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Ahmed HAS, Al-Faris NA, Sharp JW, Abduljaber IO, Ghaida SSA. Managing Resource Utilization Cost of Laboratory Tests for Patients on Chemotherapy in Johns Hopkins Aramco Healthcare. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2023; 6:111-116. [PMID: 38404459 PMCID: PMC10887474 DOI: 10.36401/jqsh-23-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/16/2023] [Accepted: 08/08/2023] [Indexed: 02/27/2024]
Abstract
Introduction Laboratory testing is a fundamental diagnostic and prognostic tool to ensure the quality of healthcare, treatment, and responses. This study aimed to evaluate the cost of laboratory tests performed for patients undergoing chemotherapy treatment in the oncology treatment center at Johns Hopkins Aramco Healthcare in Saudi Arabia. Additionally, we aimed to reduce the cost of unnecessary laboratory tests in a 1-year period. Methods This was a quality improvement study with a quasi-experimental design using DMAIC methodology. The intervention strategy involved educating staff about adhering to the British Columbia Cancer Agency (BCCA) guidelines when ordering laboratory tests for chemotherapy patients, then integrating those guidelines into the electronic health record system. Data were collected for 200 randomly selected cases with 10 different chemotherapy protocols before and after the intervention. A paired t test was used to analyze differences in mean cost for all laboratory tests and unnecessary testing before and after the intervention. Results A significant cost reduction was achieved for unnecessary laboratory tests (77%, p < 0.01) when following the BCCA guidelines. In addition, the mean cost of all laboratory tests (including necessary and unnecessary) was significantly reduced by 45.5% (p = 0.023). Conclusion Lean thinking in clinical practice, realized by integrating a standardized laboratory test guided by BCCA guidelines into the electronic health record, significantly reduced financial costs within 1 year, thereby enhancing efficient resource utilization in the organization. This quality improvement project may serve to increase awareness of further efforts to improve resource utilization for other oncology treatment protocols.
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Affiliation(s)
- Huda Al-Sayed Ahmed
- Department of Quality & Patient Safety, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Nafeesa A Al-Faris
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Joshua W Sharp
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Issam O Abduljaber
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Salam S Abou Ghaida
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
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Stenlund S, Mâsse LC, Stenlund D, Sillanmäki L, Appelt KC, Koivumaa-Honkanen H, Rautava P, Suominen S, Patrick DM. Do Patients' Psychosocial Characteristics Impact Antibiotic Prescription Rates? Antibiotics (Basel) 2023; 12:1022. [PMID: 37370341 DOI: 10.3390/antibiotics12061022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
Previous research suggests that the characteristics of both patients and physicians can contribute to the overuse of antibiotics. Until now, patients' psychosocial characteristics have not been widely explored as a potential contributor to the overuse of antibiotics. In this study, the relationship between a patient's psychosocial characteristics (self-reported in postal surveys in 2003) and the number of antibiotics they were prescribed (recorded in Finnish national registry data between 2004-2006) were analyzed for 19,300 working-aged Finns. Psychosocial characteristics included life satisfaction, a sense of coherence, perceived stress, hostility, and optimism. In a structural equation model, patients' adverse psychosocial characteristics were not related to increased antibiotic prescriptions in the subsequent three years. However, these characteristics were strongly associated with poor general health status, which in turn was associated with an increased number of subsequent antibiotic prescriptions. Furthermore, mediation analysis showed that individuals who used healthcare services more frequently also received more antibiotic prescriptions. The current study does not support the view that patients' adverse psychosocial characteristics are related to an increased number of antibiotic prescriptions. This could encourage physicians to actively discuss treatment options with their patients.
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Affiliation(s)
- Säde Stenlund
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
| | - Louise C Mâsse
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
| | - David Stenlund
- Department of Mathematics, University of British Columbia, Vancouver, BC V6T 1Z2, Canada
- Faculty of Science and Engineering, Åbo Akademi University, 20500 Turku, Finland
| | - Lauri Sillanmäki
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
- Department of Public Health, University of Helsinki, 00014 Helsinki, Finland
| | - Kirstin C Appelt
- Sauder School of Business, University of British Columbia, Vancouver, BC V6T 1Z2, Canada
| | - Heli Koivumaa-Honkanen
- Institute of Clinical Medicine (Psychiatry), University of Eastern Finland, 70029 Kuopio, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
| | - Sakari Suominen
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
- School of Health Sciences, University of Skövde, 54128 Skövde, Sweden
| | - David M Patrick
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
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Madaras-Kelly KJ, Rovelsky SA, McKie RA, Nevers MR, Ying J, Haaland BA, Kay CL, Christopher ML, Hicks LA, Samore MH. Implementation and outcomes of a clinician-directed intervention to improve antibiotic prescribing for acute respiratory tract infections within the Veterans' Affairs Healthcare System. Infect Control Hosp Epidemiol 2023; 44:746-754. [PMID: 35968847 PMCID: PMC10882581 DOI: 10.1017/ice.2022.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system. DESIGN Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period. PARTICIPANTS Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded. INTERVENTION(S) Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary. MEASURE(S) We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity. RESULTS We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78-0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59-0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73-1.09). Return visits (OR, 1.00; 95% CI, 0.94-1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92-1.59) were not different before and after implementation within facilities that performed intensive implementation. CONCLUSIONS Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity-dependent manner. No impact on ARI-related clinical outcomes was observed.
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Affiliation(s)
- Karl J Madaras-Kelly
- Boise Veterans' Affairs (VA) Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, Meridian, Idaho
| | | | - Robert A McKie
- Boise Veterans' Affairs (VA) Medical Center, Boise, Idaho
| | - McKenna R Nevers
- Salt Lake City VA Health Care System, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Jian Ying
- Salt Lake City VA Health Care System, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin A Haaland
- Salt Lake City VA Health Care System, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Chad L Kay
- VA National Academic Detailing Service, St. Louis, Missouri
| | | | - Lauri A Hicks
- Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Mathew H Samore
- Salt Lake City VA Health Care System, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City, Utah
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Saini S, Leung V, Si E, Ho C, Cheung A, Dalton D, Daneman N, Grindrod K, Ha R, McIsaac W, Oberai A, Schwartz K, Shiamptanis A, Langford BJ. Documenting the indication for antimicrobial prescribing: a scoping review. BMJ Qual Saf 2022; 31:787-799. [PMID: 35552253 DOI: 10.1136/bmjqs-2021-014582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice. OBJECTIVES We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations. ELIGIBILITY CRITERIA Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing. SOURCES OF EVIDENCE A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature. CHARTING AND ANALYSIS Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively. RESULTS We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice. CONCLUSION There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.
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Affiliation(s)
- Sharon Saini
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Elizabeth Si
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Certina Ho
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Safe Medication Practices, Toronto, Ontario, Canada
| | - Anne Cheung
- West Park Healthcare Centre, Toronto, Ontario, Canada
| | | | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Rita Ha
- North York Family Health Team, Toronto, Ontario, Canada
| | - Warren McIsaac
- Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anjali Oberai
- Wawa Family Health Team, Wawa, Ontario, Canada
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Kevin Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Bradley J Langford
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, Ontario, Canada
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Educational Interventions to Reduce Prescription and Dispensing of Antibiotics in Primary Care: A Systematic Review of Economic Impact. Antibiotics (Basel) 2022; 11:antibiotics11091186. [PMID: 36139965 PMCID: PMC9495011 DOI: 10.3390/antibiotics11091186] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Antibiotic resistance remains a crucial global public health problem with excessive and inappropriate antibiotic use representing an important driver of this issue. Strategies to improve antibiotic prescription and dispensing are required in primary health care settings. The main purpose of this review is to identify and synthesize available evidence on the economic impact of educational interventions to reduce prescription and dispensing of antibiotics among primary health care professionals. Information about the clinical impact resulting from the implementation of interventions was also gathered. PubMed, Scopus, Web of Science and EMBASE were the scientific databases used to search and identify relevant studies. Of the thirty-three selected articles, most consisted of a simple intervention, such as a guideline implementation, while the others involved multifaceted interventions, and differed regarding study populations, designs and settings. Main findings were grouped either into clinical or cost outcomes. Twenty of the thirty-three articles included studies reporting a reduction in outcome costs, namely in antibiotic cost and associated prescription costs, in part due to an overall improvement in the appropriateness of antibiotic use. The findings of this study show that the implementation of educational interventions is a cost-effective strategy to reduce antibiotic prescription and dispensing among primary healthcare providers.
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Wubishet BL, Merlo G, Ghahreman-Falconer N, Hall L, Comans T. Economic evaluation of antimicrobial stewardship in primary care: a systematic review and quality assessment. J Antimicrob Chemother 2022; 77:2373-2388. [PMID: 35724206 PMCID: PMC9410674 DOI: 10.1093/jac/dkac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/02/2022] [Indexed: 11/28/2022] Open
Abstract
Background Primary care accounts for 80%–90% of antimicrobial prescriptions, making this setting an important focus for antimicrobial stewardship (AMS) interventions. Objectives To collate the findings and critically appraise the qualities of economic evaluation studies of AMS or related interventions aimed at reducing inappropriate antimicrobial prescribing in primary care. Methods A systematic review of economic evaluations of interventions aimed at reducing inappropriate antimicrobial prescribing in primary care was performed. Published literature were retrieved through a search of Medline, Embase, EconLit and Web of Science databases for the period 2010 to 2020. The quality of the studies was assessed using the Consensus on Health Economic Criteria checklist and Good Practice Guidelines for Decision-Analytic Modelling in Health Technology Assessment. Results Of the 2722 records identified, 12 studies were included in the review (8 trial-based and 4 modelled evaluations). The most common AMS interventions were communication skills training for health professionals and C-reactive protein point-of-care testing (CRP-POCT). Types of economic evaluations included in the review were cost-effectiveness (7 studies), cost-utility (1), cost-benefit (2), cost-effectiveness and cost-utility (1) and cost analysis (1). While six of the studies found AMS interventions to be cost-effective, the other six reported them as not cost-effective or inconclusive. The quality of the studies ranged from good to low. Conclusions There were significant variations in cost-effectiveness of AMS interventions across studies and depending on the inclusion of cost components such as the cost of antimicrobial resistance. However, communication skills training and CRP-POCT were frequently cost-effective or cost-beneficial for reducing inappropriate antimicrobial prescribing.
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Affiliation(s)
- Befikadu L Wubishet
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Gregory Merlo
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Nazanin Ghahreman-Falconer
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, 4072, Australia.,Princess Alexandra Hospital, Metro South Health, Woolloongabba, Queensland, 4072, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Tracy Comans
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, 4072, Australia
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Khatri UG, Lee K, Lin T, D'Orazio JL, Patel MS, Shofer FS, Perrone J. A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD). J Med Toxicol 2022; 18:205-213. [PMID: 35415804 PMCID: PMC9004452 DOI: 10.1007/s13181-022-00890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. Methods We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. Results Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI − 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI − 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01–1.09, standard arm difference .85 95% CI .34–1.37). Conclusions A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. Trial Registration ClinicalTrials.gov Identifier: NCT03821103. Supplementary Information The online version contains supplementary material available at 10.1007/s13181-022-00890-7.
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Affiliation(s)
- Utsha G Khatri
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10029, USA.
| | - Kathleen Lee
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Digital Health, Center for Health Care Innovation, Perelman School of Medicine, Philadelphia, PA, USA
| | - Theodore Lin
- Penn Medicine Center for Digital Health, Center for Health Care Innovation, Perelman School of Medicine, Philadelphia, PA, USA
| | - Joseph L D'Orazio
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Mitesh S Patel
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Health Care Management, Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Nudge Unit, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Epidemiology & Biostatistics, Center for Public Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Addiction Medicine and Policy, Philadelphia, PA, USA
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Taylor LC, Kerrison RS, Herrmann B, Stoffel ST. Effectiveness of behavioural economics-based interventions to improve colorectal cancer screening participation: A rapid systematic review of randomised controlled trials. Prev Med Rep 2022; 26:101747. [PMID: 35284211 PMCID: PMC8914541 DOI: 10.1016/j.pmedr.2022.101747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/18/2022] [Accepted: 02/26/2022] [Indexed: 12/22/2022] Open
Abstract
We searched PubMed, PsycInfo and EconLit for RCTs that evaluated BE interventions in CRC screening. We identified 1027 papers for title and abstract review. 30 studies were eligible for the review. The most frequently tested BE intervention was incentives, followed by default principle and salience. Default-based interventions were most likely to be effective. Incentives had mixed evidence. BE remains a promising field of interest in relation to influencing CRC screening behaviours.
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Affiliation(s)
- Lily C. Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Robert S. Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Health Sciences, University of Surrey, Surrey, UK
| | | | - Sandro T. Stoffel
- Research Department of Behavioural Science and Health, University College London, London, UK
- European Commission, Joint Research Centre (JRC), Ispra, Italy
- Institute for Pharmaceutical Medicine, University of Basel, Basel, Switzerland
- Corresponding author at: Research Department of Behavioural Science and Health, University College London, London, UK.
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Williams J, Malden S, Heeney C, Bouamrane M, Holder M, Perera U, Bates DW, Sheikh A. Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review. J Patient Saf 2022; 18:e547-e562. [PMID: 35188939 PMCID: PMC8855945 DOI: 10.1097/pts.0000000000000867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures. METHODS We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts. RESULTS We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process. DISCUSSION We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.
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Affiliation(s)
- Jac Williams
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen Malden
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Catherine Heeney
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Matt Bouamrane
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Mike Holder
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Uditha Perera
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aziz Sheikh
- From the Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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Richards AR, Linder JA. Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review. Clin Ther 2021; 43:1654-1667. [PMID: 34702589 DOI: 10.1016/j.clinthera.2021.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Behavioral economics recognizes that contextual, psychological, social, and emotional factors powerfully influence decision-making. Behavioral economics has the potential to provide a better understanding of, and, through subtle environmental changes, or "nudges," improve persistent quality-of-care challenges, like ambulatory antibiotic overprescribing. Despite decades of admonitions and educational initiatives, in the United States, up to 50% of ambulatory antibiotic prescriptions remain inappropriate or not associated with a diagnosis. METHODS We conducted a Medline search and performed a narrative review that examined the use of behavioral economics to understand the rationale for, and improvement of, ambulatory antibiotic prescribing. FINDINGS Clinicians prescribe antibiotics inappropriately because of perceived patient demand, to maintain patient satisfaction, diagnostic uncertainty, or time pressure, among other reasons. Behavioral economics-informed approaches offer additional improvements in antibiotic prescribing beyond clinician education and communication training. Precommitment, in which clinicians publicize their intent to prescribe antibiotics "only when they are absolutely necessary," leverages clinicians' self-conception and a desire to act in a manner consistent with public statements. Precommitment was associated with a 20% absolute reduction in the inappropriate antibiotic prescribing for acute respiratory infections. Justification alerts, in which clinicians must provide a brief written rationale for prescribing antibiotics, leverages social accountability, redefines the status quo as an active choice, and helps clinicians to shift from fast to slow, careful thinking. With justification alerts, the absolute rate of inappropriate antibiotic prescribing decreased from 23% to 5%. Peer comparison, in which clinicians receive feedback comparing their performance to their top-performing peers, provides evidence of improved performance and leverages peoples' desire to conform to social norms. Peer comparison decreased absolute inappropriate antibiotic prescribing rates from 20% to 4%, a decrease that persisted for 12 months after the end of the intervention. Also, a one-time peer-comparison letter from a high-profile messenger to primary care practices with high rates of prescribing antibiotics, there was a 6-month, 3% decrease inantibiotic prescribing. Future directions in applying behavioral economics to the inappropriate antibiotic prescribing include paying careful attention to design details; improving intervention effectiveness and durability; making harms salient; participants' involvement in the development of interventions (the "Ikea effect"); factoring in patient satisfaction; and patient-facing nudges about antibiotic use and care-seeking. In addition, the COVID pandemic could aid in ambulatory antibiotic prescribing improvements due to changing cognitive frames around respiratory symptom evaluation and antibiotic prescribing. IMPLICATIONS To improve ambulatory antibiotic prescribing, several behavioral economics-informed approaches-especially precommitment, justification alerts, and peer comparison-have reduced the rates of inappropriate prescribing of antibiotics to low levels.
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Affiliation(s)
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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11
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A Veterans' Healthcare Administration (VHA) antibiotic stewardship intervention to improve outpatient antibiotic use for acute respiratory infections: A cost-effectiveness analysis. Infect Control Hosp Epidemiol 2021; 43:1389-1395. [PMID: 34585655 DOI: 10.1017/ice.2021.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The Core Elements of Outpatient Antibiotic Stewardship provides a framework to improve antibiotic use, but cost-effectiveness data on implementation of outpatient antibiotic stewardship interventions are limited. We evaluated the cost-effectiveness of Core Element implementation in the outpatient setting. METHODS An economic simulation model from the health-system perspective was developed for patients presenting to outpatient settings with uncomplicated acute respiratory tract infections (ARI). Effectiveness was measured as quality-adjusted life years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug events (ADEs), and healthcare utilization were obtained from the literature. Probabilities for antibiotic treatment and appropriateness, ADEs, hospitalization, and return ARI visits were estimated from 16,712 and 51,275 patient visits in intervention and control sites during the pre- and post-implementation periods, respectively. Data for materials and labor to perform the stewardship activities were used to estimate intervention cost. We performed a one-way and probabilistic sensitivity analysis (PSA) using 1,000,000 second-order Monte Carlo simulations on input parameters. RESULTS The proportion of ARI patient-visits with antibiotics prescribed in intervention sites was lower (62% vs 74%) and appropriate treatment higher (51% vs 41%) after implementation, compared to control sites. The estimated intervention cost over a 2-year period was $133,604 (2018 US dollars). The intervention had lower mean costs ($528 vs $565) and similar mean QALYs (0.869 vs 0.868) per patient compared to usual care. In the PSA, the intervention was dominant in 63% of iterations. CONCLUSIONS Implementation of the CDC Core Elements in the outpatient setting was a cost-effective strategy.
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Caturegli G, Materi J, Lombardo A, Milovanovic M, Yende N, Variava E, Golub JE, Martinson NA, Hoffmann CJ. Choice architecture-based prescribing tool for TB preventive therapy: a pilot study in South Africa. Public Health Action 2020; 10:118-123. [PMID: 33134126 DOI: 10.5588/pha.20.0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background All people with HIV who screen negative for active tuberculosis (TB) should receive isoniazid preventive therapy (IPT). IPT implementation remains substantially below the 90% WHO target. This study sought to further understanding of IPT prescription by piloting a simplified prescribing approach. Setting Primary care clinics in Matlosana, South Africa. Design This was a mixed-methods implementation study. Methods Nine providers were recruited and underwent training on 2018 WHO guidelines. A simplified prescribing tool containing antiretroviral therapy (ART) and IPT prescriptions was introduced into the workflow for 2 weeks. Prescription data were collected from file review. Interviews were conducted with prescribers. Results During the study period, 41 patients were evaluated for ART initiation; 34 (83%) files used the simplified prescribing tool. Thirty-seven (90%) patients were eligible for same-day ART and IPT initiation, of whom 36 (97%) received IPT prescription. Qualitative interviews identified the following barriers to IPT prescription: cognitive burden, extensive documentation, limited management support, paucity of training, stock-outs, and patient-related factors. Provider acceptability of the tool was favorable, with unanimous recommendation to colleagues on the basis of streamlining documentation and reminding to prescribe. Conclusions This simplified prescribing device for IPT was feasible to implement. Streamlining documentation and reminding providers to prescribe can reduce work-flow barriers to IPT provision.
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Affiliation(s)
- G Caturegli
- Division of Infectious Disease, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - J Materi
- Division of Infectious Disease, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - A Lombardo
- Division of Infectious Disease, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - M Milovanovic
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - N Yende
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - E Variava
- Department of Medicine, Tshepong Hospital, Klerksdorp, South Africa
| | - J E Golub
- Division of Infectious Disease, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - N A Martinson
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - C J Hoffmann
- Division of Infectious Disease, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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13
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Lewkowicz D, Wohlbrandt A, Boettinger E. Economic impact of clinical decision support interventions based on electronic health records. BMC Health Serv Res 2020; 20:871. [PMID: 32933513 PMCID: PMC7491136 DOI: 10.1186/s12913-020-05688-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/25/2020] [Indexed: 12/28/2022] Open
Abstract
Background Unnecessary healthcare utilization, non-adherence to current clinical guidelines, or insufficient personalized care are perpetual challenges and remain potential major cost-drivers for healthcare systems around the world. Implementing decision support systems into clinical care is promised to improve quality of care and thereby yield substantial effects on reducing healthcare expenditure. In this article, we evaluate the economic impact of clinical decision support (CDS) interventions based on electronic health records (EHR). Methods We searched for studies published after 2014 using MEDLINE, CENTRAL, WEB OF SCIENCE, EBSCO, and TUFTS CEA registry databases that encompass an economic evaluation or consider cost outcome measures of EHR based CDS interventions. Thereupon, we identified best practice application areas and categorized the investigated interventions according to an existing taxonomy of front-end CDS tools. Results and discussion Twenty-seven studies are investigated in this review. Of those, twenty-two studies indicate a reduction of healthcare expenditure after implementing an EHR based CDS system, especially towards prevalent application areas, such as unnecessary laboratory testing, duplicate order entry, efficient transfusion practice, or reduction of antibiotic prescriptions. On the contrary, order facilitators and undiscovered malfunctions revealed to be threats and could lead to new cost drivers in healthcare. While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost. Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems. Conclusion Current research studies lack consideration of comparative cost-outcome metrics as well as detailed cost components in their analyses. Nonetheless, the positive economic impact of EHR based CDS interventions is highly promising, especially with regard to reducing waste in healthcare.
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Affiliation(s)
- Daniel Lewkowicz
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Str. 2-3, 14482, Potsdam, Germany.
| | - Attila Wohlbrandt
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Str. 2-3, 14482, Potsdam, Germany
| | - Erwin Boettinger
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Str. 2-3, 14482, Potsdam, Germany.,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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Wagner Z, Montoy JCC, Drabo EF, Dow WH. Incentives Versus Defaults: Cost-Effectiveness of Behavioral Approaches for HIV Screening. AIDS Behav 2020; 24:379-386. [PMID: 30953306 DOI: 10.1007/s10461-019-02425-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Many HIV positive individuals are still undiagnosed, which has led health systems to try many approaches to expand HIV testing. In a randomized controlled trial, we found that behavioral economics interventions (opt-out testing and financial incentives) each improved HIV testing rates and these approaches are being implemented by several hospital systems. However, it is unclear if these strategies are cost-effective. We quantified the cost-effectiveness of different behavioral approaches to HIV screening-opt-out testing, financial incentives, and their combination-in terms of cost per new HIV diagnosis and infections averted. We estimated the incremental number of new HIV diagnoses and program costs using a mathematical screening model, and infections averted using and HIV transmission model. We used a 1-year time horizon and a hospital perspective. Switching from opt-into opt-out results in 39 additional diagnoses (56% increase) after 1-year at a cost of $3807 per new diagnosis. Switching from no incentive to a $1, $5, or $10 incentive adds 14, 13, and 28 new diagnoses (20, 19, and 41% increases) at a cost of $11,050, $17,984, and $15,298 per new diagnosis, respectively. Layering on financial incentives to opt-out testing enhances program effectiveness, though at a greater marginal cost per diagnosis. We found a similar pattern for infections averted. This is one of the first cost-effectiveness analyses of behavioral economics interventions in public health. Changing the choice architecture from opt-into opt-out and giving financial incentives for testing are both cost-effective in terms of detecting HIV and reducing transmission. For hospitals interested in increasing HIV screening rates, changing the choice architecture is an efficient strategy and more efficient than incentives.
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Affiliation(s)
- Zachary Wagner
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401, USA.
| | - Juan Carlos C Montoy
- Department Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Emmanuel F Drabo
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - William H Dow
- School of Public Health, University of California Berkeley, Berkeley, CA, USA
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So Many Nudges, So Little Time: Can Cost-effectiveness Tell Us When It Is Worthwhile to Try to Change Provider Behavior? J Gen Intern Med 2019; 34:783-784. [PMID: 30877456 PMCID: PMC6544771 DOI: 10.1007/s11606-019-04871-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Linnemayr S, MacCarthy S, Wagner Z, Barreras JL, Galvan FH. Using Behavioral Economics to Promote HIV Prevention for Key Populations. JOURNAL OF AIDS & CLINICAL RESEARCH 2018; 9:780. [PMID: 30906621 PMCID: PMC6428081 DOI: 10.4172/2155-6113.1000780] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In this short communication, we discuss some key behavioral economic (BE) biases that likely minimize HIV prevention efforts, explore why certain key populations such as men who have sex with men or transgender women-may be more likely to succumb to these biases, and suggest how incentives informed by BE can support these populations in their effort to remain HIV-negative. Based on our formative work in an ongoing study, we discuss two important insights regarding the use of incentives to inform future HIV prevention efforts. First, participants often expressed more excitement for prizes that were viewed as fun (e.g., movie gift cards) or luxurious (e.g., cosmetics gift cards) rather than necessities (e.g., grocery store gift cards) of the same financial value and suggests that including an element of fun can be a powerful tool for incentivizing safe HIV-related behavior. Second, participants preferred not to be "paid" to display health behaviors, indicating the way incentives are given out (and perceived) is central to their success. Going forward, a BE perspective can help improve the impact of incentives - and increase their cost-effectiveness by carefully adapting them to the preferences of their recipients.
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