Improving antibiotic initiation and duration prescribing among nursing home physicians using an audit and feedback intervention: a theory-informed qualitative analysis

Laur, Celia; Sribaskaran, Thivja; Simeoni, Michelle; Desveaux, Laura; Daneman, Nick; Mulhall, Cara; Lam, Jonathan; Ivers, Noah

doi:10.1136/bmjoq-2020-001088

Cited by 10 publications

(29 citation statements)

References 23 publications

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“…19,25,28 Behaviorally targeted assessment and feedback interventions should be evaluated in nursing home settings. 29 Even after adjusting for facility-level characteristics, the proportion of short-stay residents was found to be associated with higher facility-level antibiotic use rates, as shown previously. 4 Median antibiotic use ate in facilities where cumulative proportion of short-stay residents ≥75% was almost 2.5 times that of facilities with a lower proportion of short-stay residents.…”

Section: Discussionsupporting

confidence: 69%

“…Other important potential next steps include evaluating data elements for risk adjustment of facility-level benchmarks, 31 streamlining the generation of antibiotic use reports for individual facilities 33 and assessing the impact of prescriber audit and feedback in this setting. 29 Supplementary material. To view supplementary material for this article, please visit https://doi.org/10.1017/ash.2021.207…”

Section: Discussionmentioning

confidence: 99%

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Description of antibiotic use variability among US nursing homes using electronic health record data

Kabbani

Wang²,

Ditz³

et al. 2021

ASHE

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Background: Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders. Methods: A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models. Results: In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5–10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software). Conclusions: Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.

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Section: Discussionsupporting

confidence: 69%

Section: Discussionmentioning

confidence: 99%

Description of antibiotic use variability among US nursing homes using electronic health record data

Kabbani

Wang²,

Ditz³

et al. 2021

ASHE

View full text Add to dashboard Cite

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“…A full article-level breakdown of these scores is found in Additional file 1 : Appendix B1. Table 4 shows the adherence to each of the individual standards within the SRQR; two [ 57 , 61 ] articles met all the standards.…”

Section: Resultsmentioning

confidence: 99%

An exploration into physician and surgeon data sensemaking: a qualitative systematic review using thematic synthesis

Whitelock-Wainwright

Koh

Whitelock‐Wainwright

et al. 2022

BMC Med Inform Decis Mak

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Providing electronic health data to medical practitioners to reflect on their performance can lead to improved clinical performance and quality of care. Understanding the sensemaking process that is enacted when practitioners are presented with such data is vital to ensure an improvement in performance. Thus, the primary objective of this research was to explore physician and surgeon sensemaking when presented with electronic health data associated with their clinical performance. A systematic literature review was conducted to analyse qualitative research that explored physicians and surgeons experiences with electronic health data associated with their clinical performance published between January 2010 and March 2022. Included articles were assessed for quality, thematically synthesised, and discussed from the perspective of sensemaking. The initial search strategy for this review returned 8,829 articles that were screened at title and abstract level. Subsequent screening found 11 articles that met the eligibility criteria and were retained for analyses. Two articles met all of the standards within the chosen quality assessment (Standards for Reporting Qualitative Research, SRQR). Thematic synthesis generated five overarching themes: data communication, performance reflection, infrastructure, data quality, and risks. The confidence of such findings is reported using CERQual (Confidence in the Evidence from Reviews of Qualitative research). The way the data is communicated can impact sensemaking which has implications on what is learned and has impact on future performance. Many factors including data accuracy, validity, infrastructure, culture can also impact sensemaking and have ramifications on future practice. Providing data in order to support performance reflection is not without risks, both behavioural and affective. The latter of which can impact the practitioner’s ability to effectively make sense of the data. An important consideration when data is presented with the intent to improve performance.Registration This systematic review was registered with Prospero, registration number: CRD42020197392.

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“…These practical problem-solving strategies (i.e., “Mindlines”) [ 24 ] may eventually become a standard and unconscious element of practice—a habit. Other studies have demonstrated that a range of factors related to the patient and their situation have an impact on clinical decision-making [ 25 – 27 ]. In line with these other studies, physicians explained prescribing as a conscious weighing of risks, judging that, on the whole, prescribing antibiotics represented the lowest risk option [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

“…Prior studies agree on the important role of time pressure in that it creates circumstances where heuristics are more likely to be unconscious to avoid difficult interactions [ 14 ]. These factors can hold more or less weight on the Decision-Making Process depending on the clinical context in which the provider is practicing [ 27 , 28 ]. In the UK, similar research exploring high, medium, and low prescribers reinforces the patterns found in this study [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Coping with ‘the grey area’ of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing

et al. 2022

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Background Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms. Methods Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20th percentile versus “medium” defined as 40th to 60th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved. Results Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician–patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty. Conclusions Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices.

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Improving antibiotic initiation and duration prescribing among nursing home physicians using an audit and feedback intervention: a theory-informed qualitative analysis

Cited by 10 publications

References 23 publications

Description of antibiotic use variability among US nursing homes using electronic health record data

Description of antibiotic use variability among US nursing homes using electronic health record data

An exploration into physician and surgeon data sensemaking: a qualitative systematic review using thematic synthesis

Coping with ‘the grey area’ of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing

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