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Stevens ER, Agbakoba R, Mann DM, Hess R, Richardson SI, McGinn T, Smith PD, Halm W, Mundt MP, Dauber-Decker KL, Jones SA, Feldthouse DM, Kim EJ, Feldstein DA. Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial. BMC Med Inform Decis Mak 2023; 23:260. [PMID: 37964232 PMCID: PMC10644670 DOI: 10.1186/s12911-023-02368-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 11/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model. METHODS Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout. DISCUSSION This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 .
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Affiliation(s)
| | | | - Devin M Mann
- NYU Grossman School of Medicine, New York, NY, USA
| | - Rachel Hess
- University of Utah Health, Salt Lake City, UT, USA
| | | | | | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Wendy Halm
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- University of Wisconsin School of Nursing, Madison, WI, USA
| | - Marlon P Mundt
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | | | - Eun Ji Kim
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Ma C, Lee A, Courtney D, Castle D, Wang W. Comparing analytical strategies for balancing site-level characteristics in stepped-wedge cluster randomized trials: a simulation study. BMC Med Res Methodol 2023; 23:206. [PMID: 37700232 PMCID: PMC10496299 DOI: 10.1186/s12874-023-02027-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Stepped-wedge cluster randomized trials (SWCRTs) are a type of cluster-randomized trial in which clusters are randomized to cross-over to the active intervention sequentially at regular intervals during the study period. For SWCRTs, sequential imbalances of cluster-level characteristics across the random sequence of clusters may lead to biased estimation. Our study aims to examine the effects of balancing cluster-level characteristics in SWCRTs. METHODS To quantify the level of cluster-level imbalance, a novel imbalance index was developed based on the Spearman correlation and rank regression of the cluster-level characteristic with the cross-over timepoints. A simulation study was conducted to assess the impact of sequential cluster-level imbalances across different scenarios varying the: number of sites (clusters), sample size, number of cross-over timepoints, site-level intra-cluster correlation coefficient (ICC), and effect sizes. SWCRTs assumed either an immediate "constant" treatment effect, or a gradual "learning" treatment effect which increases over time after crossing over to the active intervention. Key performance metrics included the relative root mean square error (RRMSE) and relative mean bias. RESULTS Fully-balanced designs almost always had the highest efficiency, as measured by the RRMSE, regardless of the number of sites, ICC, effect size, or sample sizes at each time for SWCRTs with learning effect. A consistent decreasing trend of efficiency was observed by increasing RRMSE as imbalance increased. For example, for a 12-site study with 20 participants per site/timepoint and ICC of 0.10, between the most balanced and least balanced designs, the RRMSE efficiency loss ranged from 52.5% to 191.9%. In addition, the RRMSE was decreased for larger sample sizes, larger number of sites, smaller ICC, and larger effect sizes. The impact of pre-balancing diminished when there was no learning effect. CONCLUSION The impact of pre-balancing on preventing efficiency loss was easily observed when there was a learning effect. This suggests benefit of pre-balancing with respect to impacting factors of treatment effects.
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Affiliation(s)
- Clement Ma
- Biostatistics Core, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Center for Complex Interventions, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alina Lee
- Biostatistics Core, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Center for Complex Interventions, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Darren Courtney
- Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - David Castle
- Department of Psychiatry, University of Tasmania, Hobart, TAS, Australia
- Centre for Mental Health Service Innovation, Statewide Mental Health Service, Hobart, TAS, Australia
| | - Wei Wang
- Biostatistics Core, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Center for Complex Interventions, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- College of Public Health, University of South Florida, Tampa, FL, USA.
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Nevins P, Davis-Plourde K, Pereira Macedo JA, Ouyang Y, Ryan M, Tong G, Wang X, Meng C, Ortiz-Reyes L, Li F, Caille A, Taljaard M. A scoping review described diversity in methods of randomization and reporting of baseline balance in stepped-wedge cluster randomized trials. J Clin Epidemiol 2023; 157:134-145. [PMID: 36931478 PMCID: PMC10546924 DOI: 10.1016/j.jclinepi.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES In stepped-wedge cluster randomized trials (SW-CRTs), clusters are randomized not to treatment and control arms but to sequences dictating the times of crossing from control to intervention conditions. Randomization is an essential feature of this design but application of standard methods to promote and report on balance at baseline is not straightforward. We aimed to describe current methods of randomization and reporting of balance at baseline in SW-CRTs. STUDY DESIGN AND SETTING We used electronic searches to identify primary reports of SW-CRTs published between 2016 and 2022. RESULTS Across 160 identified trials, the median number of clusters randomized was 11 (Q1-Q3: 8-18). Sixty-three (39%) used restricted randomization-most often stratification based on a single cluster-level covariate; 12 (19%) of these adjusted for the covariate(s) in the primary analysis. Overall, 50 (31%) and 134 (84%) reported on balance at baseline on cluster- and individual-level characteristics, respectively. Balance on individual-level characteristics was most often reported by condition in cross-sectional designs and by sequence in cohort designs. Authors reported baseline imbalances in 72 (45%) trials. CONCLUSION SW-CRTs often randomize a small number of clusters using unrestricted allocation. Investigators need guidance on appropriate methods of randomization and assessment and reporting of balance at baseline.
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Affiliation(s)
- Pascale Nevins
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kendra Davis-Plourde
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA; Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | | | - Yongdong Ouyang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Ryan
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA; Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Xueqi Wang
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA; Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Can Meng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Luis Ortiz-Reyes
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA; Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France; INSERM CIC 1415, CHRU de Tours, Tours, France
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
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PATHWEIGH, pragmatic weight management in adult patients in primary care in Colorado, USA: study protocol for a stepped wedge cluster randomized trial. Trials 2022; 23:26. [PMID: 35012628 PMCID: PMC8744030 DOI: 10.1186/s13063-021-05954-7] [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: 08/21/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background Despite the overwhelming prevalence and health implications of obesity, it is rarely adequately addressed in a health care setting. PATHWEIGH is a pragmatic approach to weight management that uses tools built into the electronic medical record to overcome barriers and guide care. Implementation strategies are employed to facilitate adoption and use of the PATHWEIGH tools and processes. The current study will compare the effectiveness of PATHWEIGH versus standard of care (SOC) on patient weight loss in primary care and explore factors for its successful implementation. Methods A stepped wedge cluster randomized trial design will be used within an effectiveness-implementation hybrid study. Adult patient weight loss and weight loss maintenance will be compared in PATHWEIGH versus SOC in 57 family and internal medicine clinics in a large health system in Colorado, USA. Effectiveness will be evaluated using generalized linear mixed models to determine statistical differences in weight loss and weight loss maintenance at 6, 12, and 18 months. Patient-, provider-, and clinic-level predictors will be identified using mediator and moderator analyses. Conceptually guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), a mixed methods approach including quantitative (practice surveys, use tracking) and qualitative (interviews, observations) data collection will be used to determine factors impeding and facilitating adoption, implementation, and maintenance of PATHWEIGH and evaluate specified implementation strategies. A cost analysis of the practice and system costs and resources required by PATHWEIGH relative to the reimbursement collected will be performed. Discussion The effectiveness and implementation of PATHWEIGH, and their interrelatedness, for patient weight loss are collectively the focus of the current trial. Findings from this study are expected to serve as a blueprint for available and effective weight management in primary care medical practice. Trial registration ClinicalTrials.govNCT04678752. Registered on December 21, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05954-7.
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