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| Name | Class |
|---|---|
| Ontario Ministry of Health and Long Term Care | OTHER_GOV |
| Ontario Medical Association | OTHER |
| Health Quality Ontario | OTHER |
| Centre for Effective Practice |
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Two arm, pragmatic, cluster-randomized trial, with nursing homes allocated to the full, active intervention (featuring educational outreach offered to each prescriber and team members in the home) or standard quality improvement supports (including online audit and feedback reports for each prescriber in the home). The 'standard' quality improvement supports represent 'usual care' as these are to be launched province-wide; a concurrent control arm with no exposure to a quality improvement intervention is not feasible.
The Ministry of Health and Long-Term Care and Ontario Medical Association have initiated a project aiming to improve appropriateness of prescribing in long-term care facilities (aka nursing homes) through integrated educational supports for nursing home prescribers, inter-professional care teams, as well as residents and family members. The first focus of the project is appropriate prescribing of antipsychotic medications. Working with Health Quality Ontario, the policy makers have determined that all prescribers will have the opportunity to review practice reports detailing their prescribing performance for this class of medication (aka audit and feedback).
The primary question of this pragmatic, cluster-randomized trial is: What is the effect of adding educational outreach compared to the 'usual' quality improvement supports (i.e. audit and feedback) on prescribing of antipsychotic medications in long-term care?
Secondary questions include the following:
i. What is the effect of the intervention on acute care utilization (e.g., emergency room) rates? ii. What is the effect of the intervention on incidence of patient clinical outcomes and/or adverse effects associated with antipsychotic medications (e.g., falls, aggressive behaviours)? iii. What is the effect of the interventions on medications that might be used as alternatives to antipsychotic medications (e.g., benzodiazepines)? iv. What is the cost-benefit, focusing on prescribing outcomes?
Process evaluation questions include the following:
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Audit + Feedback | Active Comparator | 'Usual care' / standard quality improvement supports (including online Audit and Feedback reports for each prescriber in the home) |
|
| Audit + Feedback + Educational Outreach | Experimental | 'Active/full' intervention (featuring Educational Outreach offered to each prescriber and team members in the home) |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Audit + Feedback | Behavioral | Online Audit + Feedback practice reports detailing prescribing performance for this class of medication for each prescriber in the nursing home. (Details: http://www.hqontario.ca/Quality-Improvement/Practice-Reports/Primary-Care) |
| Measure | Description | Time Frame |
|---|---|---|
| Antipsychotic dispensing | Number of days with antipsychotic prescriptions in the last week (count, range 0 - 7) | 6 months post-intervention |
| Measure | Description | Time Frame |
|---|---|---|
| Antipsychotic prescribing | Any antipsychotic prescription during the past month (dichotomous) | 3 and 6 months post-intervention |
| Mean Antipsychotic dose | Dose equivalent of antipsychotic dispensed in the past month (continuous) |
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Inclusion criteria:
Exclusion criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Noah Ivers | Family Doctor and Research Scientist | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 32453383 | Derived | Tadrous M, Fung K, Desveaux L, Gomes T, Taljaard M, Grimshaw JM, Bell CM, Ivers NM. Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2020 May 1;3(5):e205724. doi: 10.1001/jamanetworkopen.2020.5724. | |
| 28549480 | Derived |
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| OTHER |
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| Audit + Feedback + Educational Outreach | Behavioral | The Educational Outreach program will be delivered by academic detailers, health professionals (often nurses or pharmacists) who have received specific intensive training to support prescribing providers in a particular environment, in this case long-term care homes, to make the best or appropriate clinical decisions as possible. It is defined as: "an innovative method of service-oriented educational outreach for front-line clinicians. It combines the interactive, one-on-one communication approach of industry detailers with the evidence-based, non-commercial information of academia." The Educational Outreach will be delivered in addition to online Audit + Feedback practice reports, which detail prescribing performance for this class of medication for each prescriber in the nursing home. |
|
| 3 and 6 months post-intervention |
| Benzodiazepine (or sedative) prescribing | Any prescription during the past month (dichotomous) | 3 and 6 months post-intervention |
| Anti-depressant prescribing | Any prescription during the past month (dichotomous) | 3 and 6 months post-intervention |
| Acetaminophen prescribing | Any prescription during the past month (dichotomous) | 3 and 6 months post-intervention |
| Difficulty in performing activities | Activities of Daily Living long form scale (continuous variable, range 0-28) | 3 and 6 months post-intervention |
| Aggressive behaviour scale | Extent of aggressive behaviour (continuous variable, range 0-12) | 3 and 6 months post-intervention |
| Pain | Pain scale (continuous variable, range 0-3) | 3 and 6 months post-intervention |
| Depression | Depression rating scale (continuous variable, range 0-14) | 3 and 6 months post-intervention |
| Falls | Number of falls in the past month (count) | 3 and 6 months post-intervention |
| Emergency Room visits | Number of ER visits during the previous 3 months (count) | 3 months post-intervention |
| Hospitalizations | Number of hospital visits visit during the previous 3 months (count) | 3 months post-intervention |
| Desveaux L, Saragosa M, Rogers J, Bevan L, Loshak H, Moser A, Feldman S, Regier L, Jeffs L, Ivers NM. Improving the appropriateness of antipsychotic prescribing in nursing homes: a mixed-methods process evaluation of an academic detailing intervention. Implement Sci. 2017 May 26;12(1):71. doi: 10.1186/s13012-017-0602-z. |
| 27026584 | Derived | Desveaux L, Gomes T, Tadrous M, Jeffs L, Taljaard M, Rogers J, Bell CM, Ivers NM. Appropriate prescribing in nursing homes demonstration project (APDP) study protocol: pragmatic, cluster-randomized trial and mixed methods process evaluation of an Ontario policy-maker initiative to improve appropriate prescribing of antipsychotics. Implement Sci. 2016 Mar 29;11:45. doi: 10.1186/s13012-016-0410-x. |