1. Assessment of the Effect of Behavioral Change Strategies on Knowledge Translation and Pharmacist Interventions for Antimicrobial Stewardship: PIAS-KT Study
Sukhjinder Sidhu
Sean Gorman
Richard Slavik
Nicole Bruchet
Sarah Murray
Tasha Ramsey

2. Background
Pharmacist’s prevent, identify and resolve drug therapy problems (DTPs)
Priority disease states are prevalent diseases which account for a large proportion of health care utilization and costs
ED visits, hospitalizations, prolonged length of stay
RCTs have shown that pharmacists resolving priority disease state DTPs can improve quality of drug therapy and decrease health care utilization and costs

3. Background
Continuous professional development allows pharmacists to optimize care for patients with priority disease states
Eight 4-week disease state education modules (DSEMs) were implemented at IH in 2009
At the end of each DSEM, lists of key pharmacist interventions (DSEM KPI) or evidence-based interventions proven to reduce mortality, morbidity, health utilization were developed to guide interventions
DSEMs were put into place to improve the knowledge, skills, abilities, competence and confidence of pharmacists
Pharmacists need (CPD) in therapeutics, pharmaceutical care, clinical skills, and critical appraisal to improve their knowledge, skills, abilities, attitudes, and behaviors to optimally care for patients with priority disease states or on high-risk or complex medications

4. Background
DSEMs improved the knowledge, skills, abilities, competence and confidence of pharmacists
AIMS study showed that after providing DSEMs there was a statistically significant increase in the process of care outcomes (DSEM DTPs and DSEM KPIs), but opportunity for improvement still exists

5. Rationale
Knowledge translation (KT) is defined as a dynamic and iterative process that includes the synthesis, dissemination, exchange of ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system

6. Rationale
Professional behavioral change strategies shown to improve professional practice and health outcomes include:
Audit and feedback; local opinion leaders; educational meetings; educational outreach/academic detailing; printed education material; and reminders
Proof of concept:
DSEM-KT study showed that multifaceted behavioral change strategies significantly improved the KT for heart failure therapeutics and modified behavior of IH clinical pharmacists (DSEM DTP and DSEM KPI)

7. Rationale
There is increasing concern for antibiotic resistance as infections caused by multi-drug resistant bacteria are associated with higher mortality and prolonged hospital stay
Accreditation Canada states “organizations have a program for antimicrobial stewardship to optimize antimicrobial use to aid in ensuring the safe use of high-risk medications”

8. Rationale
Goals of antimicrobial stewardship are to ensure effective treatment of patients with infection and to minimize collateral damage from antimicrobial use
Currently at IH the following antimicrobial stewardship interventions are in place:
Formulary restrictions; therapeutic substitutions; automatic stop dates; and selective reporting of antimicrobial susceptibilities
Collateral damage: increased risk of infection with antibiotic-resistant bacteria and antibiotic resistant bacteria which arises from damage to normal bacterial flora after antibiotic treatment
Interventions are restrictive

9. Rationale
Majority of evidence has shown impact of restrictive interventions on antimicrobial prescribing appropriateness, but little evidence exists on benefits of persuasive interventions
No studies have evaluated the impact of all 6 behavioral change interventions, which are persuasive, on patient outcomes, microbial outcomes, or prescribing appropriateness outcomes
Persuasive evidence: distribution of educational materials in printed form or via educational meetings; educational outreach visits (academic detailing or review and recommend change); reminders provided verbally, on paper or on computer, audit and feedback

10. Purpose
To evaluate the impact of the provision of multifaceted professional behavioral change strategies on resolution of DSEM DTPs and DSEM KPIs for disease X pts by IH pharmacists

11. Significance
If multifaceted professional behavioral change strategies increase knowledge translation and improve process of care outcomes for disease X, this will directly improve antimicrobial prescribing appropriateness for disease X
Improved antimicrobial prescribing is an acceptable surrogate for patient-important and health-system important outcomes
KPI’s for disease X are related to prescribing

12. Methods
Design
Prospective quasi-experimental, one group, pre/post study to evaluate the impact of a bundle of proven professional behavioral change strategies on process of care measures
Setting
Tertiary (KGH, RIH); regional (PRH, VJH, EKH, KBH); community (SOH, SLH, KLH, OMH, CMH) pharmacy departments (July 1/13 to June 30/14)

13. Methods Inclusion Criteria
PRE intervention quiz (Jan 6 to Jan 19/14), a multifaceted professional behavioral change intervention (Jan 20 to Feb 28/14), and a POST intervention quiz (Mar 3 to Mar 16/14) will be administered to all IH clinical pharmacists and residents
Quiz results and DTP data during the PRE intervention phase (July 1 to Dec 31/13) and the POST intervention phase (Jan 1 to June 30/14)

14. Methods
Intervention
Bundle of multifaceted proven professional behavioral change strategies improve KT for disease X KPIs will be administered
Audit and feedback on DSEM DTPs and DSEM KPIs
Local opinion leader support formalized at each site
Educational intervention via Web-X
Educational outreach visits or via Web-X
Printed education materials on DSEM KPI content
Multimodal reminders

15. Methods Primary Outcome
Change in proportion of disease X DTP/DSEM DTPs from the PRE to the POST intervention phase
Secondary Outcomes
Change in proportion of disease X KPI/DSEM KPI from the PRE to the POST intervention phase
Change in pharmacists’ quiz scores on disease X KPI therapeutics from the PRE to the POST intervention phase
To compare the change in the prevalence of DSEM DTPs being resolved by IH pharmacists
Rank Order only.. Not statistically testing – Want to evaluate if benefit for disease X DSEM is seen, but at the expense of other DSEMs, like HF and COPD, that are important priority disease states

16. Behavioral Change Strategies
Methods
PRE phase
Knowledge
Behavior
Intervention
POST phase
Knowledge
Behavior
Behavioral Change Strategies
DTP/DSEM DTP
KPI/DSEM KPI
DTP/DSEM DTP
KPI/DSEM KPI
Quiz
Quiz
1. Audit & Feedback
2. Local opinion leaders
3. Educational meetings
4. Educational outreach
5. Printed education materials
6. Reminders

17. Methods Statistical Analysis
Based on a 6-month disease X DTP count of n=936, study will be powered to detect a 15% relative risk increase (RRI) and 2.5% absolute risk increase (ARI) in the primary outcome for a 6-month PRE and POST sample period using an α ≤ 0.05, and power=0.8
Primary outcome will be analyzed with a test of proportions with two-tailed p-value adjusted to p≤0.05
Mean (SD) differences in pharmacist quiz scores will be compared with the paired Student’s t- test

18. Limitations Implementation of antimicrobial stewardship during study
Selection bias
Intervention bias
Measurement bias

19. Questions