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Published on: August 30, 2018
Physician champions are key to improving antibiotic prescribing quality
Eva M Aagaard1, Ralph Gonzales, Carlos A Camargo
1University of Colorado, Denver School of Medicine, Aurora, USA. eva.aagaard@ucdenver.edu
Background:
The previously reported IMPAACT study was a cluster randomized controlled trial of a patient and physician educational intervention designed to reduce antibiotic prescribing for acute respiratory tract infections (ARIs) in emergency departments (EDs) in the United States. On average, the intervention resulted in a modest improvement in antibiotic prescribing behavior at the end of Year 1 and further improvement after Year 2. Yet the intervention's impact was large at some sites but minimal or even negative at others. A study was undertaken to identify organizational factors that influenced the effectiveness (Organizational Effect Modifiers [OEMs]) of the intervention.
Methods:
Focus groups of nurses and ED staff and semistructured interviews of local project leaders, nurse managers, and quality improvement (QI) officers were performed at seven EDs across the United States. Effectiveness of the local project leader, institutional emphasis on patient satisfaction ratings, and institutional history with and approach to QI were initially identified as key potential OEMs. Two investigators independently read the transcripts for each site and, using prespecified rating scales, rated the presence of each OEM.
Findings:
The perceived effectiveness of the local project leader was most strongly linked to the effectiveness of the intervention. Perceived institutional emphasis on patient satisfaction and institutional history of and approach to QI (top down or bottom up) did not appear to be closely linked with intervention effectiveness.
Discussion:
An effective local leader to serve as a physician champion was key to the success of this project. Organizational factors modify the effectiveness of QI interventions targeting individual physician performance and should be addressed during program implementation.
Insights
An effective local leader, acting as a physician champion, was crucial for the success of an antibiotic stewardship intervention in emergency departments. This highlights the importance of leadership in quality improvement initiatives.
Area of Science:
- Emergency Medicine
- Infectious Diseases
- Health Services Research
Background:
- The IMPAACT study evaluated a patient and physician educational intervention to reduce antibiotic prescribing for acute respiratory tract infections (ARIs) in U.S. emergency departments (EDs).
- The intervention showed modest improvements in antibiotic prescribing, but its effectiveness varied significantly across different sites.
- This variability prompted an investigation into organizational factors influencing the intervention's success, termed Organizational Effect Modifiers (OEMs).
Purpose of the Study:
- To identify organizational factors (OEMs) that modified the effectiveness of an educational intervention aimed at reducing antibiotic prescribing for ARIs in EDs.
- To understand why the intervention's impact differed across various healthcare settings.
Main Methods:
- Qualitative data were collected through focus groups with nurses and ED staff, and semistructured interviews with local project leaders, nurse managers, and quality improvement (QI) officers at seven U.S. EDs.
- Key potential OEMs, including the effectiveness of the local project leader, institutional emphasis on patient satisfaction, and the institution's approach to QI, were assessed.
- Investigators independently rated the presence of these OEMs at each site using prespecified scales based on transcript analysis.
Main Results:
- The perceived effectiveness of the local project leader was the strongest predictor of the intervention's success.
- Institutional emphasis on patient satisfaction ratings and the institution's history and approach to QI (top-down vs. bottom-up) were not significantly linked to intervention effectiveness.
- A strong, physician-led local champion was critical for driving positive changes in antibiotic prescribing behavior.
Conclusions:
- The presence of an effective local leader, serving as a physician champion, is paramount for the successful implementation of quality improvement interventions in healthcare settings.
- Organizational factors significantly influence the effectiveness of QI interventions targeting individual physician performance and must be considered during program design and rollout.
- Future QI initiatives should prioritize identifying and empowering strong local leadership to maximize intervention impact.
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