Reducing Inappropriate Antibiotic Prescribing in Nursing Homes
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Transcript of Reducing Inappropriate Antibiotic Prescribing in Nursing Homes
Reducing Inappropriate Antibiotic Prescribing in Nursing HomesRosanna Bertrand1, Lauren Olsho1,Sheryl Zimmerman2, Louise Hadden1, Alrick Edwards1, Philip Sloane2, Madeline Mitchell2, Donna Hurd1
1Abt Associates Inc., US Health Division, Cambridge, MA, 2 University of North Carolina Chapel Hill, NC.
Abt Associates | pg 2
Presenter DisclosuresRosanna M. Bertrand
I have no personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months to disclose.
Abt Associates | pg 3
Background Antibiotics are among the most commonly prescribed
pharmaceuticals in nursing homes (NHs).
• A high proportion are inappropriate causing major public health concerns.
They result in multiple adverse consequences including increased risk of morbidity and mortality.
Loeb and colleagues developed minimum criteria (LMC) for the initiation of antibiotics in NH settings.
Abt Associates | pg 4
Loeb Minimum Criteria A set of minimum criteria to assess symptoms and signs of:
– Skin/soft-tissue infections
– Respiratory infections
– Urinary tract infections
– Fever of unknown origin
Example of LMC for urinary tract infections with catheter – Temperature on day of prescription greater than 2.4 degrees above
average routine temperature or greater than 100 degrees Fahrenheit;
OR
– New case of costovertebral angle tenderness, or symptoms of rigors, or new symptoms of delirium.
Abt Associates | pg 5
Quality Improvement (QI) Intervention Program
Abt/UNC developed a QI intervention that integrated:
• An evidence-based conceptual model
• A community-based participatory approach
• Guidelines for when to prescribe (LMC)
• Guidelines for when not to prescribe (12 conditions)
− For example, a positive culture in an asymptomatic patient
Abt Associates | pg 6
QI Intervention Program Multi-Level Target Audience
Prescribers– Medical Doctors– Nurse Practitioners– Physician Assistants
Other NH staff – Administrators– Nurses
Residents and Families
Abt Associates | pg 7
QI Intervention ProgramMulti-Method Approach
On-Site Trainings
Pocket Cards
Abt Associates | pg 8
QI Intervention ProgramPocket Card
Abt Associates | pg 9
QI Intervention ProgramMulti-Method Approach
On-Site Trainings
Pocket Cards
Written Materials and Forms
Meetings/Gatherings
Abt Associates | pg 10
Evaluation Design Quasi-experimental design
Six intervention NHs - part of UNC consortium
Six comparison NHs - matched by bed size and profit status
Three-month baseline and six-month intervention periods
N = 3,568 prescriptions over 336,522 resident days
Abt Associates | pg 11
Primary Outcomes Antibiotic prescribing rates
• Overall and by infection type: urinary, skin/soft tissue, and respiratory
Prescriber adherence to the LMC
• Conducted on a random sample of prescribing events
• Developed an indication-specific algorithm based on LMC
− Coded whether or not the LMC were met
Abt Associates | pg 12
Analyses Prescribing Rates Related to LMC Adherence
• Multivariate analyses using three months baseline from intervention and comparison site data
• Dependent variable: count of prescriptions per resident per day
• Primary explanatory variable: NH-level measure of percent of prescriptions/month meeting the LMC
Impact of the QI Intervention
• Multivariate difference-in-differences analyses to determine:
− Increase in adherence to the LMC
− Decrease in antibiotic prescribing rates
Abt Associates | pg 13
Results - LMC Adherence
0 5 10 15 20 250.0
0.5
1.0
1.5
2.0
2.5
3.0
All Indications
Percent Adherence to Loeb Criteria
Pres
crip
tions
per
100
0 Re
siden
t-Da
ys
0 5 10 15 20 25 30 35 40 450.0
0.2
0.4
0.6
0.8
1.0
1.2
Urinary Tract Infection
Percent Adherence to Loeb Criteria
Pres
crip
tions
per
100
0 Re
siden
t-Da
ys
0 1 2 3 4 5 6 7 80.0
0.2
0.4
0.6
0.8
1.0
1.2
Respiratory Infection
Percent Adherence to Loeb Criteria
Pres
crip
tions
per
100
0Re
siden
t-Da
ys
20 30 40 50 60 70 80 90 1000.0
0.1
0.2
0.3
0.4
0.5
Skin/Soft Tissue Infection
Percent Adherence to Loeb Criteria
Pres
crip
tions
per
100
0 Re
siden
t-Da
ys
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Results – QI Intervention
Mar Apr May Jun Jul Aug Sep Oct Nov10.0
10.2
10.4
10.6
10.8
11.0
11.2
11.4
11.6
11.8
Intervention Group All Indications Comparison Group All IndicationsIntervention Group Urinary Comparison Group UrinaryIntervention Group Respiratory Comparison Group RespiratoryIntervention Group Skin Comparison Group Skin
Pres
crip
tions
per
1,0
00 re
siden
t-da
ys
Follow-Up ==><==Baseline
Abt Associates | pg 15
Conclusions NHs increasingly recognized as reservoirs of
antibiotic-resistant bacteria Inappropriate overprescribing is a major contributor to
resistance Lack of support for relationship between adherence to
LMC and reduced prescribing rates
Yet, significant decline in prescribing rates in intervention sites only
QI program likely effective via other mechanisms
Recommend continued efforts to reduce prescribing
Abt Associates | pg 16
Acknowledgments The Abt/UNC team is grateful to the Agency for
Healthcare Research and Quality for funding this project.
Contract No. HHSA290200600019i, Task Order No. 11.