Improving the appropriateness of antipsychotic prescribing in nursing homes: a mixed-methods process evaluation of an academic detailing intervention

Abstract

BackgroundIn 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing.MethodsAdministrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement.ResultsNo significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication.ConclusionsParticipants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention ...

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“…The combination of both an acceptability survey and a satisfaction survey, the latter of which uses a mixed-method (qualitative and quantitative) approach, is particularly innovative. Indeed, in similar previous projects, feasibility/ experience assessment was conducted using qualitative or quantitative methods alone [44,45], or focused solely on post-intervention evaluation [46,47]. Moreover, the WHO defines "acceptability to participants" as an essential ethical issue in study design [48].…”

A multiple-behaviour investigation of goal prioritisation in physicians receiving audit and feedback to address high-risk prescribing in nursing homes

“…This may be especially important in the context of nursing home care, since our demographic data indicate that physicians spend portions of their clinical time in different facilities and are therefore shifting between different routines and workflows and likely have significant constraints on their time in each facility. External targets, internal routines, and time pressures are key components of the context of nursing homes which can undermine the success of provider behaviour change initiatives, but interventions which involve multiple team members with a range of different roles can serve to unify the team and strengthen behaviour change efforts [32]. However, individual-level A&F data is generally more useful and actionable than team-level data [33], and so, if pursued, home-level A&F should supplement rather than replace individual A&F.…”

“…Despite multiple and varied attempts to recruit physicians for interview, we were unable to recruit more than five physicians and have likely not achieved thematic saturation. However, our key themes map onto findings in the nursing home quality improvement literature, such as the influence of external policy and media reporting on behaviour change [32].…”

The construction of a framework explaining the relation between barriers to change in nursing homes: a qualitative study

“…Unfortunately, the (long-term) effectiveness of many of these interventions in terms of reduction of psychotropic drug use was shown to be limited [7,8,12,13].…”

“…In addition, a major barrier reported was the high turnover of the nursing home workforce [14][15][16][17][18][19]. Moreover, reorganizations, other innovations running at the time of the intervention, absent feeling of relevance by the staff [8,17,18,20] and the culture of the care unit, including attitude towards change, are barriers towards changing current practice [14].…”