Reducing Inappropriate Antibiotic Prescribing in Nursing Homes

1. Reducing Inappropriate Antibiotic Prescribing in Nursing Homes Rosanna Bertrand1, Lauren Olsho1, Sheryl Zimmerman2, Louise Hadden1, Alrick Edwards1, Philip Sloane2, Madeline Mitchell2,Donna Hurd1 1Abt Associates Inc.,US Health Division, Cambridge, MA, 2 University of North Carolina Chapel Hill, NC.

2. Presenter DisclosuresRosanna M. Bertrand I have no personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months to disclose.

3. Background • Antibiotics are among the most commonly prescribed pharmaceuticals in nursing homes (NHs). • A high proportion are inappropriate causing major public health concerns. • They result in multiple adverse consequences including increased risk of morbidity and mortality. • Loeb and colleagues developed minimum criteria (LMC) for the initiation of antibiotics in NH settings.

4. Loeb Minimum Criteria • A set of minimum criteria to assess symptoms and signs of: • Skin/soft-tissue infections • Respiratory infections • Urinary tract infections • Fever of unknown origin • Example of LMC for urinary tract infections with catheter • Temperature on day of prescription greater than 2.4 degrees above average routine temperature or greater than 100 degrees Fahrenheit; OR • New case of costovertebral angle tenderness, or symptoms of rigors, or new symptoms of delirium.

5. Quality Improvement (QI) Intervention Program • Abt/UNC developed a QI intervention that integrated: • An evidence-based conceptual model • A community-based participatory approach • Guidelines for when to prescribe (LMC) • Guidelines for when not to prescribe (12 conditions) • For example, a positive culture in an asymptomatic patient

6. QI Intervention Program Multi-Level Target Audience • Prescribers • Medical Doctors • Nurse Practitioners • Physician Assistants • Other NH staff • Administrators • Nurses • Residents and Families

7. QI Intervention ProgramMulti-Method Approach • On-Site Trainings • Pocket Cards

8. QI Intervention ProgramPocket Card

9. QI Intervention ProgramMulti-Method Approach • On-Site Trainings • Pocket Cards • Written Materials and Forms • Meetings/Gatherings

10. Evaluation Design • Quasi-experimental design • Six intervention NHs - part of UNC consortium • Six comparison NHs - matched by bed size and profit status • Three-month baseline and six-month intervention periods • N = 3,568 prescriptions over 336,522 resident days

11. Primary Outcomes • Antibiotic prescribing rates • Overall and by infection type: urinary, skin/soft tissue, and respiratory • Prescriber adherence to the LMC • Conducted on a random sample of prescribing events • Developed an indication-specific algorithm based on LMC • Coded whether or not the LMC were met

12. Analyses • Prescribing Rates Related to LMC Adherence • Multivariate analyses using three months baseline from intervention and comparison site data • Dependent variable: count of prescriptions per resident per day • Primary explanatory variable: NH-level measure of percent of prescriptions/month meeting the LMC • Impact of the QI Intervention • Multivariate difference-in-differences analyses to determine: • Increase in adherence to the LMC • Decrease in antibiotic prescribing rates

13. Results - LMC Adherence

14. Results – QI Intervention

15. Conclusions • NHs increasingly recognized as reservoirs of antibiotic-resistant bacteria • Inappropriate overprescribing is a major contributor to resistance • Lack of support for relationship between adherence to LMC and reduced prescribing rates • Yet, significant decline in prescribing rates in intervention sites only • QI program likely effective via other mechanisms • Recommend continued efforts to reduce prescribing

16. Acknowledgments • The Abt/UNC team is grateful to the Agency for Healthcare Research and Quality for funding this project. • Contract No. HHSA290200600019i, Task Order No. 11.