Pragmatic Factorial Cluster Trial of Framing and Comparators for Audit and Feedback

Study Overview
=================
Brief Summary
-----------------
Health Quality Ontario (HQO) is the provincial advisor on quality in health care. HQO currently conducts audit and feedback as a key quality improvement strategy. For example, it offers physicians working in long-term care homes with access to practice reports detailing rates of high-risk prescribing in comparison with others in Ontario and suggested change ideas. Research shows that providing this kind of feedback can lead to improvements in care. However, the size of these improvements depends how the feedback is presented. For instance, prior research suggests that how the results are 'framed' and what sort of benchmark the recipient is compared to may each affect how the physician will respond. This factorial trial tests each of these aspects of feedback design in the context of practice reports that nursing home physicians have already signed up to receive quarterly.

Official Title
-----------------
Pragmatic Factorial Cluster Trial of Framing and Comparators for Audit and Feedback Aiming to Address High Risk Prescribing in Nursing Homes in Ontario

Conditions
-----------------
High-risk Prescribing in Nursing Homes

Intervention / Treatment
-----------------
* Behavioral: Audit and Feedback


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: a physician licensed by the College of Physicians and Surgeons of Ontario (CPSO); practice in at least one LTC facility in Ontario;. have voluntarily signed up to receive an HQO practice report Exclusion Criteria: n/a
Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm 1, Positive Framing<br>All metrics in the audit and feedback practice reports presented with 'positive' framing, where the proportion of patients safe from risk (i.e., appropriate/desirable prescribing behaviours) is described. | Behavioral: Audit and Feedback<br> <br> |
| Experimental: Arm 2, Negative Framing<br>All metrics in the audit and feedback practice reports presented with 'negative' framing, where the proportion of patients at risk (i.e., due to inappropriate/undesirable prescribing behaviours) is described. | Behavioral: Audit and Feedback<br> <br> |
| Experimental: Arm 3, Top Quartile Comparator<br>All metrics in the audit and feedback practice reports presented and the physician-recipient's performance is compared against the 75th percentile for performance by physicians working in nursing homes in the province for each metric. | Behavioral: Audit and Feedback<br> <br> |
| Experimental: Arm 4, Average Comparator<br>All metrics in the audit and feedback practice reports presented and the physician-recipient's performance is compared against the average performance by physicians working in nursing homes in the province for each metric. | Behavioral: Audit and Feedback<br> <br> |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| CNS-active medication prescribing | monthly number of CNS-active medications per resident (antipsychotics, opioids, benzodiazepines or antidepressants (including TCAs and trazodone)) | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Benzodiazepine (or z-drug) prescribing | days supplied (continuous) | 6 months | 
| Benzodiazepine (or z-drug) rates | monthly proportion | 6 months | 
| Antipsychotic rates | monthly proportion | 6 months | 
| Antipsychotic prescribing | days supplied (continuous) | 6 months | 
| Mean Antipsychotic dose | Dose equivalent of antipsychotic dispensed (continuous) | 6 months | 
| Mean Benzodiazepine dose | Dose equivalent of benzodiazepine dispensed (continuous) | 6 months | 
| 3+ CNS-active medications | monthly proportion supplied three or more meds from the following classes: antipsychotics, opioids, benzodiazepines, or antidepressants (including TCAs and trazodone). | 6 months | 
| Anti-depressant prescribing | days supplied (continuous) - balance measure | 6 months | 
| Anti-acid prescribing | days supplied (continuous) - tracer outcome | 6 months | 
| Statin prescribing | days supplied (continuous) - tracer outcome | 6 months |