Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome

Background Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months. Results The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit–feedback program. This improvement remained unchanged until the end of the 12th month. Conclusions The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

Individual versus general structured feedback to improve agreement in grant peer review: a randomized controlled trial

Background Vast sums are distributed based on grant peer review, but studies show that interrater reliability is often low. In this study, we tested the effect of receiving two short individual feedback reports compared to one short general feedback report on the agreement between reviewers. Methods A total of 42 reviewers at the Norwegian Foundation Dam were randomly assigned to receive either a general feedback report or an individual feedback report. The general feedback group received one report before the start of the reviews that contained general information about the previous call in which the reviewers participated. In the individual feedback group, the reviewers received two reports, one before the review period (based on the previous call) and one during the period (based on the current call). In the individual feedback group, the reviewers were presented with detailed information on their scoring compared with the review committee as a whole, both before and during the review period. The main outcomes were the proportion of agreement in the eligibility assessment and the average difference in scores between pairs of reviewers assessing the same proposal. The outcomes were measured in 2017 and after the feedback was provided in 2018. Results A total of 2398 paired reviews were included in the analysis. There was a significant difference between the two groups in the proportion of absolute agreement on whether the proposal was eligible for the funding programme, with the general feedback group demonstrating a higher rate of agreement. There was no difference between the two groups in terms of the average score difference. However, the agreement regarding the proposal score remained critically low for both groups. Conclusions We did not observe changes in proposal score agreement between 2017 and 2018 in reviewers receiving different feedback. The low levels of agreement remain a major concern in grant peer review, and research to identify contributing factors as well as the development and testing of interventions to increase agreement rates are still needed. Trial registration The study was preregistered at OSF.io/n4fq3.

Web-Based Personalized Nutrition System for Delivering Dietary Feedback Based on Behavior Change Techniques: Development and Pilot Study among Dietitians

Given the complex and varied nature of individual characteristics influencing dietary behaviors, personalized dietary advice may be more effective than generalized “one-size-fits-all” advice. In this paper, we describe a web-based personalized nutrition system for improving the quality of overall diet in the general adult population. The development process included identification of appropriate behavior change techniques, modification of dietary assessment method (Meal-based Diet History Questionnaire; MDHQ), selection of dietary components, and a personalized dietary feedback tool. A pilot study was conducted online among 255 dietitians. Each completed the MDHQ, received his/her own dietary feedback report, and evaluated the relevance of the report based on 12 questions using a 5-point Likert scale from “totally disagree” (score 1) to “totally agree” (score 5). The mean value of overall acceptability score of dietary feedback report was 4.2. The acceptability score was, on average, higher in plausible energy reporters (compared with implausible energy reporters), participants who printed out the report (compared with those who did not), and those spending ≥ 20 min to read the report (compared with those spending < 20 min). This is the first attempt to develop a web-based personalized nutrition system in Japan, where dietitians were broadly supportive of the dietary feedback report.

A mixed-method approach to tailor the implementation of a participatory Total Worker Health® program

PurposeTotal Worker Health® (TWH) programs, which represent a holistic approach for advancing worker safety, health and well-being, require an employer to adapt programmatic coordination and employee involvement in program design and delivery. Organizational readiness for such measures requires competencies in leadership, communication, subject expertise and worker participation. In the absence of documented methods for TWH readiness assessment, the authors developed a process to prospectively identify implementation facilitators and barriers that may be used to strengthen organizational competencies and optimize the organizational “fit” in advance.Design/methodology/approachThe mixed-method baseline assessment instruments comprised an online organizational readiness survey and a key leader interview; these were administered with key organizational and labor leaders in five US healthcare facilities. Findings about organizational resources, skills available and potential implementation barriers were summarized in a stakeholder feedback report and used to strengthen readiness and tailor implementation to the organizational context.FindingsThe research team was able to leverage organizational strengths such as leaders' commitment and willingness to address nontraditional safety topics to establish new worker-led design teams. Information about program barriers (staff time and communication) enabled the research team to respond with proactive tailoring strategies such as training on participant roles, extending team recruitment time and providing program communication tools and coaching.Originality/valueA new method has been developed for prospective organizational readiness assessment to implement a participatory TWH program. The authors illustrate its ability to identify relevant organizational features to guide institutional preparation and tailor program implementation.

Determinants of Data Use for Decision Making in Health Facilities in Kitui County, Kenya

Background: Effective management of today’s health systems depends on the critical use of data for the policy-making, planning, monitoring of services, and making decisions. The use of data has been limited and faced with inadequacy hence vital health decisions often relying on political opportunism, donor demand, and infrequently repeated national studies which are insensitive to changes occurring over a shorter timescale. Objective: This study was designed to identify determinants of utilization of routine data for decision making by health care providers in health facilities in Kitui County in Kenya. Methods: The conceptual framework was constructed from the literature review. This was a descriptive cross-sectional study adopting quantitative and qualitative research paradigms. The district hospital was purposively selected. Multi-stage cluster sampling was used to sample the health facilities in sub-counties and simple random sampling to select the respondents from different cadres in health facilities. The 110 participants completed a self-administered questionnaire. Key informant interviews, focused group discussions, observation, and analysis of documents in health facilities were applied. Recordings were transcribed and key concepts identified. Questionnaire results were edited, coded, tabulated, and analyzed using the SPSS 18. Results: Respondents interviewed were different cadres of health care providers including doctors, clinical officers, nurses, and midwives from different levels of health facilities. Among the respondents, 70% were females, and 30% males. The majority, 64% had a diploma level of education. Nurses/ midwives were the majority, making up 81% of the workforce. The overall extent of data utilization was 66% not using data and 34% use the routine generated data. The following actors influence utilization of routine data: frequency of meetings held ( =42.036, df=1, p=0.001), data storage and analyzing methods ( = 30.582, df=1, p=0.001), and continuous professional training ( = 49.782, df=1, p=0.0001). Organization of the district health system influenced routine data utilization through the frequency of support supervision ( =30.000, df=1, p=0.001), issues assessed during supervision ( =49.164, df=2, p=0.002) and feedback report from the supervisors ( =5.236, df=1, p=0.022). Conclusion: The study demonstrated limited utilization of routine data for decisions in health facilities and recommended the need for capacity building for data utilization through on job training and strengthening the curriculum in health training institutions in data-related areas. The ministry of health can standardize the parallel reporting levels and unify the reporting tools and finally ensure the districts have structured meetings, support supervision, and feedback to the health care providers.

Creating a culture of quality: our experience with providing feedback to frontline hospitalists

BackgroundOne way to provide performance feedback to hospitalists is through the use of dashboards, which deliver data based on agreed-upon standards. Despite the growing trend on feedback performance on quality metrics, there remain limited data on the means, frequency and content of feedback that should be provided to frontline hospitalists.ObjectiveThe objective of our research is to report our experience with a comprehensive feedback system for frontline hospitalists, as well as report the change in our quality metrics after implementation.Design, setting and participantsThis quality improvement project was conducted at a tertiary academic medical centre among our hospitalist group consisting of 46 full-time faculty members.Intervention or exposureA monthly performance feedback report was distributed to provide ongoing feedback to our hospitalist faculty, including an individual dashboard and a peer comparison report, complemented by coaching to incorporate process improvement tactics into providers’ daily workflow.Main outcomes and measuresThe main outcome of our study is the change in quality metrics after implementation of the monthly performance feedback reportResultsThe dashboard and rank order list were sent to all faculty members every month. An improvement was seen in the following quality metrics: length of stay index, 30-day readmission rate, catheter-associated urinary tract infections, central line-associated bloodstream infections, provider component of Healthcare Consumer Assessment of Healthcare Providers and Systems scores, attendance at care coordination rounds and percentage of discharge orders placed by 10:00.ConclusionsImplementation of a monthly performance feedback report for hospitalists, complemented by peer comparison and guidance on tactics to achieve these metrics, created a culture of quality and improvement in the quality of care delivered.

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

BackgroundIn nursing homes, 25%–75% of antibiotic days of treatment are inappropriate or unnecessary and are often continued for longer durations than necessary. In Ontario, physicians can receive a provincial audit and feedback report that provides individualised, confidential, data about their antibiotic prescribing. Objectives of this study were to explore antibiotic prescribing of nursing home physicians and the influence of the report.MethodsAll physicians who received a personalised MyPractice: Long-Term Care report from Ontario Health (Quality) (OH(Q)) in January 2019 (n=361) were eligible to participate in semistructured telephone interviews that were recorded then transcribed verbatim. Recruitment emails were sent from OH(Q) until saturation of ideas. Analysis was conducted by two team members inductively, then deductively using the theoretical domains framework, a comprehensive, theory-informed framework to classify determinants of specific behaviours.ResultsInterviews were conducted with n=18 physicians; 78% (n=14) were men, practising for an average of 27 years, with 18 years of experience working in nursing homes. Physicians worked in a median of 2 facilities (range 1–6), with 72% (n=13) in an urban setting. 56% (n=10) were medical directors for at least one home. Professional role and identity impacted all aspects of antibiotic prescribing. Key roles included being an ‘Appropriate prescriber’, an ‘Educator’ and a ‘Change driver’. For antibiotic initiation, these roles interacted with Knowledge, Skills, Beliefs about consequence, Beliefs about capabilities, and Social influence to determine the resulting prescribing behaviour. When considering the impact of interacting with the report, participants’ perceived roles interacted with Reinforcement, Social influence, and Intention. Environmental context and resources was an overarching domain.ConclusionThis theory-informed approach is being used to inform upcoming versions of existing audit and feedback initiatives. Appealing to the role that prescribers see themselves offers a unique opportunity to encourage desired changes, such as providing tools for physicians to be Educators and facilitating, particularly medical directors, to be Change drivers.

Evaluation of an OPEN Stewardship generated feedback intervention to improve antibiotic prescribing among primary care veterinarians in Ontario, Canada and Israel: protocol for evaluating usability and an interrupted time-series analysis

IntroductionAntimicrobial resistance (AMR) impacts the health and well-being of animals, affects animal owners both socially and economically, and contributes to AMR at the human and environmental interface. The overuse and/or inappropriate use of antibiotics in animals has been identified as one of the most important drivers of the development of AMR in animals. Effective antibiotic stewardship interventions such as feedback can be adopted in veterinary practices to improve antibiotic prescribing. However, the provision of dedicated financial and technical resources to implement such systems are challenging. The newly developed web-based Online Platform for Expanding Antibiotic Stewardship (OPEN Stewardship) platform aims to automate the generation of feedback reports and facilitate wider adoption of antibiotic stewardship. This paper describes a protocol to evaluate the usability and usefulness of a feedback intervention among veterinarians and assess its impact on individual antibiotic prescribing.Methods and analysisApproximately 80 veterinarians from Ontario, Canada and 60 veterinarians from Israel will be voluntarily enrolled in a controlled interrupted time-series study and their monthly antibiotic prescribing data accessed. The study intervention consists of targeted feedback reports generated using the OPEN Stewardship platform. After a 3-month preintervention period, a cohort of veterinarians (treatment cohort, n=120) will receive three feedback reports over the course of 6 months while the remainder of the veterinarians (n=20) will be the control cohort. A survey will be administered among the treatment cohort after each feedback cycle to assess the usability and usefulness of various elements of the feedback report. A multilevel negative-binomial regression analysis of the preintervention and postintervention antibiotic prescribing of the treatment cohort will be performed to evaluate the impact of the intervention.Ethics and disseminationResearch ethics board approval was obtained at each participating site prior to the recruitment of the veterinarians. The study findings will be disseminated through open-access scientific publications, stakeholder networks and national/international meetings.

User-Centered Design in Pediatric Acute Care Settings Antimicrobial Stewardship

Background Antibiotic prescribing in ambulatory care centers is increasing. Previous research suggests that 20 to 50% of antibiotic prescriptions are either unnecessary or inappropriate. Unnecessary antibiotic consumption can harm patients by increasing antibiotic resistance and drug-associated toxicities, and the reasons for such use are multifactorial. Antimicrobial Stewardship Programs (ASP) were developed to guide better use of antibiotics. A core element of ASP is to provide feedback to clinical providers. To create clinically meaningful feedback, user-center design (UCD) is a robust approach to include end-users in the design process to improve systems. Objective The study aimed to take a UCD approach to developing antibiotic prescribing feedback through input from clinicians in two ambulatory care settings. Methods We conducted two group prototyping sessions with pediatric clinicians who practice in the emergency department and urgent care settings at a tertiary care children's hospital. Participants received background on the problem of antibiotic prescribing and then were interviewed about their information needs, perceived value, and desired incentives for a prescribing feedback system. Sessions concluded with their response and recommendations to sample sections of an antibiotic feedback report including orienting material, report detail, targeted education, and resources. Results A UCD approach was found to be highly valuable in the development of a feedback mechanism that is viewed as desirable by clinicians. Clinicians preferred interpreting the data themselves with aids such as diagrams and charts over the researcher concluded statements about the clinician's behavior. Specific feedback that clinicians considered redundant were removed from the model if preexisting alerts were established. Conclusion Integrating a UCD approach in developing ASP feedback identified desirable report characteristics that substantially modified preliminary wireframes for feedback. Future research will evaluate the clinical effectiveness of our feedback reports in outpatient settings.