics of this scale published in the literature. By sharing this process for designing the metrics and the process of distribution, the authors hope to influence other health systems to attempt to curb the opioid pandemic through peer comparison. Future research examining the effects of this intervention could demonstrate significant reductions in opioid prescribing, thus potentially reducing the progression of individual patients to opioid use disorder and the associated increased risk of morbidity and mortality.

Predictors of university students’ intentions to enroll in computer programming courses: a mixed-method investigation

Students in technology majors such as Computer Science and Information Technology need to take a series of computer programming courses to graduate. Yet, not all students will persist in taking programming courses as required, and little is known about the factors influencing their enrollment intentions. Research is needed to better understand which factors predict students’ enrollment intentions for programming courses. Based on Expectancy-Value Theory, we surveyed three hundred university students in China to measure their intentions of enrolling in future programming courses and factors influencing their enrollment intentions. Mediated Multiple Indicators Multiple Causes models were run to identify the relationships between these factors and enrollment intentions. Expectancies, intrinsic value, attainment value, and utility value of the courses directly predict enrollment intentions. Peer comparison, quality of teaching, and programming experiences were found to influence enrollment intentions through expectancies and values indirectly. No gender difference was found in expectancies and enrollment intentions. Qualitative data analysis confirmed the findings from the quantitative data analysis and further revealed that course difficulty is another major factor influencing enrollment intentions. These findings have implications for supporting students' expectancies and values in computer programming and curriculum design.

An Analysis of Chinese Publicly Listed Pharmaceutical Company CSR Disclosures

Increased public awareness toward Corporate Social Responsibility (CSR) has intensified the pressure on the pharmaceutical industry to adopt more responsible practices. As a top supplier of Western pharmaceutical companies, Chinese pharmaceutical companies are not immune to these same pressures as they engage with overseas regulators and investors. This study analyzes the factors that contribute to the CSR disclosures of publicly listed Chinese pharmaceutical companies covering 2014–2018. In the analysis, peer comparison and market-driven incentives to disclose a firm’s CSR impacts and risks come out as a robust determinant of overall disclosure and its components. While stakeholder awareness and strategic CSR have some varying degrees of associations with the five pillars of CSR disclosures, institutional framework and spill-over effect seem to have only limited influence on these disclosures. The results highlight some interesting dynamics and can provide insights into the implications of fostering a CSR-oriented business culture.

Appropriateness of antibiotic prescribing in paediatrics: retrospective controlled study assessing a multifaceted intervention in Northern Italy in a 7-year period

BackgroundAcademic detailing, audit and feedback, and peer comparison have been advocated as effective ways to promote appropriateness of prescribing and antimicrobial stewardship (AMS). This study explored the effectiveness of a...

Impact of Instagram on Financial Self-Perception A Study of Pakistani Adolescents

This study investigates the connection between Instagram use and feelings of financial inadequacy among Pakistani adolescents. As digital mediaplatforms progressively permeate daily life, their effect on users' self-perception and financial outlook has turned into a critical area of exploration. Thispaper focuses on Instagram, a platform known for its visual-driven content that frequently exhibits material riches and lavish ways of life.Using a quantitative approach, a survey was conducted and distributed among 50 adolescents from ages 15-19 from different socio-economicbackgrounds living in Lahore, Pakistan. The findings uncover a strong correlation between Instagram use and feeling of financial inadequacy.Adolescents who had lower family income were more likely to feel financially inadequate. Data also showed that adolescents also use Instagram toavoid personal problems and it further explained how content depicting wealth and peer comparison on Instagram worsen these sentiments of financial inadequacy. The research highlights the requirement for mindfulness and potential interventions to moderate the unfavorable mental effects of socialmedia on young users in developing countries.

Comparing Apples to Oranges: Why Self-Referenced Performance Reviews are more Effective than Peer Comparisons

Abstract: This article argues that self-referenced performance reviews are more effective for employee motivation and development than traditional peer comparison reviews. It draws on self-determination theory to explain how comparing employees to their peers undermines the psychological needs of competence, autonomy, and relatedness, diminishing intrinsic motivation. In contrast, self-referenced reviews that focus on individuals' past performance, strengths, and areas for growth better support these needs. Evidence suggests this approach fosters engagement and productivity by promoting a growth mindset oriented toward continual self-improvement rather than competition. Additionally, qualitative case studies of organizations that shifted to a self-referenced review model found increased morale, collaboration, and business outcomes as employees concentrated on progress within their control rather than relative standings. The article concludes self-referenced reviews align with human motivation science and are more constructive for building high-performing, cohesive workforces.

Comparison of peer, self, and faculty objective structured clinical examination evaluations in a PharmD nonprescription therapeutics course

PurposeObjective structured clinical examinations (OSCE) are a valuable assessment within healthcare education, as they provide the opportunity for students to demonstrate clinical competency, but can be resource intensive to provide faculty graders. The purpose of this study was to determine how overall OSCE scores compared between faculty, peer, and self-evaluations within a Doctor of Pharmacy (PharmD) curriculum. MethodsThis study was conducted during the required nonprescription therapeutics course. Seventy-seven first-year PharmD students were included in the study, with 6 faculty members grading 10–15 students each. Students were evaluated by 3 graders: self, peer, and faculty. All evaluators utilized the same rubric. The primary endpoint of the study was to compare the overall scores between groups. Secondary endpoints included interrater reliability and quantification of feedback type based on the evaluator group. ResultsThe maximum possible score for the OSCE was 50 points; the mean scores for self, peer, and faculty evaluations were 43.3, 43.5, and 41.7 points, respectively. No statistically significant difference was found between the self and peer raters. However, statistical significance was found in the comparison of self versus faculty (p = 0.005) and in peer versus faculty (p < 0.001). When these scores were correlated to a letter grade (A, B, C or less), higher grades had greater similarity among raters compared to lower scores. Despite differences in scoring, the interrater reliability, or W score, on overall letter grade was 0.79, which is considered strong agreement. ConclusionsThis study successfully demonstrated how peer and self-evaluation of an OSCE provides a comparable alternative to traditional faculty grading, especially in higher performing students. However, due to differences in overall grades, this strategy should be reserved for low-stakes assessments and basic skill evaluations.

A narrative review of anxiety regulation in PhD students based on Green model.

To gain a better understanding of the factors that contribute to anxiety among PhD students and the reasons for poor regulation in the current situation, this paper analyses the existing literature on anxiety among PhD students using Green's model. It also compares and evaluates various methods of regulating anxiety. The literature review to extract information on the causes and levels of anxiety, methods and outcomes of anxiety intervention and regulation, and to make comparisons. The study reveals that the phenomenon of PhD students' anxiety has intensified globally in recent years, especially after the end of the epidemic. PhD students experience anxiety due to research pressure, economic pressure, future development, and interpersonal pressure. The main influencing factors are currently the relationship with the supervisor, development prospects, social support, and peer comparison. Among the stress relief methods, the regulation of self-relaxation was found to have better effects on mild anxiety, such as positive thinking, meditation, yoga and physical exercise can be helpful for emotion release then help focus on problem solved. Whereas severe anxiety may require institutional and pharmacological support, also including using psychological therapy such as behavioral cognitive therapy and systematic desensitization methods. For university, competence to provide course-assisted guidance, such as writing groups, peer support, and time management, is also important. Academic communities should pay attention to the guidance on academic fairness. However, PhD students are often unaware of the resources available to them for coping with stress and may not take the initiative to seek psychological counseling or institutional assistance. Therefore, PhD students should receive support from various sources, be guided to express their thoughts, and receive additional education and academic assistance to manage stress. This will enhance their confidence and aid in improving their scientific research.

Spinal posture, mobility, and position sense in adolescents with chest wall deformities: a comparison of pectus excavatum, pectus carinatum and healthy peers

PurposeThe study aimed to compare spinal posture, mobility, and position sense in adolescents with pectus excavatum (PE), pectus carinatum (PC), and healthy control (HC).Methods22 with PE, 22 with PC, and 21 HC were included in the study. The spinal posture (thoracic kyphosis, lumbar lordosis, pelvic tilt, thoracic, lumbar, pelvic lateral tilt angles) and mobility (thoracic, lumbar, hip/sacral, and overall, in the sagittal and frontal plane) with the spinal mouse, and spinal position sense (repositing errors) with the inclinometer were assessed.ResultsThe thoracic kyphosis angle of PE and PC was higher than in HC (p < 0.001; p = 0.001). Hip/sacral mobility in the sagittal plane was lower in the PE and PC than control, respectively (p < 0.001; p < 0.001). Overall sagittal spinal mobility (p:0.007) and hip/sacral mobility in the frontal plane (p:0.002) were lower in the PC than in HC. Overall frontal spinal mobility was lower in the PE and PC than in HC (p:0.002; p:0.014). The PE and PC repositing errors were higher (p < 0.001; p:0.014).ConclusionThe study found that adolescents with PE and PC had decreased spinal mobility, spinal alignment disorders, and a decline in spinal position sense. It is important not to overlook the spine during physical examinations of adolescents with chest wall deformities. In clinical practice, we suggest that adolescents with chest deformities should undergo a spine evaluation and be referred for physical therapy to manage spinal disorders.

Nudging the nudger: Performance feedback and organ donor registrations

In a randomized controlled trial conducted in three waves over 2.5 years and involving nearly 700 customer-service representatives (CSRs) from a Canadian government service agency, we studied how providing CSRs with repeated performance feedback, with or without peer comparison, affected their subsequent organ donor registration rates. The feedback resulted in a 25 % increase in daily signups compared to otherwise equivalent encouragements and reminders. Adding benchmark information about peer performance did not amplify or diminish this effect. We observed increased registration rates for both high and low performers. A post-intervention survey indicates that CSRs in all conditions found the information included in the treatments helpful and motivating, and that signing up organ donors makes their job more meaningful. We also found suggestive evidence that performance feedback with benchmark information was the most motivating and created the least pressure to perform.

The Impact of Tele-Stewardship on Rural Antibiotic Prescribing Practices

Background: Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. This study addresses need for better AS in rural areas by implementing and evaluating bundled outpatient AS interventions using tele-stewardship in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center. Methods: The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls and app-based microlearning modules (QuizTime), and (4) quarterly audit/feedback with peer comparison on guideline-concordant antibiotic use via tele-meeting and email. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children &lt; 1 8 years collected during the baseline period (Jan–Dec 2022) to the intervention period (Jan-Sept 2023). Two academic PC clinics and one ED where interventions were not implemented were included as “controls”. The primary outcome is percent of encounters that result in an antibiotic prescription. Secondary outcomes include (1) percent of encounters with guideline-concordant antibiotic choice for otitis media (AOM), streptococcal pharyngitis (GAS), sinusitis, and community-acquired pneumonia (CAP); (2) percent of encounters with 5-day antibiotic duration for AOM, sinusitis, and CAP; and (3) percent of encounters with rapid GAS testing. ED sinusitis data not analyzed due to small N. Significance was determined by calculating 95% confidence intervals for the difference of proportions. Results: There were 139,474 PC encounters (91,706 baseline and 47,768 intervention) and 94,205 ED encounters (54,138 baseline and 40,067 intervention) among 20 PC prescribers and 38 ED prescribers from January 2022-September 2023. Compared to baseline, the antibiotic prescription rate decreased 1.1% in intervention PCs but increased 0.9% in control PCs (Figure 1). Compared to baseline, the antibiotic prescription rate decreased by 0.4% in the intervention EDs but increased 3.1% in the control ED (Figure 1). Secondary outcomes showed significantly increased proportions of guideline concordant ED AOM prescriptions, 5-day PC AOM prescriptions (Figure 2), guideline concordant ED streptococcal pharyngitis prescriptions (Figure 3), and guideline concordant PC sinusitis prescriptions (Figure 4). There was a decrease in GAS tests in intervention PCs and EDs (Figure 6). Conclusions: Interim analysis shows bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural PC clinics compared to control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.Disclosure: Sophie Katz: Research Grant - Pfizer; Research Grant - Dolly Parton Pediatric Infectious Diseases Research Fund; Consultant - Optum

Two Novel Antibiotic Use Metrics for Facilities and Individual Prescribers in Post-Acute and Long-Term Care Settings

Background: Measuring and reporting antibiotic use are essential to antimicrobial stewardship activities. The most common metric to assess facility-level use is days of antibiotic therapy per 1000 days of care (DOT/1000 DOC). This metric may be difficult to calculate, not be readily comparable, or not provide actionable data to individual prescribers, particularly those that work in post-acute and long-term care (PALTC) settings. Here we use data from a centralized dispensing pharmacy to develop antibiotic use metrics suitable for offering individualized feedback to prescribers working in PALTC settings. Methods: We obtained medication dispensing data and resident census data for 13 PALTC settings within the same network. After omitting non-pharmacologic items and limiting the data to medications dispensed from 1/2020 – 12/2022, we determined the following metrics by month: days of antibiotic therapy (DOT), number of medications prescribed, number of antibiotic courses prescribed (antibiotic starts), and the number of individual residents issued a prescription for any medication (unique residents). These metrics were assessed for each facility (2020 – 2022) and for prescribers responsible for &gt; 1% of prescriptions within that facility (2022 only). Prescriber-level unique residents was the number of residents issued a prescription by the given provider. We obtained facility-level census data to calculate antibiotic DOT/1000 resident days of care (DOC) as a standard to which we compared novel metrics. Results: During the 3-year study period, 1718 prescribers at 13 PALTC settings wrote for 672256 medications, including 31087 antibiotic courses. At the facility level, the correlation between monthly antibiotic starts (courses)/unique residents and antibiotic DOT/1000 DOC was 0.83 (p &lt; 0 .0001). The correlation between monthly antibiotic DOT/unique residents and antibiotic DOT/1000 DOC was 0.98 (p &lt; 0 .0001). Trends in monthly values of both novel metrics and DOT/1000 DOC were consistent across the examined period (Figure 1). For individual prescribers, both novel metrics permit assessment and comparison of antibiotic prescription rates over time (Figure 2). Conclusions: Pharmacy dispensing data can be used to determine antibiotic DOT/unique residents and antibiotic starts/unique residents at the facility level and for individual providers. The novel metric antibiotic DOT/unique residents demonstrated strong correlation with antibiotic DOT/1000 DOC at the facility level. In addition to supporting tracking and reporting of antibiotic use among PALTC settings, these new metrics permit visualization of the antibiotic prescribing rates of individuals prescribers, as well as peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC.

Implementation of Outpatient Automated Stewardship Information System (OASIS©) Audit and Feedback in Two Healthcare Systems

Background: Combating antibiotic resistance, exacerbated by widespread unnecessary outpatient antibiotic prescriptions, necessitates innovative stewardship solutions. Audit and feedback reports are effective but often resource heavy. We introduced a free, open-source system, Outpatient Automated Stewardship Information System (OASIS©), for automating the creation and distribution of recurring audit and feedback reports to clinicians to improve antibiotic prescribing. Methods: We used mixed methods to evaluate implementation of OASIS© across 11 clinics at Denver Health and Hospital Authority (DHHA) and Children’s Hospital Colorado (CHCO) from July 2022 to August 2023. Both sites host their own Epic® electronic healthcare and enterprise data warehouse systems. R statistical software was utilized to retrieve and process the data needed to create individual[HCM1] clinician audit and feedback reports with peer comparison. Reports were provided for 1) antibiotics prescribed for respiratory diagnoses, 2) antibiotics prescribed for respiratory diagnoses where antibiotics are never indicated, 3) first-line antibiotic prescribing for acute otitis media (AOM), and 4) five-day duration of antibiotics for children two years and older with AOM. Feedback reports for each metric were emailed to clinicians for three consecutive months. The primary outcome was adaptations needed to implement OASIS©. Secondary outcomes included fidelity (measured by email readership), time to set up and maintain the program, and barriers and facilitators to implementation (assessed by four qualitative interviews with OASIS© stakeholders). Results: The most significant adaptations made pertained to the automation of OASIS© reports for organizations not using R for data retrieval and reporting, setting up OASIS© specific email addresses, and validating clinician fidelity via read receipts. Fidelity was higher at DHHA (91-100%) compared to CHCO (10-30%). When interviewed, data analysts expressed that time for initial setup ranged from 1-6 hours. After reporting was automated, the estimated monthly time to send reports was 10 minutes. Views on setup complexity were split, but all recognized the readability of the reports and OASIS©’s value for improving prescribing behaviors. The greatest barriers to implementation included obtaining analytic resources for initial setup and the need to download additional R packages. No interviewee had prior experience creating audit and feedback reports. Conclusions: Implementing OASIS© requires addressing system diversity and knowledge gaps in outpatient informatics and antibiotic stewardship. Despite these challenges, the tool proved efficient and beneficial for monitoring and reporting antimicrobial prescribing. This free tool could likely be effectively disseminated to other health systems given the limited time and resources required for adaptations, setup, and monitoring. [HCM1]I

Identifying Outpatient-Specialized High-Volume Prescribers of Antibiotics in Older Adult Populations – Philadelphia, PA 2021

Background: Inappropriate antibiotic use promotes antibiotic resistance which poses a threat to public health. Outpatient settings are responsible for 80-90% of all antibiotic use, yet up to 50% of these prescriptions may be inappropriate and at least 33% completely unnecessary. To promote outpatient antibiotic stewardship (AS), the Philadelphia Department of Public Health (PDPH) identified outpatient high-volume prescribers (HVPs) in Philadelphia and provided them with peer comparison letters along with evidence-based AS educational resources. Method: We identified HVPs using overall and drug specific antibiotic volume and rates from the Centers of Medicare and Medicaid Services (CMS) Part D Prescribers by Provider and by Provider and Drug publicly available datasets for 2021. We restricted analyses to Philadelphia prescribers specializing in internal medicine, family practice, or general practice with antibiotic and beneficiary claim counts ≥ 11. We further restricted the Provider and Drug dataset to prescribers of high-consequence drugs: levofloxacin, ciprofloxacin, and azithromycin. Prescribers with subspecialities where these three drugs are commonly used appropriately were excluded from letter distribution. We analyzed U.S. Census Bureau American Community Survey (ACS) data for overall HVPs on census tract-level to describe health equity demographic characteristics. Result: A total of 1,001 prescribers with 67,145 total antibiotic claims, and 306 unique prescribers (77 levofloxacin, 176 ciprofloxacin, and 250 azithromycin) with 37,057 total antibiotic claims met the inclusion criteria in the Provider and the Provider and Drug datasets, respectively. There were 101 overall HVPs, and 89 unique drug-specific HVPs (20 levofloxacin, 45 ciprofloxacin, and 63 azithromycin) based on the highest 10% and 25% of prescribers by antibiotic volume, respectively. The overall HVPs contributed 42.0% of all antibiotic claims. The drug-specific HVPs contributed 60.5% of all antibiotic claims and 55.5% of levofloxacin, ciprofloxacin, and azithromycin claims. These 3 drugs contributed 45.1% of all antibiotic claims. Among the overall and drug-specific HVPs, we sent peer comparison letters to the top 10 by rate per 1,000 beneficiaries (overall) and per 1,000 antibiotic claims (drug-specific), who fell within the following prescribing rates: overall 954-2,714, levofloxacin 84-396, ciprofloxacin 288-723, and azithromycin 496-1,000. Conclusion: This initiative identified prescribers at risk for inappropriate use of antibiotics, and empowered these same prescribers to self-reflect on how they prescribe antibiotics. Efforts by local health departments to provide HVPs with peer comparison feedback and AS educational resources may improve the provider knowledge and prescribing habits across different healthcare systems, targeting prescribers at highest risk for misuse or overuse of antibiotics.Disclosure: Jane Gould: Spouse receives salary support- Incyte

Clinician- and Patient-Directed Communication Strategies for Patients With Cancer at High Mortality Risk

Serious illness conversations (SICs) that elicit patients' values, goals, and care preferences reduce anxiety and depression and improve quality of life, but occur infrequently for patients with cancer. Behavioral economic implementation strategies (nudges) directed at clinicians and/or patients may increase SIC completion. To test the independent and combined effects of clinician and patient nudges on SIC completion. A 2 × 2 factorial, cluster randomized trial was conducted from September 7, 2021, to March 11, 2022, at oncology clinics across 4 hospitals and 6 community sites within a large academic health system in Pennsylvania and New Jersey among 163 medical and gynecologic oncology clinicians and 4450 patients with cancer at high risk of mortality (≥10% risk of 180-day mortality). Clinician clusters and patients were independently randomized to receive usual care vs nudges, resulting in 4 arms: (1) active control, operating for 2 years prior to trial start, consisting of clinician text message reminders to complete SICs for patients at high mortality risk; (2) clinician nudge only, consisting of active control plus weekly peer comparisons of clinician-level SIC completion rates; (3) patient nudge only, consisting of active control plus a preclinic electronic communication designed to prime patients for SICs; and (4) combined clinician and patient nudges. The primary outcome was a documented SIC in the electronic health record within 6 months of a participant's first clinic visit after randomization. Analysis was performed on an intent-to-treat basis at the patient level. The study accrued 4450 patients (median age, 67 years [IQR, 59-75 years]; 2352 women [52.9%]) seen by 163 clinicians, randomized to active control (n = 1004), clinician nudge (n = 1179), patient nudge (n = 997), or combined nudges (n = 1270). Overall patient-level rates of 6-month SIC completion were 11.2% for the active control arm (112 of 1004), 11.5% for the clinician nudge arm (136 of 1179), 11.5% for the patient nudge arm (115 of 997), and 14.1% for the combined nudge arm (179 of 1270). Compared with active control, the combined nudges were associated with an increase in SIC rates (ratio of hazard ratios [rHR], 1.55 [95% CI, 1.00-2.40]; P = .049), whereas the clinician nudge (HR, 0.95 [95% CI, 0.64-1.41; P = .79) and patient nudge (HR, 0.99 [95% CI, 0.73-1.33]; P = .93) were not. In this cluster randomized trial, nudges combining clinician peer comparisons with patient priming questionnaires were associated with a marginal increase in documented SICs compared with an active control. Combining clinician- and patient-directed nudges may help to promote SICs in routine cancer care. ClinicalTrials.gov Identifier: NCT04867850.