NSG/506 Week 6: Decision-Making for Systems-Based Outcomes, sample paper

From One Prescriber to Six Clinics: A Nurse Practitioner's Systems-Level Decision to Reduce Antibiotic Prescribing for Acute Bronchitis

[Student Name]

University of Phoenix

NSG/506: Transition to Advanced Practice Nursing

Week 6 Assignment

[Instructor Name]

[Date]

The clinic network, clinicians and data are a composite written for a model paper.

Every clinician who has seen a patient with a week of cough and a demand for antibiotics knows the individual decision: explain that most bronchitis is viral, offer symptom relief and resist the prescription, or give in to save time and satisfy the patient. A composite nurse practitioner who serves as quality lead for a six-clinic primary care network faced a different decision. When she reviewed a year of network data, she found that 61% of visits coded as acute bronchitis in otherwise healthy adults ended with an antibiotic prescription, and that the rate ranged from 34% to 82% across the network's 23 clinicians. The question was no longer how she should treat the next cough; it was how the network should be arranged so that dozens of clinicians made the right decision more often without having to try harder. This paper describes her systems-based decision.

The Problem in System Terms

Antibiotics do not help most adults with acute bronchitis, which is usually viral, and they cause side effects, costs and antibiotic resistance. The problem is national. Fleming-Dutra et al. (2016), analyzing U.S. ambulatory care visits, estimated that at least 30% of outpatient antibiotic prescriptions were unnecessary, with acute respiratory conditions such as bronchitis, sinusitis and viral infections accounting for much of the excess.

The network's data added three system-level facts. First, variation among clinicians was wide, which meant the problem was not driven by patients alone. Second, clinicians with the highest rates saw the most patients per day, suggesting time pressure. Third, the electronic record's acute cough order set listed antibiotics first, making prescribing the easiest path. These facts pointed away from blaming individuals and toward changing the system in which they worked.

Strategies and Their Evidence

The Centers for Disease Control and Prevention's core elements of outpatient antibiotic stewardship describe four areas for any outpatient setting: commitment from leadership, action to implement policies and interventions, tracking and reporting of prescribing, and education and expertise (Sanchez et al., 2016). Within those areas, several specific strategies have been tested.

Education alone is the most common response and the least effective when used alone. Audit and feedback, giving clinicians data on their own performance, has stronger evidence: Ivers et al. (2012), in a Cochrane review of 140 randomized trials, found that audit and feedback generally produced small but important improvements in professional practice, with larger effects when baseline performance was low, feedback was given more than once, it came from a supervisor or respected colleague and it included explicit targets and an action plan.

Behavioral interventions add further strength. Meeker et al. (2016) randomized primary care practices to three behavioral interventions for inappropriate antibiotic prescribing for acute respiratory infections: suggested alternatives in the electronic record, accountable justification requiring clinicians to write a reason for prescribing, and peer comparison emails telling each clinician how his or her rate compared with the lowest-prescribing peers. Accountable justification and peer comparison each significantly reduced inappropriate prescribing compared with control, while suggested alternatives did not have a significant independent effect.

The Decision

The nurse practitioner compared the strategies against three criteria: strength of evidence, feasibility in the network's electronic record and acceptability to clinicians. She chose a bundle of three elements. First, monthly peer comparison reports sent to each clinician, showing his or her rate for acute bronchitis against the network's top performers, delivered by the network's medical director and chief nurse practitioner together to give the feedback credible sponsorship. Second, an accountable justification prompt in the record requiring a brief free-text reason when an antibiotic is ordered with a bronchitis diagnosis. Third, a redesigned cough order set that lists symptomatic treatments and a patient handout explaining the natural course of bronchitis first, with antibiotics available but not the default.

She chose not to rely on education sessions as a main strategy, because the evidence shows limited effect when used alone, although a short launch presentation explaining the data and the plan was included. She also considered and rejected a hard stop that would block antibiotic orders for bronchitis, judging that it would provoke workarounds, such as coding a different diagnosis, and erode trust.

Implementation

Implementation followed the core elements. Leadership commitment came first: the network's board approved antibiotic stewardship as a quality priority and assigned the nurse practitioner protected time to lead it. Informatics staff built the justification prompt and the new order set, which were tested with four clinicians before launch. The first peer comparison report was sent one month after launch, and reports continued monthly. Patients received a handout explaining why antibiotics were not prescribed and what to expect as the cough resolves, which helped clinicians explain their decisions within a short visit.

The nurse practitioner met individually with the three highest-prescribing clinicians before the reports began, not to reprimand them but to explain the program and ask what would help. Two mentioned that patients threatened to leave poor reviews; the handout and a short script for the conversation were developed partly in response.

Ethical Considerations in Peer Comparison

Peer comparison works partly through social pressure, and that raises questions a quality leader must answer before using it. Reports could shame clinicians whose patient panels differ, for example a clinician who sees more older adults with lung disease, for whom antibiotics are more often appropriate. The nurse practitioner addressed this in three ways. The measure was limited to otherwise healthy adults with a bronchitis diagnosis, excluding patients with chronic lung disease or immune compromise, so that clinicians were compared on similar patients. Reports were sent privately to each clinician, never posted publicly or used in performance evaluations during the first year. And the report framed the comparison positively, telling clinicians whether they were among the top performers rather than ranking everyone from best to worst. A systems decision that relies on professional motivation has to protect the fairness and trust that make that motivation possible; otherwise clinicians learn to dispute the data instead of changing their practice.

Measuring Systems-Based Outcomes

The primary outcome is the network's antibiotic prescribing rate for acute bronchitis in otherwise healthy adults, with a target below 30% within twelve months. Secondary measures include the range of rates across clinicians, since narrowing variation is itself a system outcome, and the use of the new order set. Balancing measures include return visits within 14 days for the same complaint and diagnoses of pneumonia within 30 days, to detect harm from undertreatment, and any shift in diagnosis coding from bronchitis to conditions that might justify antibiotics, such as sinusitis, which would suggest the program was being gamed rather than followed. Patient satisfaction scores for these visits are also tracked, since clinicians fear losing them.

Conclusion

The final week of the transition course asks the advanced practice nurse to think beyond the patient in front of her. A nurse practitioner who found that most bronchitis visits in her network ended with an unnecessary antibiotic chose a systems decision instead of another reminder: peer comparison feedback, accountable justification and a redesigned order set, supported by leadership and measured with outcome, process and balancing measures. The decision will be judged not by any single visit but by whether the whole network prescribes more wisely a year from now.

References

Fleming-Dutra, K. E., Hersh, A. L., Shapiro, D. J., Bartoces, M., Enns, E. A., File, T. M., Jr., Finkelstein, J. A., Gerber, J. S., Hyun, D. Y., Linder, J. A., Lynfield, R., Margolis, D. J., May, L. S., Merenstein, D., Metlay, J. P., Newland, J. G., Piccirillo, J. F., Roberts, R. M., Sanchez, G. V., ... Hicks, L. A. (2016). Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA, 315(17), 1864-1873. https://doi.org/10.1001/jama.2016.4151

Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., O'Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 2012(6), Article CD000259. https://doi.org/10.1002/14651858.CD000259.pub3

Meeker, D., Linder, J. A., Fox, C. R., Friedberg, M. W., Persell, S. D., Goldstein, N. J., Knight, T. K., Hay, J. W., & Doctor, J. N. (2016). Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. JAMA, 315(6), 562-570. https://doi.org/10.1001/jama.2016.0275

Sanchez, G. V., Fleming-Dutra, K. E., Roberts, R. M., & Hicks, L. A. (2016). Core elements of outpatient antibiotic stewardship. MMWR Recommendations and Reports, 65(6), 1-12. https://doi.org/10.15585/mmwr.rr6506a1