Federal Register / Vol. 76, No. 58 / Friday, March 25, 2011 / Notices 16779 

via e-mail, and may include a telephone 

non-response follow-up. Telephone 

non-response follow-up for mailed 

surveys is not counted as a telephone 

survey in Exhibit 1. Not more than 600 

persons, over 3 years, will participate in 

telephone surveys that will take about 

40 minutes. Web-based surveys will be 

conducted with no more than 3,000 

persons and will require no more than 

10 minutes to complete. About 1,500 

persons will participate in focus groups 

which may last up to two hours, while 

in-person interviews will be conducted 

with 600 persons and will take about 1 

hour. Automated data collection will be 

conducted for about 1,500 persons and 

could take up to 1 hour. Cognitive 

testing will be conducted with about 

600 persons and is estimated to take 1⁄2; 

hours to complete. The total burden 

over 3 years is estimated to be 8,900 

hours (about 2,967 hours per year). 

Exhibit 2 shows the estimated cost 

burden over 3 years, based on the 

respondent’s time to participate in these 

research activities. The total cost burden 

is estimated to be $298,239. 

EXHIBIT 1—ESTIMATED BURDEN HOURS OVER 3 YEARS

Type of information collection Number of 

respondents 

Number of 

responses per 

respondent 

Hours per 

response 

Total burden 

hours 

Mail/e-mail * .............................................................................................. 6,000 1 20/60 2,000 

Telephone ................................................................................................ 600 1 40/60 400 

Web-based ............................................................................................... 3,000 1 10/60 500 

Focus Groups .......................................................................................... 1,500 1 2.0 3,000 

In-person .................................................................................................. 600 1 1.0 600 

Automated ** ............................................................................................ 1,500 1 1.0 1,500 

Cognitive Testing *** ................................................................................ 600 1 1.5 900 

Totals ................................................................................................ 13,800 na na 8,900 

* May include telephone non-response follow-up in which case the burden will not change. 

** May include testing of database software, CAPI software or other automated technologies. 

*** May include cognitive interviews for questionnaire or toolkit development, or ‘‘think aloud’’ testing of prototype Web sites. 

EXHIBIT 2—ESTIMATED COST BURDEN OVER 3 YEARS

Type of information collection Number of 

respondents 

Total burden 

hours 

Average wage 

rate * 

Total cost 

burden 

Mail/e-mail ................................................................................................ 6,000 2,000 $33.51 $67,020 

Telephone ................................................................................................ 600 400 33.51 13,404 

Web-based ............................................................................................... 3,000 500 33.51 16,755 

Focus Groups .......................................................................................... 1,500 3,000 33.51 100,530

In-person .................................................................................................. 600 600 33.51 20,106

Automated ................................................................................................ 1,500 1,500 33.51 50,265 

Cognitive Testing ..................................................................................... 600 900 33.51 30,159 

Totals ................................................................................................ 13,800 8,900 na 298,239 

* Based upon the average wages for 29–000 (Healthcare Practitioner and Technical Occupations), ‘‘National Compensation Survey: Occupational Wages in the United States, May 2009,’’ U.S. Department of Labor, Bureau of Labor Statistics. 

Estimated Annual Costs to the Federal 

Government 

Information collections conducted 

under this generic clearance will in 

some cases be carried out under 

contract. Assuming four data collections 

per year (either mail/e-mail, telephone, 

Web-based or in-person) at an average 

cost of $150,000 each, and two focus 

groups, automated data collections or 

lab experiments at an average cost of 

$20,000 each, total contract costs could 

be $640,000 per year. 

Request for Comments 

In accordance with the above-cited 

Paperwork Reduction Act legislation, 

comments on AHRQ’s information 

collection are requested with regard to 

any of the following: (a) Whether the 

proposed collection of information is 

necessary for the proper performance of 

AHRQ healthcare research and 

healthcare information dissemination 

functions, including whether the 

information will have practical utility; 

(b) the accuracy of AHRQ’s estimate of 

burden (including hours and costs) of 

the proposed collection(s) of 

information; (c) ways to enhance the 

quality, utility, and clarity of the 

information to be collected; and (d) 

ways to minimize the burden of the 

collection of information upon the 

respondents, including the use of 

automated collection techniques or 

other forms of information technology. 

Comments submitted in response to 

this notice will be summarized and 

included in the Agency’s subsequent 

request for OMB approval of the 

proposed information collection. All 

comments will become a matter of 

public record. 

Dated: March 15, 2011. 

Carolyn M. Clancy, 

Director. 

[FR Doc. 2011–6855 Filed 3–24–11; 8:45 am] 

BILLING CODE 4160–90–M 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Agency for Healthcare Research and 

Quality 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Agency for Healthcare Research 

and Quality, HHS. 

ACTION: Notice. 

SUMMARY: This notice announces the 

intention of the Agency for Healthcare 

Research and Quality (AHRQ) to request 


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16780 Federal Register / Vol. 76, No. 58 / Friday, March 25, 2011 / Notices 

that the Office of Management and 

Budget (OMB) approve the proposed 

information collection project: 

‘‘Connecting Primary Care Practices with 

Hard-to-Reach Adolescent Populations.’’ 

In accordance with the Paperwork 

Reduction Act, 44 U.S.C. 3501–3521, 

AHRQ invites the public to comment on 

this proposed information collection. 

This proposed information collection 

was previously published in the Federal 

Register on January 13th, 2011 and 

allowed 60 days for public comment. No 

comments were received. The purpose 

of this notice is to allow an additional 

30 days for public comment. 

DATES: Comments on this notice must be 

received by April 25, 2011. 

ADDRESSES: Written comments should 

be submitted to: AHRQ’s OMB Desk 

Officer by fax at (202) 395–6974 

(attention: AHRQ’s desk officer) or by email at 0IRA_submission@omb.eop.gov 

(attention: AHRQ’s desk officer). 

Copies of the proposed collection 

plans, data collection instruments, and 

specific details on the estimated burden 

can be obtained from the AHRQ Reports 

Clearance Officer. 

FOR FURTHER INFORMATION CONTACT: 

Doris Lefkowitz, AHRQ Reports 

Clearance Officer, (301) 427–1477, or by 

e-mail at 

doris.lefkowitz@AHRQ.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

Proposed Project 

Connecting Primary Care Practices With 

Hard-to-Reach Adolescent Populations 

The overall goal of this exploratory 

project is to improve the quality of 

adolescent health care. The project will 

address suboptimal adolescent care with 

respect to health risk behaviors, which 

can have serious health consequences. 

In particular, failure to address health 

risk behaviors among adolescents (e.g., 

smoking, substance abuse, poor diets, 

physical inactivity, and high-risk sexual 

behavior) contributes significantly to 

increased morbidity and mortality. 

Adolescents (11–17 years of age) 

constitute 17% of the population of the 

U.S., but they are responsible for only 

7% of medical office visits. As a result, 

primary care providers have relatively 

less opportunity to evaluate and counsel 

adolescents in their offices than most 

other patients. Even when adolescents 

receive routine health care, open 

communication with their health care 

providers may be problematic. A 

national survey found that the majority 

of adolescent boys and girls in the 

U.S. report at least 1 of 8 potential 

health risks, but most (63%) had not 

spoken to their doctor about any of 

these (Klein & Wilson, 2002). Improved 

engagement and communication 

between adolescents and their primary 

care providers could increase the 

likelihood that effective preventive 

services and health care are provided. It 

could also improve the efficiency of 

health care services for adolescents, in 

terms of appointments kept and 

adherence to recommended screening or 

treatment recommendations. 

Technological interventions to 

improve care may be particularly 

appropriate for adolescents, since they 

are typically the early adopters of new 

technology (Skinner, Biscope, Poland, & 

Goldberg, 2003). Use of in-office 

electronic screeners before 

appointments has proven useful (Olson, 

Gaffney, Lee, &Starr 2008; Salerno, 

2008; Yi, Martyn, Salerno, & DarlingFisher,). Outside of the office, youth 

have increasingly turned to the internet 

for health-related information, and have 

also rapidly adopted mobile technology 

(Lenhart. Line, Campbell. & Purcell, 

2010) and social media (Lenhart, 

Purcell, Smith& Zickuhr, 2010). Health 

plans (e.g., Kaiser Permanente) and 

practices (Hawn, 2009) have conducted 

early work in applying patient-centered 

web and mobile technologies. These 

projects have included interventions to 

decrease patient no-show rates, increase 

the use of sunscreen, and engage 

adolescents in diabetes management. 

Much work remains to be done, 

however, in understanding how primary 

care practices can best embrace 

advances in communications and 

information technology to improve 

health outcomes for adolescent patients. 

This project has the following goals: 

(1) Explore the benefits of 

supplementing an electronic in-office 

pre-visit screener with a set of Web 

technologies for adolescent outreach 

and engagement outside of office visits. 

a. The Rapid Assessment for 

Adolescent Preventive Services© 

(RAAPS), as described below, will be 

used for in-office pre-visit screening. 

b. The Web technologies will include 

(i) a Web page for more static content 

such as information about practices and 

health-related commentary from 

practice clinicians and staff, (ii) a 

Facebook page for social interaction 

about health topics including topical 

content that will engage adolescents in 

conversations about general, not 

personal, health behaviors and 

encouraging youth to discuss these 

issues with their primary care 

practitioners at clinic visits, and (iii) a 

Twitter site that will allow youth to use 

mobile phones with text messaging to 

subscribe to Facebook posts. 

(2) Increase adolescent visits to 

primary care and identification of health 

risks during visits. 

(3) Promote healthier behavior in four 

domains: (1) Diet, (2) physical activity, 

(3) substance abuse (smoking, alcohol, 

and use of other recreational drugs), and 

(4) sexual health. 

(4) Develop a manual of best practices 

for these components in primary care. 

This study is being conducted by 

AHRQ through its contractor, State 

Network of Colorado Ambulatory 

Practices and Partners (SNOCAP–USA), 

a practice-based research network 

(PBRN) based at the University of 

Colorado Denver, pursuant to AHRQ’s 

statutory authority to conduct and 

support research on healthcare and on 

systems for the delivery of such care, 

including activities with respect to the 

quality, effectiveness, efficiency, 

appropriateness and value of healthcare 

services and with respect to clinical 

practice, including primary care and 

practice-oriented research. 42 U.S.C. 

299a(a)(1) and (4). 

Method of Collection 

This project will be conducted in four 

primary care practice sites that have a 

substantial number of adolescent 

patients. The following activities and 

data collections will be implemented: 

(1) RAAPS questionnaire. Practices 

will use the 21-item RAAPS 

questionnaire for in-office pre-visit 

screening. RAAPS was developed by the 

University of Michigan Regional 

Alliance for Healthy Schools to elicit 

information about risky adolescent 

behaviors that should be addressed, but 

often are missed, in primary care. It is 

available in both paper and online 

forms; the latter will be used in this 

project. The primary purpose of the 

RAAPS questionnaire is to improve 

clinical recognition of risky behaviors so 

that personal counseling may be 

provided. 

(2) Process measures for web 

technologies. For each of the web 

technologies used (the web page, 

Facebook page, and Twitter site), data 

on the number of unique visitors, the 

frequency of their visits, and their 

activities (e.g. whether they create a new 

post or ‘‘like’’ postings) will be obtained 

by the research team. These data will 

not include personally identifiable 

information (e.g. the user’s username, 

birth date, IP address, etc.). OMB 

clearance is not required for this data 

collection. 

(3) Extraction of medical record data. 

Staff members at each practice will use 

their clinical information systems to 

extract medical record data for use by 

the research team. Data to be extracted 


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consist of (a) Contact information for 

patients seen in the 18 months prior to 

the start date for implementation of 

RAAPS and the web technologies. This 

is the sample frame for the adolescent 

behavior and communication survey. 

These data will be used by the project 

staff to prepare the recruitment 

mailings. (b) Clinic notes for adolescents 

seen in the 12 months prior to 

implementation start date and for 

adolescents seen in the 12 months 

following the implementation start date. 

Clinic notes will be made accessible 

either by pulling paper charts or 

printing notes from electronic medical 

records. The notes will be reviewed and 

abstracted by the research team to assess 

whether the intervention had the 

intended effect of increasing adolescent 

visits to primary care and the 

identification of potential health risks 

during visits. 

(4) Consent-assent form. This is used 

to obtain consent from the parent or 

guardian and assent from the adolescent 

to participate in the adolescent behavior 

and communication survey. 

(5) Adolescent behavior and 

communication survey. A questionnaire 

(by mail, with an online option) will be 

administered twice to adolescent 

patients for whom consent-assent has 

been obtained: Once at baseline and 

again six months after the intervention. 

The purpose of this survey is to measure 

the adolescent’s level of comfort with 

discussing their health with their 

clinician and their level of satisfaction 

with their medical care, and to see how 

this changes after the intervention. 

(6) Post-visit satisfaction survey. 

Practices will provide adolescents with 

a brief, post-card sized anonymous 

questionnaire at every office visit during 

the study period. The purpose is to 

assess the perceived utility of the 

RAAPS questionnaire, and whether the 

visit was related to the project’s web 

technologies. 

(7) Adolescent focus groups. Eight 

adolescents (two from each practice) 

will provide feedback on the web page, 

Facebook, and Twitter pages. There will 

be one in-person group meeting preimplementation, followed by a series of 

3 additional asynchronous group 

discussions conducted via the web at 

three-month intervals. These provide a 

process for user-centered design and 

refinement of the of web technologies. 

(8) Adolescent ‘‘think-aloud’’ sessions. 

These sessions, which will be 

conducted near the end of the study 

period, will involve a set of eight 

adolescent patients (two from each 

practice) that did not participate in the 

focus groups. Subjects will come to the 

practice for individual sessions in 

which they will be asked to say aloud 

what they are thinking about the web 

technologies as they navigate them as 

they typically would. The purpose is to 

assess the perceived utility of the 

components of the web, Facebook, and 

Twitter pages. 

(9) Clinician semi-structured 

interviews. At each site, individual 

interviews will be conducted with two 

clinicians (eight clinicians total). The 

purpose is to assess clinician 

perceptions of the effects of the RAAPS 

questionnaire and the web technologies 

on the clinical encounter and the care 

they provide. 

(10) Administrator-staff semistructured interviews. At each site, 

semi-structured interviews will be 

conducted with the practice manager 

and a front-desk staff member. The 

purpose is to assess the effect of the 

interventions on the check in process 

and other business processes. 

(11) Semi-structured interviews for 

the draft manual. The draft manual of 

best practices in primary care for 

adoption of web and assessment 

technologies (such as the RAAPS 

questionnaire) developed by the 

research team will be sent to the 

practice manager and the practice 

director (lead clinician) of each site. 

Their feedback will be solicited by 

telephone roughly two weeks later. This 

‘‘member checking’’ enhances the 

validity of the manual’s conclusions and 

recommendations. 

The results from this exploratory 

project will be used to inform 

development of a manual to assist 

primary care practices in adopting 

interventions to improve the 

effectiveness of their outreach to and 

interactions with adolescent patients. In 

addition, information collected in the 

RAAPS questionnaire may be used by 

clinicians to improve clinical care. 

Estimated Annual Respondent Burden 

Exhibit 1 shows the estimated 

annualized burden hours for the 

respondents’ time to participate in this 

research. Among the 776 adolescent 

patients across the 4 participating 

practices, 310 are expected to complete 

the RAAPS questionnaire, which takes 

about 12 minutes to complete, at each 

office visit (on average there will be an 

estimated 1.25 office visits per patient). 

Practice staff members will perform the 

extraction of medical record data preimplementation, and again postimplementation, for 50 patients. This 

task is estimated to require 4 hours per 

practice (slightly less than 5 minutes per 

patient record). 

The consent-assent form for 

participation in the adolescent behavior 

and communication survey will be sent 

to the homes of all adolescents in the 

practice’s panels. The estimated average 

time for reading and responding to the 

form is 15 minutes. The adolescent 

behavior and communication survey 

will be completed twice, pre and post 

intervention, by 186 adolescent patients 

and requires 15 minutes to complete. 

The post-visit satisfaction survey will be 

completed by each of the 310 

participating adolescent patients after 

each office visit and will take 1 minute 

to complete. 

A series of four focus groups will be 

held with 8 adolescent patients over the 

course of the study period with each 

session lasting about 1.5 hours. In 

addition to the focus groups one ‘‘think 

aloud’’ session will be held with a group 

of 8 adolescent patients and will also 

take 1.5 hours. 

Feedback from the practice staff and 

the clinicians will be obtained through 

3 different semi-structured interviews. 

Two staff members from each of the 4 

practices will participate in these 

interviews. The clinician and 

administrator-staff semi-structured 

interviews will each last 30 minutes. 

Semi-structured interviews for the draft 

manual will require about one hour total 

(30 minutes to review the manual and 

30 minutes to participate in the 

interview). The total annualized burden 

is estimated to be 479 hours. 

Exhibit 2 shows the estimated 

annualized cost burden associated with 

the respondents’ time to participate in 

this research. The total annual cost 

burden is estimated to be $7,980. 

EXHIBIT 1—ESTIMATED ANNUALIZED BURDEN HOURS

Activity/data collection Number of 

respondents 

Number of 

responses per 

respondent 

Hours per 

response 

Total 

burden 

hours 

RAAPS questionnaire ...................................................................................... 310 1.25 12/60 78 

Extraction of medical record data .................................................................... 4 2 4 32 


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EXHIBIT 1—ESTIMATED ANNUALIZED BURDEN HOURS—Continued 

Activity/data collection Number of 

respondents 

Number of 

responses per 

respondent 

Hours per 

response 

Total 

burden 

hours 

Consent-assent form ....................................................................................... 776 1 15/60 194 

Adolescent behavior and communication survey ............................................ 186 2 15/60 93 

Post-visit satisfaction survey ............................................................................ 310 1.25 1/60 6 

Adolescent focus groups ................................................................................. 8 4 1.5 48 

Adolescent ‘‘think-aloud’’ sessions .................................................................. 8 1 1.5 12 

Clinician semi-structured interviews ................................................................ 4 2 30/60 4 

Administrator-staff semi-structured interviews ................................................. 4 2 30/60 4 

Semi-structured interviews for the draft manual .............................................. 4 2 1 8 

Total .......................................................................................................... 1,614 na na 479 

EXHIBIT 2—ESTIMATED ANNUALIZED COST BURDEN

Activity/data collection cost Number of 

respondents 

Total 

burden 

hours 

Average hourly wage rate 1Total 

burden 

RAAPS questionnaire ...................................................................................... 310 78 2 $9.01 $703 

Extraction of medical record data .................................................................... 4 32 3 18.15 581 

Consent-assent form ....................................................................................... 776 194 4 22.11 4,289 

Adolescent behavior and communication survey ............................................ 186 93 2 9.01 838 

Post-visit satisfaction survey ............................................................................ 310 6 2 9.01 54 

Adolescent focus groups ................................................................................. 8 48 2 9.01 432 

Adolescent ‘‘think-aloud’’ sessions .................................................................. 8 12 2 9.01 108 

Clinician semi-structured interviews ................................................................ 4 4 5 84.53 338 

Administrator-staff semi-structured interviews ................................................. 4 4 6 29.63 119 

Semi-structured interviews for the draft manual .............................................. 4 8 7 64.75 518 

Total .......................................................................................................... 1,614 479 na 7,980 

1 Mean hourly and wage costs for Colorado were derived from the Bureau of Labor and Statistics National Compensation Survey for May 2009 

(http://www.bls.gov/oes/current/oes_co.htm). 2 Hourly rate for an entry level worker (occupation code 35–0000) estimates the cost of time for adolescents, although many will not be employed. 3 Hourly rate for medical records and health information technician (29–2071). 

3 Hourly rate for medical records and health information technician (29–2071). 

4 Hourly rate for the mean for all occupations (00–0000) estimates the cost of time for the parent or guardian of the adolescent.

5Average of hourly rates for a family medicine practitioner (29–1062) and a general internist (29–1063). 

6Average of (1) the hourly rate for a medical and health services manager (11–9111) and (2) the average of the hourly rates for a receptionist 

(43–4171) and a medical assistant (31–9092). 7Average of (1) the hourly rate for a medical and health services manager (11–9110) and (2) the average of the hourly rates for a family medicine practitioner (29–1062) and a general internist (29–1063). 

Estimated Annual Costs to the Federal 

Government 

Exhibit 3 shows the estimated total 

and annualized cost to the Federal 

Government for conducting this 

research. These estimates include the 

costs associated with the project such as 

the preparation of survey administration 

procedures, labor costs, administrative 

expenses, costs associated with copying, 

postage, and telephone expenses, data 

management and analysis, and 

preparation of final reports. The 

annualized and total costs are identical 

since the data collection period will last 

for one year. The total cost is estimated 

to be $436,524. 

EXHIBIT 3—ESTIMATED TOTAL AND ANNUALIZED COST

Cost component Total cost Annualized 

cost 

Project Development ............................................................................................................................................... $72,364 $72,364 

Data Collection Activities ......................................................................................................................................... 48,904 48,904 

Data Processing and Analysis ................................................................................................................................. 73,937 73 937 

Publication of Results .............................................................................................................................................. 21,890 21,890 

Project Management ................................................................................................................................................ 75,733 75,733 

Overhead ................................................................................................................................................................. 143,696 143,696 

Total .................................................................................................................................................................. 436,524 436,524 

Request for Comments 

In accordance with the Paperwork 

Reduction Act, comments on AHRQs 

information collection are requested 

with regard to any of the following: 

(a) Whether the proposed collection of 

information is necessary for the proper 

performance of AHRQ healthcare 

research and healthcare information 


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Federal Register / Vol. 76, No. 58 / Friday, March 25, 2011 / Notices 16783 

dissemination functions, including 

whether the information will have 

practical utility; (b) the accuracy of 

AHRQ’s estimate of burden (including 

hours and costs) of the proposed 

collection(s) of information; (c) ways to 

enhance the quality, utility, and clarity 

of the information to be collected; and 

(d) ways to minimize the burden of the 

collection of information upon the 

respondents, including the use of 

automated collection techniques or 

other forms of information technology. 

Comments submitted in response to 

this notice will be summarized and 

included in the Agency’s subsequent 

request for OMB approval of the 

proposed information collection. All 

comments will become a matter of 

public record. 

Dated: March 15, 2011. 

Carolyn M. Clancy, 

Director. 

[FR Doc. 2011–6857 Filed 3–24–11; 8:45 am] 

BILLING CODE 4160–90–M 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Agency for Healthcare Research and 

Quality 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Agency for Healthcare Research 

and Quality, HHS. 

ACTION: Notice. 

SUMMARY: This notice announces the 

intention of the Agency for Healthcare 

Research and Quality (AHRQ) to request 

that the Office of Management and 

Budget (OMB) approve the proposed 

information collection project: ‘‘Using 

Nursing Home Antibiograms to Improve 

Antibiotic Prescribing and Delivery.’’ In 

accordance with the Paperwork 

Reduction Act, 44 U.S.C. 3501–3521, 

AHRQ invites the public to comment on 

this proposed information collection. 

DATES: Comments on this notice must be 

received by May 24, 2011. 

ADDRESSES: Written comments should 

be submitted to: Doris Lefkowitz, 

Reports Clearance Officer, AHRQ, by 

e-mail at 

doris.lefkowitz@AHRQ.hhs.gov. 

Copies of the proposed collection 

plans, data collection instruments, and 

specific details on the estimated burden 

can be obtained from the AHRQ Reports 

Clearance Officer. 

FOR FURTHER INFORMATION CONTACT: 

Doris Lefkowitz, AHRQ Reports 

Clearance Officer, (301) 427–1477, or by 

e-mail at 

doris.lefkowitz@AHRQ.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

Proposed Project 

Using Nursing Home Antibiograms To 

Improve Antibiotic Prescribing and 

Delivery 

Overuse and inappropriate use of 

antibiotics, particularly broad-spectrum 

antibiotics, is recognized as a serious 

problem in nursing homes (NHs). The 

adverse consequences of inappropriate 

prescribing practices including drug 

reactions/interactions, secondary 

complications, and the emergence of 

multi-drug resistant organisms, have 

become more common. For example, in 

one point-prevalence survey of 117 NH 

residents, 43 percent were culturepositive for one or more antimicrobialresistant pathogens, including 

methicillin-resistant staphylococcus 

aureas (24 percent), extended-spectrum 

+-lactamase-producing klebsiella 

pneumoniae (18 percent) or Escherichia 

coli (15 percent), and vancomycinresistant enterococci. Inappropriate 

overprescribing and overuse of broadspectrum antibiotics, when narrower 

spectrum drugs would suffice, are 

believed to be important contributors to 

this problem. 

Physicians typically begin antibiotics 

for suspected infections in NH residents 

without waiting for bacteriology 

laboratory culture results. If there is a 

clinical failure (e.g., patient does not 

improve), the physician may request a 

bacteriology laboratory test, but will 

often try a second antibiotic without 

waiting for culture confirmation. If a NH 

resident is deteriorating, many NHs do 

not try a second antibiotic but will 

instead transfer the patient to a hospital 

emergency department (ED). In the ED, 

physicians must make quick decisions 

about whether to continue the first 

antibiotic prescribed in the NH or start 

another, again often without culture 

results. 

NH patients are transferred to EDs for 

all sorts of medical reasons, including 

but not limited to infections. When NH 

patients arrive at an ED, physicians may 

identify a urinary tract, respiratory, or 

other infection that was not the primary 

reason for the ED visit. Thus, patients 

may not leave the NH with a suspected 

bacterial infection or taking any 

antibiotics, but an infection is suspected 

in the ED and the first antibiotic is 

prescribed there. 

As a result of the above complexities, 

NHs are increasingly recognized as 

reservoirs of antibiotic-resistant 

bacteria. Antibiograms aggregate 

information for an entire institution 

over a period of several months or a 

year. They display the organisms 

present in clinical specimens sent for 

laboratory testing, and the susceptibility 

of each organisms to an array of 

antibiotics. Antibiograms are routinely 

prepared by hospital laboratories but are 

not routine in the NH setting. The 

culmination of this project will be a NH 

Antibiogram toolkit so that NHs can 

create facility-specific antibiograms that 

are cost-effective and helpful to 

physicians who must make antibiotic 

prescription decisions without 

bacteriology laboratory test results, for 

patients in NHs, and for patients who 

are transferred from the NH to the ED. 

Outcomes of interest for antibiograms 

include reduced reliance on broadspectrum antibiotics as initial therapy, 

and fewer clinical failures of antibiotics 

that are first prescribed. The 

development of a toolkit will be the first 

step in this process; future studies are 

required to test the toolkit and, 

subsequently, the effectiveness of NH 

antibiograms. 

The objectives of the study are to: 

1. Develop a standardized method for 

determining antibiotic susceptibility 

patterns and developing NH-specific 

antibiograms; 

2. Extract preliminary data from NH 

facilities of various sizes and types to 

guide the development of the draft 

toolkit; and 

3. Develop a draft toolkit to guide a 

wide variety of sizes and types of NHs 

in developing and sharing antibiogram 

information with prescribing providers 

(i.e., physicians and physician 

extenders) and EDs. 

Three NHs and one ED will 

participate in this study, which will be 

conducted in two phases. The first 

phase will include one small NH and 

one ED and is intended to test the data 

collection instruments and to draft the 

initial toolkit, including the creation of 

a NH specific antibiogram. The second 

phase will expand the study by adding 

two larger NHs, while retaining the 

same NH and ED as in the first phase 

and is intended to further test the data 

collection instruments and refine the 

draft toolkit. Each phase will use the 

same methods and data collections. 

This study is being conducted by the 

Agency for Healthcare Research and 

Quality through its contractors, Abt 

Associates and the Brigham and 

Women’s Hospital ED, pursuant to the 

Agency for Healthcare Research and 

Quality’s statutory authority to conduct 

and support research on healthcare and 

on systems for the delivery of such care, 

including activities with respect to the 

quality, effectiveness, efficiency, 

appropriateness and value of healthcare 


erowe on DSK5CLS3C1PROD with NOTICES