Quality Improvement Organizations Research Articles

An age-friendly approach to primary care in an academic health system.

Age-friendly care, addressing what matters most, medications, mentation, and mobility, is a successful model for improving older adult care. We describe the initial outcomes of age-friendly care implementation in five primary care clinics in an academic health system. In partnership with a regional quality improvement (QI) organization, we used practice facilitation to implement age-friendly care from July 2020 to June 2023. Clinic workflows and electronic health record (EHR) templates were modified to capture six QI measures for patients ≥65 years: Documenting what matters most to patients Advance care planning (ACP) Annual cognitive screening Caregiver referral to dementia community resources Fall-risk screening Co-prescription of opioid and sedative-hypnotic drugs Providers were alerted if patients had positive screens and given support tools for clinical decision-making. QI measures from January-June 2023 were compared to the year prior to implementation. Providers and staff were interviewed about implementation barriers and facilitators. All six measures improved in Geriatrics and and other clinics showed improvement in ACP and cognitive screening. All clinics had high fall-risk screening rates (≥85%). The least improved measure was co-prescription of opioids and sedative-hypnotics with co-prescription rates ranging from 7% to 39%. Implementation hinged on leadership prioritization, practice facilitator guidance, clinical team buy-in, EHR functionality, and clinical performance review. Three clinics received Age-Friendly Health System recognition. A QI approach using practice facilitation and EHR templates improved some but not all age-friendly care measures. Future interventions will focus on training in high-risk medication tapering and elicitation of health goals.

Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network

Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network). A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration). Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%). Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.

More of a Good Thing: A Framework to Grow and Strengthen the PALTC Careforce

The current staffing shortage across all disciplines of post-acute and long-term care (PALTC) settings is affecting the health and safety of residents, as well as the well-being of the current staff. The need to retain and recruit new talent to this challenging but fulfilling setting demands that we look to existing evidence-based strategies and identify ways to implement them quickly, effectively, and in a sustainable way. Using the 4 Ms Framework of the Age-Friendly Health System developed by the Institute for Healthcare Improvement and the John A. Hartford Foundation (What Matters, Medication, Mentation, and Mobility), we can build on successful strategies to address what matters to staff, mental health, career mobility, and the overall safety and wellness of our nation's careforce. This paper summarizes “More of a Good Thing: A Framework to Grow and Strengthen the PALTC Careforce,” a series of 6 roundtable discussions held in 2022 that brought together clinicians, industry leaders, and change-makers to share strategies that have been researched and successfully implemented and discuss ways to scale and disseminate them to a broader audience. The role of PALTC leadership is highlighted, with key points from the final roundtable discussion outlined, and challenging leadership to think about what they can begin doing immediately to build trust with existing staff and lay the foundation for a stronger nursing home careforce. Next steps for “More of a Good Thing” include a survey of participants about what they have tried, what has been successful, and what barriers they face; a series of focused interviews with leaders; and potential collaboration with quality improvement organizations to help facilities build on and implement the strategies presented.

Trends in Long-Term Ventilation Care in U.K. Children and Young People-Further Consideration Required for Pediatric Critical Care Services.

The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning. A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets. Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings. Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018. None. When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%). The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services.

Weight gain in pregnancy and infant birthweight after the onset of the COVID-19 pandemic: an interrupted time series analysis

BackgroundIncreased weight gain and decreased physical activity have been reported in some populations since the coronavirus disease 2019 (COVID-19) pandemic, but this has not been well characterized in pregnant populations. ObjectivesOur objective was to characterize the impact of the COVID-19 pandemic and associated countermeasures on pregnancy weight gain and infant birthweight in a US cohort. MethodsWashington State pregnancies and births (1 January, 2016 to 28 December, 2020) from a multihospital quality improvement organization were examined for pregnancy weight gain, pregnancy weight gain z-score adjusted for pregestational BMI and gestational age, and infant birthweight z-score, using an interrupted time series design that controls for underlying time trends. We used mixed-effect linear regression models, controlled for seasonality and clustered at the hospital level, to model the weekly time trends and changes on 23 March, 2020, the onset of local COVID-19 countermeasures. ResultsOur analysis included 77,411 pregnant people and 104,936 infants with complete outcome data. The mean pregnancy weight gain was 12.1 kg (z-score: −0.14) during the prepandemic time period (March to December 2019) and increased to 12.4 kg (z-score: −0.09) after the onset of the pandemic (March to December 2020). Our time series analysis found that after the pandemic onset, the mean weight gain increased by 0.49 kg (95% CI: 0.25, 0.73 kg) and weight gain z-score increased by 0.080 (95% CI: 0.03, 0.13), with no changes in the baseline yearly trend. Infant birthweight z-scores were unchanged (−0.004; 95% CI: −0.04, 0.03). Overall, the results were unchanged in analyses stratified by pregestational BMI categories. ConclusionsWe observed a modest increase in weight gain after the onset of the pandemic among pregnant people but no changes in infant birthweights. This weight change could be more important in high BMI subgroups.

The effect of the right care, right place, right time (R3) initiative on Medicare health service use among older affordable housing residents.

To determine the effect of an affordable housing-based supportive services intervention, which partnered with health and community service providers, on Medicare health service use among residents. Analyses used aggregated fee-for-service Medicare claims data from 2017 to 2020 for beneficiaries living in 34 buildings in eastern Massachusetts. Using a quasi-experimental design, a "difference-in-differences" framework was employed to isolate changes in outcomes, focusing on changes in pre- and post-intervention health service use across two stages of the intervention. Phase 1 encompassed the initial implementation period, and Phase 2 introduced a strategy to target residents at high risk of poor health outcomes. Key health service outcomes included hospitalizations, 30-day hospital readmission, and emergency department use. Medicare claims data for 10,412 individuals were obtained from a Quality Improvement Organization and aggregated at the building level. Analyses for Phase 1 found that hospital admission rates, emergency department admissions and payments, and hospital readmission rates grew more slowly for intervention sites than comparison sites. These findings were strengthened after the introduction of risk-targeting in Phase 2. Compared to selected control buildings, residents in intervention buildings experienced significantly lower rates of increases in inpatient hospitalization rates (-16% vs. +6%), hospital admission days (-25% vs. +29%), average hospital days (-12% vs. +14%), hospital admission payments (-22% vs. +33%), and 30-day hospital readmission rates (-22% vs. +54%). When accounting for the older age of the intervention residents, the size of the decline recorded in emergency department admissions was 6.7% greater for the intervention sites than the decline in comparison sites. A wellness-focused supportive services intervention was effective in reducing select health service use. The introduction of risk-targeting further strengthened this effect. Age-friendly health systems would benefit from enhanced partnerships with affordable housing sites to improve care and reduce service use for older residents.

Leveraging Partnerships for a Nursing Home COVID Learning Community

The rapid and uncertain trajectory of community spread in nursing homes statewide spurred action by the University of North Texas Health Science Center to create a nursing home (NH) COVID learning community. As an existing ECHO hub, we assembled an interdisciplinary team leveraging local NH partnerships, a regional Quality Improvement Organization (QIO), and a regional emergency response task force to rapidly scale up delivery. Specialist teams include a geriatrician and NH medical director, administrator, nursing administration, infection control expert, and a QIO specialist. With the IHI curriculum as a road map for essential training elements, we adapt each week’s agenda based on the interests and concerns of the participating nursing facilities and the incidence rate in our community. At this time, we have two more sessions before completion of phase 1. The three cohorts are engaging 151 participants from 68 nursing facilities with a total attendance of 747.

Facing the Challenges of Understanding and Managing Behavior and Psychiatric Issues

Facing the Challenges of Understanding and Managing Behavior and Psychiatric Issues

Centers for Medicare and Medicaid's Qin‐Qio Targeted Response Intervention Associated with Reductions in COVID‐19 Incidence in Nursing Homes

Research ObjectiveIn 2020 COVID‐19 became the leading cause of death in the United States,[1] with nursing home (NH) residents accounting for approximately 40% of all COVID‐19 deaths.[2] To help NHs combat COVID‐19, the Centers for Medicare and Medicaid Services (CMS) directed targeted response (TR) interventions through its twelve Quality Improvement Network – Quality Improvement Organization (QIN‐QIOs) contractors. TR involves focused onsite and/or virtual one‐on‐one technical assistance to nursing homes. For COVID‐19 TR, the most common QIN‐QIO‐reported activities include: assistance with developing and implementing policies and improved processes for hand hygiene, ensuring availability and proper use of personal protective equipment, and general infection control. CMS’ criteria to refer NHs for QIN‐QIO assistance varied over the entire study period as the program evolved. At various times, these criteria included: infection control‐related health inspection deficiencies, NHs located in counties designated as geographic hot spots, having 30 or more new COVID‐19 cases in the past week. NH participation in TR is voluntary and free‐of‐charge. The objective of this study was to assess TR impact on COVID‐19 incidence in NHs.Study DesignWe used a quasi‐experimental observational design. NHs may have started receiving TR any time between April 24, and October 28, 2020. COVID‐19 incidence data were obtained for May 31 through November 29, 2020 from the National Healthcare Safety Network. Each program NH was matched at the time of first QIN‐QIO interaction with a similar non‐TR NH. Matching characteristics were: overall NH star rating, health inspections star rating, bed size, state, area deprivation index, and county‐level COVID incidence in the month of and the month prior to first receipt of TR. We used longitudinal regression models in the period following first QIN‐QIO interaction to compare COVID‐19 incidence between NHs that received TR to matched controls that did not. Generalized estimating equations with a Poisson distribution and log‐link were used to model COVID‐19 incidence, TR status and a full set of covariates.Population StudiedCMS‐certified NHs providing short‐stay, long‐stay, or both types of care.Principal FindingsAmong the 2474 NHs that received TR in the study period, 2013 were matched to 2013 similar NHs that did not. Depending on the month, COVID‐19 incidence after matching was similar or higher in the TR group at baseline, but all other covariates were balanced. In this preliminary analysis, NHs receiving TR had 27.7% (p‐value <0.0001, 95% CI: 17.2%–36.9%) lowered COVID‐19 incidence compared to similar NHs that did not receive TR. Effect estimates withstood early sensitivity analyses.ConclusionsThe TR intervention was associated with a decline in COVID‐19 incidence in TR NHs relative to non‐TR NHs. Future analyses will explore which aspects of TR and QIN‐QIOs may have been most effective and the attributes of nursing homes that demonstrated improvement.Implications for Policy or PracticeDeploying TR for quality improvement in NHs in real‐time demonstrated a relative improvement in infection control. CMS should consider expanding TR to a broader range of outcomes. In addition, we must continue to conduct real‐time evaluation of the QIN‐QIO program as the tools and technologies evolve to prevent infections and other negative outcomes in facilities.Primary Funding SourceCenters for Medicare and Medicaid Services.

Improving Arthroplasty Efficiency and Quality Through Concentrating Service Volume by Complexity: Surviving the Medicare Policy Changes

We have an academic medical center (AMC), an associated community-based hospital (CBH) and several ambulatory care centers which are being prepared to provide same day discharge (SDD) total joint arthroplasty (TJA) and unicompartmental knee arthroplasty (UKA). The near-capacity AMC cared for medically and technically complicated TJA patients. The CBH wanted to increase volume, improve margins, and become a center of excellence with an efficient hospital outpatient department and SDD TJA experience. MethodsWe transitioned primary, uncomplicated TJA, UKA, and minimally invasive TJA to the CBH. Revision surgeries, patients with extensive comorbidities, and complex primaries were performed at the AMC. Protocols were developed to facilitate SDD UKA and total hip arthroplasty (THA) as well as rapid recovery protocols for total knee arthroplasty (TKA) at both hospitals. A protocol-based system was put in place to make both hospitals ready for the removal of TKA from the Inpatient-Only list to avoid Quality Improvement Organization and possible resultant Recovery Audit Contractor audits if referred after implementation. ResultsThe CBH volume increased 36.7% (+239). AMC volume slightly decreased (−0.46%, −5) resulting in an increase in margin contribution for the system. CBH quality metrics (surgical site infections, length of stay, readmissions, and mortality) were improved. Surgeon satisfaction improved as their volume, efficiency, quality metrics, and finances were enhanced.Although CBH per case revenue was 80.3% and 74.4% of the AMC for THA and TKA, net margins were 3.6% and 18.8% higher for THA and TKA, respectively. Increased efficiency, lower hospital cost, and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. ConclusionThis strategy will help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient which will be subjected to further decreases in net revenue per patient.

The impact of health-related supports in senior housing on ambulance transfers and visits to emergency departments: The Right Care, Right Place, Right Time Project.

To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18months. Intervention sites included seven Boston-area buildings, with five buildings at comparable settings acting as controls. Data derive from building-level ambulance data from emergency responders; building-level Medicare claims data on emergency department utilization; and individual-level baseline assessment data from participants in the intervention (n=353) and control (n=208) sites. We used a pre/postdifference in difference quasi-experimental design applying several analytic methods. The preintervention period was January 2016-March 2017, while the intervention period was July 2017-December 2018. Emergency responders provided aggregate transfer data on a daily basis for intervention and control buildings; the Quality Improvement Organization provided quarterly aggregate data on emergency department visit rates; and assessment data came from a modified Vitalize 360 assessment and coaching tool. The study found an 18.2% statistically significant decline in ambulance transfers in intervention buildings, with greater declines in buildings that had fewer services available at baseline, compared to other intervention sites. Analysis of Medicare claims data, adjusted for the proportion of residents over 75 per building, found fewer visits to emergency departments in intervention buildings. Health-related supports in senior housing sites can be effective in reducing emergency transfers and visits to emergency departments.

Using Health Plan Authorization Data to Predict Hospitalizations and Readmissions in a Combined Commercial and Medicaid Population.

Health plans develop predictive models to predict key clinical events (eg, admissions, readmissions, emergency department visits). The authors developed predictive models of admissions and readmissions for a quality improvement organization with many large government and private health plan clients. Its membership and authorization data were used to develop models predicting 2019 inpatient stays, and 2019 readmissions following 2019 admissions, based on patients' age and sex, diagnoses identified and procedures requested in 2018 authorizations, and 2018 admission authorizations. In addition to testing multivariate models, risk scores were calculated for admission and readmission for all patients in the model. The admissions model (C = 0.8491) is much more accurate than the readmissions model (C = 0.6237). Measures of risk score central tendency and skewness indicate that the vast majority of members had little risk of hospitalization in 2019; the mean (standard deviation) was 0.042 (0.074), and the median was 0.018. These risk scores can be used to identify members at risk of admission and to support proactive risk management (eg, design of health management programs). Different risk thresholds can be used to identify different subsets of members for follow-up, depending on overall strategy and available resources. This model development project was novel in employing authorization data rather than utilization data. Advantages of authorization data are their timeliness, and the fact that they are sometimes the only data available, but disadvantages of authorization data are that authorized services are not always actually performed, and diagnoses are often "rule out" rather than final diagnoses.

Doctors Without Borders Lends a Gloved Hand to U.S. Nursing Homes

Doctors Without Borders Lends a Gloved Hand to U.S. Nursing Homes

Colorectal surgery collaboratives: The Michigan experience

The Michigan Surgical Quality Collaborative (MSQC) was one of the first large-scale regional collaborative quality improvement (CQI) organizations, bringing together surgeons and nurses from 70 Michigan hospitals with a goal of improving surgical outcomes. In this article, we describe the evolution of the MSQC, the science of collaborative quality improvement, and the colorectal surgery-focused projects that MSQC has implemented. Colorectal surgery initiatives have focused on (1) surgical site infection reduction, (2) improving quality of care for colorectal cancer, (3) enhanced recovery pathways, (4) technical skills coaching using video review, and (5) opioid use reduction.

Targeted Assessment for Prevention: A Statewide Collaborative

Background: Infection preventionists (IPs) are the backbone of the quality and safety matrix of their organizations. Tools to help locate potential gaps can provide unique viewpoints from frontline staff. The CDC provides a Targeted Assessment for Prevention (TAP) strategy that identifies vulnerabilities in the prevention of healthcare-associated infection (HAIs). Methods: A statewide quality improvement organization, partnering with the CDC TAP team, administered TAP facility assessments for catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), and Clostridioides difficile infection (CDI) to a collaborative of 15 acute-care and 2 long-term acute hospitals. More than 800 respondents filled out surveys based on their individualized perceptions of infection prevention practices. Results: The survey results yielded the following lagging indicators: lack of awareness of nursing and physician champions, need for competency-based training of clinical equipment, and feedback on device utilization. At the hospital system level, one improvement team focused on CDI, uncovered leading and lagging areas in general infrastructure, antibiotic stewardship, early detection and appropriate testing, contact precautions, and environmental cleaning. To culminate the TAP collaborative, the cohort of organizations, supported by interdisciplinary teams, participated in a full-day TAP workshop in which they reviewed detailed analyses of their HAI data and assessment results, shared best practices for infection prevention and planned for specific improvement projects using the plan-do-study-act model. Conclusions: Results of a statewide analysis of HAI prevention data and opportunities at a local level were reviewed. The TAP strategy can be used to target opportunities for improvement, to assess gaps in practice, and to develop and implement interventions for improving outcomes. Healthcare facilities and quality improvement organizations can drive infection prevention actions.Funding: NoneDisclosures: None

Nursing Home Responses to Performance-based Accountability: Results of a National Survey.

The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures. Nationally representative survey. A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016. A total of 1,182 SNFs (58% of random sample of 2,045 SNFs). Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five-Star Quality Rating System's quality measure rating. SNFs reported making an average of 13 QI changes (interquartile range = 11-16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a .48-star higher quality measure rating (95% confidence interval = .003-.98 stars; P = .05). In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements.

The Mayo Clinic Hospital Mortality Reduction Project

Quality improvement, regulatory, and payer organizations use various definitions of hospital mortality as clinical outcome measures. In this prospective study, the authors evaluated a multicomponent intervention aimed at reducing inpatient mortality in a multistate healthcare delivery system. The project was initiated because of a statistically nonsignificant upward trend in mortality suggested by a six-quarter rise in the observed/expected mortality ratio generated by the Vizient Clinical Data Base and Resource Manager. The design of the mortality reduction plan was influenced by the known limitations of using hospital-wide mortality as a quality improvement measure. The primary objective was to reduce mortality through focused care redesign. The project leadership team attempted to implement standardized system-wide improvements while allowing individual hospitals to simultaneously pursue site-specific practice redesign opportunities. Between Q3, 2015, and Q4, 2017, system-wide mortality reduced from 1.78 to 1.53 (per 100 admissions; p = .01). The actual plan implemented in Mayo Clinic's hospitals is included as Appendix A to this article, published online as Supplemental Digital Content. The authors included it to allow comparison with similar efforts at other healthcare systems, as well as to stimulate criticism and discussion by readers.

THE IMPACT OF THE R3 PROGRAM ON SERVICE UTILIZATION, COSTS, AND QUALITY OF LIFE

Relatively few housing with services evaluations employ rigorous multiple group quasi-experimental designs rather than simple before/after research designs. This study employs a pre-post experimental design with a comparison group to analyze whether the R3 program led to reductions in certain key utilization measures, including emergency department visits, inpatient hospitalizations, ambulance usage, and skilled nursing facility admissions, over 18 months. Also examined is whether resident quality of life indicators changed over the period. Data derive from assessments with 410 residents in four intervention sites and 227 residents in five comparison group sites. Also obtained was data on emergency department transfers from first responder services and Medicare fee-for-service data from the local quality improvement organization. Results suggest that the program has positive implications for service utilization, costs, and quality of life. Early detection and intervention inherent in the R3 program may improve resident quality of life while lowering service utilization and costs.

2069. A Unique Approach to Outpatient Antibiotic Stewardship in Rural Southern Ohio

BackgroundA five county rural community in southern Ohio was identified as having significantly higher than average rates of antibiotic use. The hospital system serving this area, Southern Ohio Medical Center (SOMC), began initial efforts in antimicrobial stewardship focusing on inpatient prescribing. However, most antimicrobial consumption occurs in the outpatient setting. Early attempts to improve antibiotic prescribing focused on only provider education and resulted in little change. Providers felt they were performing well, or their patients were more complex and prescribing the antibiotics was warranted. SOMC partnered with the state Quality Improvement Organization, HSAG, to design an intervention to address these challenges.MethodsAll outpatient and emergency room encounters with acute bronchitis and upper respiratory infection (URI) (ICD-10 codes [J00, J06.9, and J20.X]) were included in the analysis. Using criteria from a National Quality Forum measure, concomitant diagnoses were excluded to identify encounters where an associated condition may indicate the case is more complex. A 6-month baseline and two additional 6-month remeasurement periods were analyzed. Providers were given letters, peer-to-peer antimicrobial data comparison, and in-person feedback with guideline-driven recommendations for these conditions.ResultsBaseline analysis indicated 50% of all encounters without a coded concomitant diagnosis resulted in antibiotic prescriptions. There was a reduction in the overall rate at each remeasurement period, to 34% and then 12%. This resulted in a 76% relative improvement rate (RIR) overall at the final remeasurement period. At baseline, the highest volume setting, urgent care, had a prescribing rate of 71%. Urgent-care prescriptions reduced each remeasurement to 45% and 13%, resulting in an 81% RIR.ConclusionImplementing a robust outpatient stewardship program in a rural nonacademic setting is not without unique challenges. By using peer comparison of provider performance data on prescribing habits in uncomplicated patients with URI and acute bronchitis in addition to education, the rate of appropriate antibiotic use improved. Disclosures All authors: No reported disclosures.

The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care-Associated Infections at the Local Level.

The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care-Associated Infections at the Local Level.