Feedback to Improve Rational Strategies of Antibiotic Initiation and Duration in Long Term Care (FIRST AID -LTC) - Phase 2

Study Overview
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Brief Summary
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There is a high rate of inappropriate antibiotic use in LTC facilities, with both unnecessary initiation and prolongation of treatments. Although there are challenges to rational antibiotic use in LTC, the variability in antibiotic initiation and use of prolonged treatment durations is driven by prescriber tendencies rather than resident characteristics. Audit-and-feedback is a well-established intervention to improve professional practices, and is ideally suited for use to improve antibiotic prescribing tendencies in LTC. The literature is saturated with trials indicating benefit of audit-and-feedback, but is in dire need of studies to identify methods to improve the impact of this technique. Health Quality Ontario (HQO), a key partner in the FIRST AID-LTC research program, is already providing audit-and-feedback for other inappropriate prescribing practices in LTC, and has identified antibiotic prescribing as a priority focus.

Detailed Description
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The overarching goals of FIRST AID - LTC are two-fold: Improve rational antibiotic prescribing by physicians to minimize harms among LTC residents. Advance the science of audit-and-feedback to improve physician prescribing practices. Specific Aims To advance audit-and-feedback implementation science: 1. by determining whether social comparison incentives, personal maintenance of certification incentives, and informing physicians of their report opening status (i.e., never opened a report vs. opened at least one report), can lead to increased opening of the feedback report and greater reductions in antibiotic use than standard email messaging. Anticipated Contributions to Health-Related Knowledge Although the literature is inundated with trials examining the impact of audit-and-feedback compared to usual care, there is a need for studies to improve audit-and-feedback delivery. FIRST AID-LTC will test optimal delivery and peer comparison techniques for audit-and-feedback. The knowledge learned can be extrapolated to antibiotic interventions in LTC in other provinces across Canada, as well more broadly to inappropriate medication prescribing practices in LTC. Anticipated Contributions to Health Care, Health Systems and Health Outcomes FIRST AID-LTC will lead to immediate reductions in excess antibiotic use in Ontario LTC facilities, which in turn should result in substantial reductions in direct drug costs, as well as downstream complications of allergy, organ toxicity, C. difficile infections and antimicrobial resistance. With easy transferability to other Canadian provinces, the improvements in cost-savings and patient outcomes could be massive in scope.

Official Title
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Feedback to Improve Rational Strategies of Antibiotic Initiation and Duration in Long Term Care (Phase 2)

Conditions
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Antibiotic Initiation, Antibiotic Duration

Intervention / Treatment
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* Behavioral: Social Comparison Email vs. Standard Email
* Behavioral: Maintenance Certification Email vs. Standard Email
* Behavioral: Report Opening Status Email vs. Standard Email (among previous report openers and non-openers)


Participation Criteria
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Eligibility Criteria
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To Identify an LTC Resident Inclusion Criteria: An individual having a minimum of 2 records on separate days within the quarter meeting any combination of the following criteria: a record for a non-emergency long-term care inpatient service OR an Ontario Drug Benefits record administered in long-term care Index date = The analysis will be anchored on the most recent of either of the records above with a given quarter or their date of death (whichever date is earliest) Exclusion Criteria: Non-Ontario resident at index date Invalid age (age<19 or age>115) at index date Missing or invalid sex or date of birth at index date Death date is >7 days before index date If the individual does not live in a nursing home or home for the aged Cannot be linked to a Most Responsible Physician (MRP) (see methodology below) To identify the Most Responsible Physician (MRP) Using Virtual Rostering For each patient in the above resident cohort, the study team will retrieve all records from health care providers in the 6 month period preceding the index date (180 days), keeping only records from physicians who have a specialty of 1) general practice, 2) community medicine or 3) geriatrics. Steps for MRP assignment: Step 1) The study team will first select physicians with highest count of OHIP records for the monthly management of a nursing home or home for the aged. This is completed for as many residents as possible. Step 2) If there were no monthly management fee records as described above then the physician with the highest count of non-emergency long-term care inpatient services records for each patient will be selected. This step is only applied to residents who could not be matched to a physician by Step 1. **Physician must have seen the patient one or more times in 90 days prior to and including index date to be considered MRP. This criteria is applied to ensure the physician has seen the resident within the reporting quarter. Step 3) Some patients will virtually roster to physicians in Enrollment groups, some will virtually roster to physicians that are not in a group. For these, we will recode enrollment program type to 'NOR' (not otherwise rostered) - these are likely fee for service physicians.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Assess three interventional parallel study models consisting of two intervention arms each
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: LTC Physicians Receive Social Comparison Email<br>All LTC physicians who receive a social comparison email | Behavioral: Social Comparison Email vs. Standard Email<br>* Evaluate whether emails with social comparison incentives will encourage greater report opening by physicians leading to greater reductions in antibiotic use, than a standard email without social comparison incentives<br>|
| No Intervention: LTC Physicians Do Not Receive Social Comparison Email<br>All LTC physicians who do not receive a social comparison email | |
| Active Comparator: LTC Physicians Receive Maintenance Certification Email<br>All LTC physicians who receive a maintenance certification email | Behavioral: Maintenance Certification Email vs. Standard Email<br>* Evaluate whether emails with maintenance certification incentives will encourage greater report opening by physicians leading to greater reductions in antibiotic use, than a standard email without social comparison incentives<br>|
| No Intervention: LTC Physicians Do Not Receive Maintenance Certification Email<br>All LTC physicians who do not receive a maintenance certification email | |
| Active Comparator: LTC Physician Has (or has not) Opened Prior Report<br>LTC physicians who opened (or has not opened) at least one report receive an email informing them of their report opening status | Behavioral: Report Opening Status Email vs. Standard Email (among previous report openers and non-openers)<br>* Evaluate whether emails informing physicians of their report opening status (among those who have previously opened at least one report and those who have never opened a report) will encourage greater report opening by physicians leading to greater reductions in antibiotic use, than a standard email without report opening status information<br>|
| No Intervention: LTC Physician Has (or has not) Opened Prior Report (Control)<br>LTC physicians who opened (or has not opened) at least one report receive a standard email without report opening status | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of report opening | Percentage of physicians opening/accessing the report at least once in the 3 month interval following email send out | 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| ER visit or hospitalization for infection | The percentage of a LTC physicians' patients that experienced an ER visit or hospitalization due to a potential antibiotic-related harm, including: allergy, general medicine adverse event, diarrhea, C. difficile infection, or infection with an antibiotic-resistant organism | 3 months | 
| ER visit or hospitalization for antibiotic harms | To test for harms related to decreased antibiotic use by comparing the percentage of LTC physicians' patients that experience an infection-related ER visit or admission | 3 months | 
| Net clinical impact | Measure the net clinical impact of the intervention, by comparing all-cause ER visits and hospitalizations and mortality | 3 months | 
| Anti-psychotic use | The percent reduction in anti-psychotic use | 3 months | 
| Benzodiazepine use | The percent reduction in benzodiazepines | 3 months | 
| Antibiotic initiation | Percentage of patients initiated on an antibiotic | 3 months | 
| Antibiotic duration | Percentage of antibiotic treatments prolonged > 7 days | 3 months |