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Candon M, Shen S, Rothbard A, Reed A, Everett M, Demp N, Weingartner M, Fadeyibi O. Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia. BMC Health Serv Res 2024; 24:574. [PMID: 38702737 PMCID: PMC11067128 DOI: 10.1186/s12913-024-11029-5] [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: 08/03/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target. METHODS In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card. RESULTS Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card. CONCLUSIONS A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan.
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Affiliation(s)
- Molly Candon
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Siyuan Shen
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
| | - Aileen Rothbard
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail Reed
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mia Everett
- Community Behavioral Health, Philadelphia, PA, USA
| | - Neal Demp
- Community Behavioral Health, Philadelphia, PA, USA
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McCleary N, Desveaux L, Presseau J, Reis C, Witteman HO, Taljaard M, Linklater S, Thavorn K, Dobell G, Mulhall CL, Lam JMC, Grimshaw JM, Ivers NM. 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. Implement Sci 2023; 18:13. [PMID: 37165413 PMCID: PMC10173488 DOI: 10.1186/s13012-023-01271-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/06/2023] [Indexed: 05/12/2023] Open
Abstract
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.
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Affiliation(s)
- Nicola McCleary
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
| | - Laura Desveaux
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Justin Presseau
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Catherine Reis
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | - Holly O Witteman
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada
- Department of Family and Emergency Medicine, Laval University, Québec City, Canada
| | - Monica Taljaard
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Stefanie Linklater
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada
| | - Kednapa Thavorn
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Gail Dobell
- Health System Performance, Ontario Health, Toronto, Canada
| | - Cara L Mulhall
- Health System Performance, Ontario Health, Toronto, Canada
| | | | - Jeremy M Grimshaw
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
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3
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Singer A, Kosowan L, Abrams EM, Katz A, Lix L, Leong K, Paige A. Implementing an audit and feedback cycle to improve adherence to the Choosing Wisely Canada recommendations: clustered randomized trail. BMC PRIMARY CARE 2022; 23:302. [PMID: 36435746 PMCID: PMC9701433 DOI: 10.1186/s12875-022-01912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Audit and Feedback (A&F), a strategy aimed at promoting modified practice through performance feedback, is a method to change provider behaviour and reduce unnecessary medical services. This study aims to assess the use of A&F to reduce antibiotic prescribing for viral infections and antipsychotic prescribing to patients with dementia. METHODS Clustered randomized trial of 239 primary care providers in Manitoba, Canada, participating in the Manitoba Primary Care Research Network. Forty-six practices were randomly assigned to one of three groups: control group, intervention 1 (recommendations summary), intervention 2 (recommendations summary and personalized feedback). We assessed prescribing rates prior to the intervention (2014/15), during and immediately after the intervention (2016/17) and following the intervention (2018/19). Physician characteristics were assessed. RESULTS Between 2014/15-2016/17, 91.6% of providers in intervention group 1 and 95.9% of providers in intervention group 2 reduced their antibiotic and antipsychotic prescribing rate by ≥ 1 compared to the control group (77.6%) (p-value 0.0073). This reduction was maintained into 2018/19 at 91.4%. On multivariate regression alternatively funded providers had 2.4 × higher odds of reducing their antibiotic prescribing rate compared to fee-for-service providers. In quantile regression of providers with a reduction in antibiotic prescribing, alternatively funded (e.g. salaried or locum) providers compared to fee-for-service providers were significant at the 80th quantile. CONCLUSIONS Both A&F and recommendation summaries sent to providers by a trusted source reduced unnecessary prescriptions. Our findings support further scale up of efforts to engage with primary care practices to improve care with A&F. TRIAL REGISTRATION ClinicalTrials.gov NCT05385445, retrospectively registered, 23/05/2022.
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Affiliation(s)
- Alexander Singer
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Leanne Kosowan
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Alan Katz
- Departments of Community Health Science & Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Centre for Health Policy, Winnipeg, MB, Canada
| | - Lisa Lix
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Katrina Leong
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Allison Paige
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Daneman N, Lee S, Bai H, Bell CM, Bronskill SE, Campitelli MA, Dobell G, Fu L, Garber G, Ivers N, Kumar M, Lam JMC, Langford B, Laur C, Morris AM, Mulhall CL, Pinto R, Saxena FE, Schwartz KL, Brown KA. Behavioral Nudges to Improve Audit and Feedback Report Opening among Antibiotic Prescribers: A Randomized Controlled Trial. Open Forum Infect Dis 2022; 9:ofac111. [PMID: 35392461 PMCID: PMC8982784 DOI: 10.1093/ofid/ofac111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
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 three behavioral nudging techniques delivered by email to improve report opening.
Methods
We conducted a pragmatic randomized controlled trial among Ontario long-term care (LTC) 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 more than 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%CI 1.10-2.07, p=0.011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR (aOR) 1.74 (95%CI 1.24-2.45, p=0.0014). 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=0.026; aOR 2.16, 95%CI 1.33-3.50, p=0.0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR 1.28, 95%CI 1.14-1.43, p<0.001).
Conclusions
Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.
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Affiliation(s)
- Nick Daneman
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Ontario, Canada
- ICES, Ontario, Canada
- Institute of Health Policy, Management and Evaluation and Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Chaim M Bell
- ICES, Ontario, Canada
- Institute of Health Policy, Management and Evaluation and Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Susan E Bronskill
- ICES, Ontario, Canada
- Institute of Health Policy, Management and Evaluation and Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Gary Garber
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Noah Ivers
- ICES, Ontario, Canada
- Institute of Health Policy, Management and Evaluation and Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Celia Laur
- Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew M Morris
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Kevin L Schwartz
- Public Health Ontario, Ontario, Canada
- ICES, Ontario, Canada
- Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
| | - Kevin A Brown
- Public Health Ontario, Ontario, Canada
- ICES, Ontario, Canada
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Boone CG, Bishop AC, Ivers N, Desveaux L, Tadrous M. Audit and feedback in community pharmacy: An untapped strategy of quality improvement. Can Pharm J (Ott) 2021; 155:79-81. [PMID: 35300026 PMCID: PMC8922220 DOI: 10.1177/17151635211056528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/25/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022]
Affiliation(s)
| | - Andrea C. Bishop
- Toronto, Ontario; the Nova Scotia College of Pharmacists, Halifax, Nova Scotia
| | - Noah Ivers
- Women’s College Hospital Research Institute, Toronto, Ontario
| | - Laura Desveaux
- Women’s College Hospital Research Institute, Toronto, Ontario
- Trillium Health Partners, Mississauga, Ontario
| | - Mina Tadrous
- Women’s College Hospital Research Institute, Toronto, Ontario
- University of Toronto, Toronto, Ontario
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Thavorn K, Kumar S, Reis C, Lam J, Dobell G, Mulhall C, Grimshaw JM, Ivers N. Audit feedback interventions to address high-risk prescriptions in long-term care homes: a costing study and return on investment analysis. Implement Sci Commun 2021; 2:125. [PMID: 34711294 PMCID: PMC8554856 DOI: 10.1186/s43058-021-00225-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 09/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Audit and feedback is a common implementation strategy, but few studies describe its costs. 'MyPractice' is a province-wide audit and feedback initiative to improve prescribing in nursing homes. This study sought to estimate the costs of 'MyPractice' and assess whether the financial benefit of 'MyPractice' offsets those costs. METHODS We conducted a costing study from the perspective of the Ontario government. Total cost of 'MyPractice' was calculated as the sum of the costs of producing and disseminating the reports (covering three report releases) which were obtained from Ontario Health staff interviews and document reviews. Return on investment (ROI) was calculated as the ratio of net cost-savings and the intervention cost. Cost savings were based on the effectiveness of 'MyPractice' derived from a published cohort study. Cost-savings attributable to 'MyPractice' were estimated from the changes in the rates of antipsychotics over time between physicians who signed up and viewed the reports and those who did not sign up to the reports. RESULTS Total intervention costs were C$223,691 (C$838 per physician and C$74,564 per release). Costs incurred during the development phase accounted for 74% of the total cost (C$166,117), while implementation costs for three report releases were responsible for 26% of the total costs (C$57,575). The ROI for every C$1 spent on the 'MyPractice' intervention was 1.02 (95% CI 0.51, 1.93) for three report releases. CONCLUSION 'MyPractice' report offers a good return on investment and the value for money could improve with greater number of report releases.
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Affiliation(s)
- Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
- ICES, Toronto, Ontario, Canada.
| | - Srishti Kumar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Catherine Reis
- Women's College Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Jonathan Lam
- Ontario Health (Quality), Toronto, Ontario, Canada
| | - Gail Dobell
- Ontario Health (Quality), Toronto, Ontario, Canada
| | - Cara Mulhall
- Ontario Health (Quality), Toronto, Ontario, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Noah Ivers
- ICES, Toronto, Ontario, Canada
- Women's College Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Trenaman SC, Bowles SK, Kirkland SA, Andrew MK. Potentially Inappropriate Drug Duplication in a Cohort of Older Adults with Dementia. CURRENT THERAPEUTIC RESEARCH 2021; 95:100644. [PMID: 34589160 PMCID: PMC8458971 DOI: 10.1016/j.curtheres.2021.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Concurrent use of 2 nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, loop diuretics, angiotensin-converting enzyme inhibitors, or anticoagulants is considered potentially inappropriate by Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment criteria. OBJECTIVE The objective was to examine drug duplication in a cohort of older adults with dementia. METHODS Cohort entry for Nova Scotia Seniors' Pharmacare Program beneficiaries was the date an International Classification of Diseases ninth edition or 10th edition code for dementia was recorded in accessed databases between March 1, 2005, and March 31, 2015. Medication dispensation and sociodemographic data were captured from the Nova Scotia Seniors' Pharmacare Program database between April 1, 2010, and March 31, 2015. Duplication was considered when 2 drugs from the same class were dispensed such that the supply in the patient's possession could overlap for more than 30 days. We reported number of cases of duplication and duration of overlap. Sex differences in drug duplication were assessed with bivariate logistic regression. RESULTS In the cohort of 28,953 Nova Scotia Seniors' Pharmacare Program beneficiaries with dementia, we documented concurrent use in 101 (1.7%) nonsteroidal anti-inflammatory drugs users (mean duration = 75.6 days), 95 (1.0%) selective serotonin reuptake inhibitors users (mean duration = 146.6 days), 5 (0.07%) loop diuretic users (mean duration = 530.6 days), 183 (2.0%) angiotensin-converting enzyme inhibitor users (mean duration = 123.9 days), and 160 (3.5%) anticoagulant users (mean duration = 63.6 days). Nonsteroidal anti-inflammatory drug pairs were most commonly celecoxib with naproxen or diclofenac. Selective serotonin reuptake inhibitors duplication was most commonly sertraline with citalopram. No sex differences in risk for drug duplication were identified. CONCLUSIONS Drug duplication was identified in a cohort of older adults with dementia and is a feasible target for intervention. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).
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Affiliation(s)
- Shanna C. Trenaman
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan K. Bowles
- Nova Scotia Health, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan A. Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melissa K. Andrew
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
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8
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Vanstone JR, Patel S, Degelman ML, Abubakari IW, McCann S, Parker R, Ross T. Development and implementation of a clinician report to reduce unnecessary urine drug screen testing in the ED: a quality improvement initiative. Emerg Med J 2021; 39:471-478. [PMID: 33980661 PMCID: PMC9132872 DOI: 10.1136/emermed-2020-210009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/25/2021] [Accepted: 03/07/2021] [Indexed: 11/12/2022]
Abstract
Background Unnecessary testing is a problem-facing healthcare systems around the world striving to achieve sustainable care. Despite knowing this problem exists, clinicians continue to order tests that do not contribute to patient care. Using behavioural and implementation science can help address this problem. Locally, audit and feedback are used to provide information to clinicians about their performance on relevant metrics. However, this is often done without evidence-based methods to optimise uptake. Our objective was to improve the appropriate use of laboratory tests in the ED using evidence-based audit and feedback and behaviour change techniques. Methods Using the behaviour change wheel, we implemented an audit and feedback tool that provided information to ED physicians about their use of laboratory tests; specifically, we focused on education and review of the appropriate use of urine drug screen tests. The report was designed in collaboration with end users to help maximise engagement. Following development of the report, audit and feedback sessions were delivered over an 18-month period. Results Data on urine drug screen testing were collected continually throughout the intervention period and showed a sustained decrease among ED physicians. Test use dropped from a monthly departmental average of 26 urine drug screen tests per 1000 patient visits to only eight tests per 1000 patient visits following the initiation of the audit and feedback intervention. Conclusion Audit and feedback reduced unnecessary urine drug screen testing in the ED. Regular feedback sessions continuously engaged physicians in the audit and feedback intervention and allowed the implementation team to react to changing priorities and feedback from the clinical group. It was important to include the end users in the design of audit and feedback tools to maximise physician engagement. Inclusion in this process can help ensure physicians adopt a sense of ownership regarding which metrics to review and provides a key component for the motivation aspect of behaviour change. Departmental leadership is also critical to the process of implementing a successful audit and feedback initiative and achieving sustained behaviour change.
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Affiliation(s)
- Jason Robert Vanstone
- Stewardship and Clinical Appropriateness, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Shivani Patel
- Stewardship and Clinical Appropriateness, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Michelle L Degelman
- Stewardship and Clinical Appropriateness, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Ibrahim W Abubakari
- Digital Health, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Shawn McCann
- eHealth Saskatchewan, Regina, Saskatchewan, Canada
| | - Robert Parker
- Stewardship and Clinical Appropriateness, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Terry Ross
- Emergency Medicine, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
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9
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Tadrous M, Fung K, Desveaux L, Gomes T, Taljaard M, Grimshaw JM, Bell CM, Ivers NM. Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial. JAMA Netw Open 2020; 3:e205724. [PMID: 32453383 PMCID: PMC7251442 DOI: 10.1001/jamanetworkopen.2020.5724] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/17/2020] [Indexed: 01/22/2023] Open
Abstract
Importance Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness. Objective To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics. Design, Setting, and Participants We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat. Intervention Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch. Main Outcomes and Measures The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months. Results A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P = .49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P < .001) and depression (mean [SD] Depression Rating Scale score, 2.18 [2.37] vs 2.81 [2.65]; P < .001) at 6 months. Conclusions and Relevance The intervention did not further reduce antipsychotic prescribing in nursing homes beyond system-level secular trends occurring alongside usual care. Our findings highlight the need for a more targeted approach to quality improvement strategies, including academic detailing, that account for the timing and topic of interventions. Trial Registration ClinicalTrials.gov Identifier: NCT02604056.
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Affiliation(s)
- Mina Tadrous
- ICES, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | - Laura Desveaux
- Women’s College Research Institute, Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- University of Ottawa School of Epidemiology, Public Health and Preventive Medicine, Ottawa, Ontario, Canada
| | - Jeremy M. Grimshaw
- University of Ottawa School of Epidemiology, Public Health and Preventive Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chaim M. Bell
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Noah M. Ivers
- ICES, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Unviersity of Toronto, Toronto, Ontario, Canada
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Enhancing Quality Care in Ontario Long-Term Care Homes Through Audit and Feedback for Physicians. J Am Med Dir Assoc 2020; 21:420-425. [DOI: 10.1016/j.jamda.2019.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022]
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