reducing inappropriate antibiotic prescribing in nursing homes

Reducing Inappropriate Antibiotic Prescribing in Nursing HomesRosanna Bertrand1, Lauren Olsho1,Sheryl Zimmerman2, Louise Hadden1, Alrick Edwards1, Philip Sloane2, Madeline Mitchell2, Donna Hurd1

1Abt Associates Inc., US Health Division, Cambridge, MA, 2 University of North Carolina Chapel Hill, NC.

Abt Associates | pg 2

Presenter DisclosuresRosanna M. Bertrand

I have no personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months to disclose.


Background Antibiotics are among the most commonly prescribed

pharmaceuticals in nursing homes (NHs).

• A high proportion are inappropriate causing major public health concerns.

They result in multiple adverse consequences including increased risk of morbidity and mortality.

Loeb and colleagues developed minimum criteria (LMC) for the initiation of antibiotics in NH settings.


Loeb Minimum Criteria A set of minimum criteria to assess symptoms and signs of:

– Skin/soft-tissue infections

– Respiratory infections

– Urinary tract infections

– Fever of unknown origin

Example of LMC for urinary tract infections with catheter – Temperature on day of prescription greater than 2.4 degrees above

average routine temperature or greater than 100 degrees Fahrenheit;

OR

– New case of costovertebral angle tenderness, or symptoms of rigors, or new symptoms of delirium.


Quality Improvement (QI) Intervention Program

Abt/UNC developed a QI intervention that integrated:

• An evidence-based conceptual model

• A community-based participatory approach

• Guidelines for when to prescribe (LMC)

• Guidelines for when not to prescribe (12 conditions)

− For example, a positive culture in an asymptomatic patient


QI Intervention Program Multi-Level Target Audience

Prescribers– Medical Doctors– Nurse Practitioners– Physician Assistants

Other NH staff – Administrators– Nurses

Residents and Families


QI Intervention ProgramMulti-Method Approach

On-Site Trainings

Pocket Cards


QI Intervention ProgramPocket Card


QI Intervention ProgramMulti-Method Approach

On-Site Trainings

Pocket Cards

Written Materials and Forms

Meetings/Gatherings


Evaluation Design Quasi-experimental design

Six intervention NHs - part of UNC consortium

Six comparison NHs - matched by bed size and profit status

Three-month baseline and six-month intervention periods

N = 3,568 prescriptions over 336,522 resident days


Primary Outcomes Antibiotic prescribing rates

• Overall and by infection type: urinary, skin/soft tissue, and respiratory

Prescriber adherence to the LMC

• Conducted on a random sample of prescribing events

• Developed an indication-specific algorithm based on LMC

− Coded whether or not the LMC were met


Analyses Prescribing Rates Related to LMC Adherence

• Multivariate analyses using three months baseline from intervention and comparison site data

• Dependent variable: count of prescriptions per resident per day

• Primary explanatory variable: NH-level measure of percent of prescriptions/month meeting the LMC

Impact of the QI Intervention

• Multivariate difference-in-differences analyses to determine:

− Increase in adherence to the LMC

− Decrease in antibiotic prescribing rates


Results - LMC Adherence

0 5 10 15 20 250.0

0.5

1.0

1.5

2.0

2.5

3.0

All Indications

Percent Adherence to Loeb Criteria

Pres

crip

tions

per

100

0 Re

siden

t-Da

ys

0 5 10 15 20 25 30 35 40 450.0

0.2

0.4

0.6

0.8

1.0

1.2

Urinary Tract Infection


Pres

crip

tions

per

100

0 Re

siden

t-Da

ys

0 1 2 3 4 5 6 7 80.0

0.2

0.4

0.6

0.8

1.0

1.2

Respiratory Infection


Pres

crip

tions

per

100

0Re

siden

t-Da

ys

20 30 40 50 60 70 80 90 1000.0

0.1

0.2

0.3

0.4

0.5

Skin/Soft Tissue Infection


Pres

crip

tions

per

100

0 Re

siden

t-Da

ys


Results – QI Intervention

Mar Apr May Jun Jul Aug Sep Oct Nov10.0

10.2

10.4

10.6

10.8

11.0

11.2

11.4

11.6

11.8

Intervention Group All Indications Comparison Group All IndicationsIntervention Group Urinary Comparison Group UrinaryIntervention Group Respiratory Comparison Group RespiratoryIntervention Group Skin Comparison Group Skin

Pres

crip

tions

per

1,0

00 re

siden

t-da

ys

Follow-Up ==><==Baseline


Conclusions NHs increasingly recognized as reservoirs of

antibiotic-resistant bacteria Inappropriate overprescribing is a major contributor to

resistance Lack of support for relationship between adherence to

LMC and reduced prescribing rates

Yet, significant decline in prescribing rates in intervention sites only

QI program likely effective via other mechanisms

Recommend continued efforts to reduce prescribing


Acknowledgments The Abt/UNC team is grateful to the Agency for

Healthcare Research and Quality for funding this project.

Contract No. HHSA290200600019i, Task Order No. 11.

reducing inappropriate antibiotic prescribing in nursing homes

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