Tiffany Brown

Background: Among all ambulatory antibiotic prescriptions, about 20% are non-visit-based (ordered outside of an in-person clinical encounter), and about 30% are not associated with an infection-related diagnosis code. Objective/Methods: To identify the rationale for ambulatory antibiotic prescribing, we queried the electronic health record (EHR) of a single, large health system in the Midwest United States to identify all oral antibiotics prescribed from November 2018 to February 2019 and examined visit, procedure, lab, department, and diagnosis codes. For the remaining antibiotic prescriptions—mostly non-visit-based, no-infectious-diagnosis-documented—we randomly selected and manually reviewed the EHR to identify a prescribing rationale and, if none was present, surveyed prescribers for their rationale. Results: During the study period, there were 47,619 antibiotic prescriptions from 1177 clinicians to 41,935 patients, of which 2608 (6%) were eligible non-visit-based, no-infectious-diagnosis-documented. We randomly selected 2298. There was a documented rationale for 2116 (92%) prescriptions. The most common documented reasons—not mutually exclusive—were patient-reported symptoms (71%), persistence of symptoms after initial management (18%), travel (17%), and responding to lab or imaging results (11%). We contacted 160 clinicians who did not document any prescribing rationale in the EHR and received responses from 62 (39%). Clinicians’ stated reasons included upcoming or current patient travel (19%), the antibiotic was for the prescriber’s own family member (19%), or the clinician made a diagnosis but did not document it in the EHR (18%). Conclusions: Non-visit-based, no-infectious-diagnosis-documented antibiotic prescriptions were most often in response to patient-reported symptoms, though they also occur for a variety of other reasons, some problematic, like in the absence of documentation or for a family member.

Ambulatory antibiotic stewards, researchers, and performance measurement programs choose different durations to associate diagnoses with antibiotic prescriptions. We assessed how the apparent appropriateness of antibiotic prescribing changes when using different look-back and look-forward periods. Examining durations of 0 days (same-day), −3 days, −7 days, −30 days, ±3 days, ±7 days, and ±30 days, we classified all ambulatory antibiotic prescriptions in the electronic health record of an integrated health care system from 2016 to 2019 (714,057 prescriptions to 348,739 patients by 2391 clinicians) as chronic, appropriate, potentially appropriate, inappropriate, or not associated with any diagnosis. Overall, 16% percent of all prescriptions were classified as chronic infection related. Using only same-day diagnoses, appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 14%, 36%, 22%, and 11% of prescriptions, respectively. As the duration of association increased, the proportion of appropriate antibiotics stayed the same (range, 14% to 18%), potentially appropriate antibiotics increased (e.g., 43% for −30 days), inappropriate stayed the same (range, 22% to 24%), and not-associated antibiotics decreased (e.g., 2% for −30 days). Using the longest look-back-and-forward duration (±30 days), appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 18%, 44%, 20%, and 2% of prescriptions, respectively. Ambulatory programs and studies focused on appropriate or inappropriate antibiotic prescribing can reasonably use a short duration of association between an antibiotic prescription and diagnosis codes. Programs and studies focused on potentially appropriate antibiotic prescribing might consider examining longer durations.

Background Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms. Objective To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing. Design We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019. Participants Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot. Main Measures Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease. Interventions Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a “commitment nudge” that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a “justification nudge” that asked for a reason when high-risk polypharmacy was present. One practice received both. Key Results Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%). Conclusions EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

Appropriate vaccinations are important for patients with rheumatoid arthritis (RA), who are often treated with highly immunosuppressive therapies that increase their risk of infection. However, rates of vaccination among patients with RA are below optimal levels. We conducted a patient survey to assess self-reported vaccination status and to compare that status with electronic health record (EHR) data. We recruited randomly selected patients with RA in an academic practice in 2013. Eligible participants had a diagnosis of RA, at least 1 visit to a rheumatology clinic in each of the previous 2 years, were 18 years or older, and had English listed as their preferred language. The survey included the following domains: a) patient self-reported receipt of influenza, pneumococcal (PNVX), and herpes zoster (HZVX) vaccinations; b) attitudes about these vaccines, including reasons for unvaccinated status, if applicable; and c) provider recommendations about these vaccines. Based on participants' self-report, we found a high vaccination rate for influenza during the previous season (79.4%), a moderate rate of any previous vaccination for pneumococcus (53.9%), and a very low rate of any previous vaccination for herpes zoster (7.8%). If we assume that all self-reports are accurate and we include vaccinations recorded in the EHR that were not reported by patients, the vaccination rates were approximately 8% to 9% higher for PNVX and HZVX. Vaccination rates are low among patients with RA based on self-report data. Further research is needed to investigate system-level barriers to vaccination and the impact of evidence-based, provider-level interventions on vaccination rates.

Purpose We previously found that a multifaceted outreach intervention achieved 82 % annual adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT). This study assessed adherence to FOBT after a second outreach. Methods We followed 225 patients in community health centers in Chicago, Illinois, who were randomized to the intervention group. Our primary analysis focused on 124 patients who completed FOBT during the first outreach and were due again for annual FOBT; 90 % were Latino, 87 % preferred to speak Spanish, and 77 % were uninsured. Second outreach consisted of (1) a mailed reminder letter, a free fecal immunochemical test (FIT) with postage-paid return envelope, (2) automated phone and text messages, (3) automated reminders 2 weeks later if the FIT was not returned, and (4) a telephone call after 3 months. Our main outcome was completion of FIT within 6 months of the due date. We also analyzed the proportion of the original 225 patients who were fully screened for CRC over the 2-year study period. Results A total of 88.7 % of patients completed a FIT within 6 months of their second outreach. Over the 2 years since the first outreach, 71.6 % of the 225 patients assigned to the intervention group were fully up to date on CRC screening, another 11.1 % had been screened suboptimally, and 17.3 % were inadequately screened or not screened. Conclusions It is possible to achieve high rates of CRC screening over a 2-year period for vulnerable populations using outreach with FIT as a primary strategy.

Colorectal cancer (CRC) is common and leads to significant morbidity and mortality. Although screening with fecal occult blood testing (FOBT) or endoscopy has been shown to decrease CRC mortality, screening rates remain suboptimal. Screening rates are particularly low for people with low incomes and members of underrepresented minority groups. FOBT should be done annually to detect CRC early and to reduce CRC mortality, but this often does not occur. This paper describes the design of a multifaceted intervention to increase long-term adherence to FOBT among poor, predominantly Latino patients, and the design of a randomized controlled trial (RCT) to test the efficacy of this intervention compared to usual care.