The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial.

BACKGROUND: The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record. METHODS: Teladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1-7% absolute differences in antibiotic prescribing among groups. DISCUSSION: Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use. CLINICALTRIALS: gov: NCT05138874.

Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial.

BACKGROUND: Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed. OBJECTIVE: To test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance. DESIGN: Cluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers." MAIN MEASURES: The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building. KEY RESULTS: Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p<.05), educational value (1.86, 1.17-2.96) and relationship building (1.63, 1.13-2.35) (both p<.01). CONCLUSIONS: The pandemic has shed light on clinicians' commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists' performance can be measured and improved with feedback using aspirational norms. TRIAL REGISTRATION: clinicaltrials.gov NCT03784950.