Doctor of Philosophy

dissertatio

Implementing a simplified targeted feedback method to reduce fluoroquinolone prescriptions in emergency departments

Minh Le, PharmD Alyssa Christensen, PharmD, BCIDP, Brent Footer, PharmD, BCPS Providence Health System, Oregon Implementing a simplified targeted feedback method to reduce fluoroquinolone prescriptions in emergency departments Background: The CDC has proclaimed antibiotic resistance to be one of the biggest public health challenges of our time. Although fluoroquinolones (FQs) are among the most widely prescribed antibiotics in the ambulatory setting, there have been recent efforts to reduce their usage due to mounting concerns regarding their safety profile and resistance patterns. Provider audit-and-feedback has been shown to be among the most effective antimicrobial stewardship interventions, but the auditing process requires significant healthcare resources, is time consuming, and must be continuous in order to have sustained durability. The purpose of this study is to determine if targeted provider feedback and education material can reduce FQ prescriptions independent of prospective auditing and feedback. Methods: This is an ongoing, multicenter, quasi experimental study across all emergency departments of a large healthcare system within the Oregon region. The primary objective is to decrease overall FQ prescriptions. Secondary objectives include reduction of FQ prescriptions by individual prescriber and study site. Pre-intervention antibiotic data was gathered between October and December 2019. Aggregate FQ prescription data was extrapolated by individual prescriber and study site and distributed in January. Education material containing the latest guideline recommendations and relevant practice pearls was also provided. Post-intervention data was then gathered between February and March 15. This study has been approved and given exempt status by the institutional review board. Results: There was a total decrease in both FQ and all antibiotic prescriptions in the post-intervention period. Total encounters in which a FQ was prescribed was significantly lower in the post-intervention period with a difference of 2 (95% CI 1.6 to 2.3; p 1 FQ prescriptions) for each provider, there was a statistically significant reduction in FQ rates from 140 providers (78.2%) in the pre-intervention period to 66 (39.3%) in the post-intervention period (p-value=0.0084). There was not enough data to perform statistics on FQ rates per provider or between study sites. Conclusion: Targeted provider feedback led to an overall decrease in FQ prescriptions. Although the preliminary results are encouraging, more data is needed to detect the true impact of the intervention and analyze trends.https://digitalcommons.psjhealth.org/pharmacy_PGY1/1014/thumbnail.jp

Impact of real-time antimicrobial stewardship team intervention versus conventional microbiology reporting on time to appropriate antimicrobial therapy in patients with Enterobacterales bacteremia

Scott C. King Alyssa B. Christensen, Brent W. Footer, Timothy G. Shan, Kim Health, Ivor Thomas, and Margret Oethinger Impact of real-time antimicrobial stewardship team intervention versus conventional microbiology reporting on time to appropriate antimicrobial therapy in patients with Enterobacterales bacteremia. Introduction: The benefit of rapid laboratory speciation combined with real time antimicrobial stewardship team (AMT) interventions has been shown to improve patient outcomes and decrease hospital costs. The Providence Oregon region conducts direct from blood culture matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) identification, which results in decreased time to organism identification. The MALDI-TOF identification has allowed the AMT to intervene earlier than a health system using standard MALDI identification or comparable methods. The purpose of this study is to assess the impact of real time notification plus AMT intervention on clinical outcomes in patients with Enterobacterales blood stream infections (BSI). Methods: This was an IRB approved, retrospective, multi-center, pre- and post- quasi-experimental study conducted at eight acute care hospitals in the Providence Health & Services Oregon region. Adult patients (\u3e18 years old) with a diagnosed BSI caused by an Enterobacterales species were included. The control group was from August 2018 to January 2019 and the intervention group was from February 2019 to June 2019. Patients were matched based on age, gender, and admission to the ICU. Exclusion criteria included polymicrobial infection, Pitt bacteremia score \u3e1, unable to take PO therapy, and patients discharged to hospice care. During the intervention period the AMT members received real-time alerts for all blood culture speciation via a paging system. These cases where then reviewed and recommendations were made to the primary care team based off an approved protocol. The primary outcome for the study was time to de-escalation of therapy. Secondary outcomes include hospital length of stay and total duration of therapy. Results: A total of 60 patients were include in this study: 30 patients in the pre-intervention group and 30 patients in the post-intervention group. The most common age group was patients 60-69 years of age (43% vs 43%). The most common causative organism for the BSI was found to be Escherichia coli (76.7% vs 50%). During the intervention period a decrease was noted in median time to de-escalation of therapy (2.7 days vs 1.8 days, p=0.0061) and length of stay (5.3 days vs 4.3 days, p=0.0475). There was no statistical difference in the total length of therapy (combined inpatient and outpatient duration) noted between the two groups (9 days vs 9.5 days, p=1). Conclusion: The results show a statistically significant decrease in both time to de-escalation and length of stay within the intervention group due to AMT recommendations. This is in line with previous studies and also highlights the benefit de-escalation could have on length of stay in the hospital. Studies with larger samples sizes should be considered to further explore these results. IRB Status: Approvedhttps://digitalcommons.psjhealth.org/pharmacy_PGY1/1009/thumbnail.jp

The effect of simulated narratives that leverage EMR data on shared decision-making: a pilot study

BACKGROUND: Shared decision-making can improve patient satisfaction and outcomes. To participate in shared decision-making, patients need information about the potential risks and benefits of treatment options. Our team has developed a novel prototype tool for shared decision-making called hearts like mine (HLM) that leverages EHR data to provide personalized information to patients regarding potential outcomes of different treatments. These potential outcomes are presented through an Icon array and/or simulated narratives for each “person” in the display. In this pilot project we sought to determine whether the inclusion of simulated narratives in the display affects individuals’ decision-making. Thirty subjects participated in this block-randomized study in which they used a version of HLM with simulated narratives and a version without (or in the opposite order) to make a hypothetical therapeutic decision. After each decision, participants completed a questionnaire that measured decisional confidence. We used Chi square tests to compare decisions across conditions and Mann–Whitney U tests to examine the effects of narratives on decisional confidence. Finally, we calculated the mean of subjects’ post-experiment rating of whether narratives were helpful in their decision-making. RESULTS: In this study, there was no effect of simulated narratives on treatment decisions (decision 1: Chi squared = 0, p = 1.0; decision 2: Chi squared = 0.574, p = 0.44) or Decisional confidence (decision 1, w = 105.5, p = 0.78; decision 2, w = 86.5, p = 0.28). Post-experiment, participants reported that narratives helped them to make decisions (mean = 3.3/4). CONCLUSIONS: We found that simulated narratives had no measurable effect on decisional confidence or decisions and most participants felt that the narratives were helpful to them in making therapeutic decisions. The use of simulated stories holds promise for promoting shared decision-making while minimizing their potential biasing effect

Diagnosis of depression among adolescents – a clinical validation study of key questions and questionnaire

<p>Abstract</p> <p>Background</p> <p>The objective of the study is to improve general practitioners' diagnoses of adolescent depression. Major depression is ranked fourth in the worldwide disability impact.</p> <p>Method/Design</p> <p>Validation of 1) three key questions, 2) SCL-dep6, 3) SCL-10, 4) 9 other SCL questions and 5) WHO-5 in a clinical study among adolescents. The Composite International Diagnostic Interview (CIDI) is to be used as the gold standard interview. The project is a GP multicenter study to be conducted in both Norway and Denmark. Inclusion criteria are age (14–16) and fluency in the Norwegian and Danish language. A number of GPs will be recruited from both countries and at least 162 adolescents will be enrolled in the study from the patient lists of the GPs in each country, giving a total of at least 323 adolescent participants.</p> <p>Discussion</p> <p>The proportion of adolescents suffering from depressive disorders also seems to be increasing worldwide. Early interventions are known to reduce this illness. The earlier depression can be identified in adolescents, the greater the advantage. Therefore, we hope to find a suitable questionnaire that could be recommended for GPs.</p