Population-Wide Peer Comparison Audit and Feedback to Reduce Antibiotic Initiation and Duration in Long-Term Care Facilities with Embedded Randomized Controlled Trial.

BACKGROUND: Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents. METHODS: We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter. RESULTS: Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference -2.65%, 95% confidence interval [CI]: -4.93 to -.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports. CONCLUSIONS: Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466.

Engagement is a necessary condition to test audit and feedback design features: results of a pragmatic, factorial, cluster-randomized trial with an embedded process evaluation.

BACKGROUND: While audit & feedback (A&F) is an effective implementation intervention, the design elements which maximize effectiveness are unclear. Partnering with a healthcare quality advisory organization already delivering feedback, we conducted a pragmatic, 2 × 2 factorial, cluster-randomized trial to test the impact of variations in two factors: (A) the benchmark used for comparison and (B) information framing. An embedded process evaluation explored hypothesized mechanisms of effect. METHODS: Eligible physicians worked in nursing homes in Ontario, Canada, and had voluntarily signed up to receive the report. Groups of nursing homes sharing physicians were randomized to (A) physicians' individual prescribing rates compared to top-performing peers (the top quartile) or the provincial median and (B) risk-framed information (reporting the number of patients prescribed high-risk medication) or benefit-framed information (reporting the number of patients not prescribed). We hypothesized that the top quartile comparator and risk-framing would lead to greater practice improvements. The primary outcome was the mean number of central nervous system-active medications per resident per month. Primary analyses compared the four arms at 6 months post-intervention. Factorial analyses were secondary. The process evaluation comprised a follow-up questionnaire and semi-structured interviews. RESULTS: Two hundred sixty-seven physicians (152 clusters) were randomized: 67 to arm 1 (median benchmark, benefit framing), 65 to arm 2 (top quartile benchmark, benefit framing), 75 to arm 3 (median benchmark, risk framing), and 60 to arm 4 (top quartile benchmark, risk framing). There were no significant differences in the primary outcome across arms or for each factor. However, engagement was low (27-31% of physicians across arms downloaded the report). The process evaluation indicated that both factors minimally impacted the proposed mechanisms. However, risk-framed feedback was perceived as more actionable and more compatible with current workflows, whilst a higher target might encourage behaviour change when physicians identified with the comparator. CONCLUSIONS: Risk framing and a top quartile comparator have the potential to achieve change. Further work to establish the strategies most likely to enhance A&F engagement, particularly with physicians who may be most likely to benefit from feedback, is required to support meaningfully addressing intricate research questions concerning the design of A&F. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02979964 . Registered 29 November 2016.

Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing.

Background: Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work. Method: We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized. Results: Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]). Conclusions: The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.

What is already known about the topic?: The causal assumptions and key components of implementation interventions are often not well described, which limits the influence of implementation science on implementation practice. What does this paper add?: This work provides an approach for surfacing the causal assumptions from intervention developers (through interviews with eight participants) and active ingredients from intervention materials, focusing on two real-world interventions already delivered at scale and designed to promote safer opioid prescribing. The analysis provides a comprehensive intervention description and reveals the extent to which final interventions align with developers' intentions. What are the implications for practice, research, or policy?: The findings provide a foundation for future work which will describe the effectiveness of these interventions (alone and in combination) and explore whether they achieve change in the intended ways, thereby providing an example of a more fulsome intervention evaluation. More broadly, our methods can be used by implementation practitioners to review and reflect on their intervention development process and support comprehensive intervention descriptions.

Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial.

Background: Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested 3 behavioral nudging techniques delivered by email to improve report opening. Methods: We conducted a pragmatic randomized controlled trial among Ontario long-term care prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions. Results: The trial included 421 physicians caring for >28 000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio [OR], 1.51 [95% confidence interval {CI}, 1.10-2.07], P = .011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR [aOR], 1.74 [95% CI, 1.24-2.45], P = .0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR, 1.62 [95% CI, 1.06-2.47], P = .026; aOR, 2.16 [95% CI, 1.33-3.50], P = .0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR, 1.28 [95% CI, 1.14-1.43], P < .001). Conclusions: Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback. Clinical Trials Registration: NCT04187742.

The relationship of 60 disease diagnoses and 15 conditions to preference-based health-related quality of life in Ontario hospital-based long-term care residents.

BACKGROUND: Population-based diagnosis- and condition-specific health-related quality of life (HRQoL) scores are required for decision-making and research purposes. These HRQoL scores do not exist for hospital-based long-term care (LTC) residents. OBJECTIVE: To estimate the impact of 60 diseases and 15 conditions on caregiver-assessed preference-based HRQoL. METHODS: Residents in hospital-based LTC facilities in Ontario, Canada were identified from administrative databases containing resident minimum data set (MDS) assessments completed between August 1st, 2003 and March 31st, 2008. A preference-based HRQoL measure, the MDS Health-Status Index (MDS-HSI) score, was calculated for 66,193 residents. Average MDS-HSI scores and multivariate linear regression models were used to estimate the impact of the diagnoses and conditions, respectively. RESULTS: After adjusting for age, sex, and other diagnoses, aphasia exhibited the largest negative relationship to the MDS-HSI (-0.085), followed by cancer (-0.072) and Alzheimer disease (-0.062). Cancer was also the second most prevalent diagnosis (27.6%). Lack of balance was a common condition (87.3%) and it had the greatest negative relationship to MDS-HSI scores among the 15 conditions (-0.099). The diagnoses and conditions regression models had R values of 0.12 and 0.34, respectively, suggesting that clinical conditions provided better explanatory variables for the MDS-HSI than diagnoses. CONCLUSIONS: The findings suggest that diseases affect preference-based HRQoL differently in a hospital-based LTC population compared with previous studies in the general population. The population-based MDS-HSI scores from this study can be used as reference values in cost-effectiveness analyses for hospital-based LTC populations.

Enhancing Quality Care in Ontario Long-Term Care Homes Through Audit and Feedback for Physicians.

The province of Ontario in Canada is an example of a jurisdiction that is using a specific quality improvement mechanism, known as "audit and feedback," to help clinicians enhance the care they provide to long-term care (LTC) home residents. This program, launched in 2015, is unique in that the reports are provided across an entire jurisdiction. These reports were co-designed with clinicians, including medical directors, scientists, and other stakeholders, and are updated regularly to maintain their relevance to medical practice in LTC. The data for the reports is calculated using record linkage with available administrative data sources. The reports are updated with new data 4 times each year and emailed directly to physicians who have requested their report. The reports are designed to have an overall dashboard summarizing the practice level data with a comparison to all physicians in Ontario. More detailed information on their data such as trend data and resources for quality improvement are found in subsequent pages of the report. These reports are a tool to support physicians in quality improvement efforts in their LTC practice. We believe the role of a medical director is very important in both the uptake and use of these reports as the medical director would act as a trusted advisor who can influence quality of care overall within an LTC home. We are also testing a new format for delivering the reports in an interactive online format that enables more options for viewing practice data. Initial evaluation of these reports shows that there is a statistically significant impact on reducing the prescription of antipsychotic medications in LTC homes. In future, we hope to see a larger effect on the latest topic included in the reports: antibiotic prescribing.

Effectiveness of confidential reports to physicians on their prescribing of antipsychotic medications in nursing homes.

BACKGROUND: Antipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing. METHODS: This population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively. RESULTS: Of 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant. INTERPRETATION: Almost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.

Toward a standard definition and measurement of persistence with drug therapy: Examples from research on statin and antihypertensive utilization.

BACKGROUND: Long-term utilization of prescription drugs for chronic conditions such as hypertension and/or hypercholesterolemia is a reality for millions of individuals, yet therapies may be discontinued before they can exert their beneficial effect. Several studies have measured the mean duration of therapy (ie, persistence) using administrative health databases. However, the terminology and methodology used for measuring persistence varied across studies, making it difficult to compare persistence rates. OBJECTIVES: The objectives of this study were to identify currently used measures of persistence and to propose a standard operational definition for use in administrative database analyses of drug utilization. METHODS: MEDLINE was searched for English-language articles published between January 1997 and June 2005 that quantified the concepts of persistence, adherence, compliance, or continuity with statin or antihypertensive therapy using administrative prescription claims databases. The conceptual and operational definitions of persistence used in the identified studies were categorized and applied to prescription-refill data for a hypothetical patient to compare the durations of persistence resulting from each method. RESULTS: Thirty-one articles were identified and reviewed. Few of the studies explicitly stated the conceptual definition of persistence used. Five methods of measuring persistence were identified: anniversary models, minimum-refills models, refill-sequence models, proportion-of-days-covered models, and hybrid models. When these models were applied to data for the hypothetical patient, total persistence with drug therapy ranged from 7 days to >1 year. CONCLUSIONS: There continue to be inconsistencies in the definition of persistence and the methods by which it is measured. A standard operational definition of persistence should be 2-dimensional, quantifying not only the total duration of therapy, but also the intensity of medication-taking within this interval.

Cost-effectiveness of screening for anal precancers in HIV-positive men.

OBJECTIVE: To assess the cost-effectiveness of high-resolution anoscopy (HRA), anal cytology, and anal human papillomavirus (HPV) detection in screening for histologic high-grade anal intraepithelial neoplasia (AIN 2/3) in HIV-positive MSM. DESIGN: Participants were 401 HIV-positive MSM who were screened for anal cancer in a tertiary care HIV clinic. METHODS: A decision analytical model was used to determine the cost-effectiveness of three anal cancer screening strategies: the direct use of HRA; HRA only if anal cytology was abnormal; and HRA only if oncogenic HPV was present. The model included the use of different thresholds for abnormal cytology and also combined cytology and HPV testing. The outcome was the number of AIN 2/3 cases detected. Costs were estimated from institutional data and sensitivity/specificity of cytology and HPV tests were obtained from the screening study. RESULTS: The costs ($ US) per procedure for HRA, cytology, and HPV testing were $193, $90, and $95, respectively. The direct use of HRA was the most cost-effective strategy. It detected 98 individuals with AIN 2/3 and had a cost-effectiveness of $809 per AIN 2/3 case detected. Using probabilistic sensitivity analysis, three other strategies had similar costs per case detected and might be as cost-effective as HRA. CONCLUSION: In HIV-infected MSM, the direct use of HRA is the most cost-effective strategy for detecting AIN 2/3. The higher cost per use for HRA was offset by the high sensitivity and low specificity of HPV and cytology testing.