Life In The Slower Lane

Here is the structured PICO analysis for the thirty-first article you uploaded:

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Full Title (verbatim and exact):

“Improvements in Antibiotic Appropriateness for Cystitis in Older Nursing Home Residents: A Quality Improvement Study With Randomized Assignment”

Hanlon JT, Perera S, Schweon S, et al.

Journal of the American Medical Directors Association (JAMDA), 2021; 22(1):173–177

DOI: https://doi.org/10.1016/j.jamda.2020.07.040

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Type of Article:

Randomised quality improvement study (cluster-randomised trial)

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PICO Analysis:

Population:

• Older adults (aged ≥65) living in 25 U.S. nursing homes
• Focused on non-catheterised residents with probable uncomplicated cystitis
• Cases identified using consensus diagnostic criteria for urinary tract infections in older adults 

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Intervention:

A low-intensity antimicrobial stewardship program focused on improving antibiotic prescribing for cystitis, consisting of:

1. A 1-hour educational webinar led by a multidisciplinary team (physician, pharmacist, nurse)
2. Pocket cards summarising consensus diagnosis and treatment guidelines
3. Physician order sets with preferred empiric antibiotic treatments and durations 

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Comparator:

• Usual care in nursing homes assigned to the control group
• No structured intervention or educational materials provided

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Outcome:

1. Person-centred outcomes:

• Not directly assessed, but proxy metrics of medication safety and appropriateness were used, including:
  • Avoidance of unnecessary drug side effects (e.g. drug-drug interactions, excessive duration)

2. Process outcomes:

• Primary outcome (for this substudy):
  • Antibiotic appropriateness assessed using a modified Medication Appropriateness Index (MAI) across four domains:
    • Effectiveness
    • Dosage
    • Drug-drug interactions
    • Duration
• Key findings:
  • 21% relative reduction in inappropriate prescribing (rate 0.13 vs 0.21 per 1000 resident days) – not statistically significant
  • Statistically significant improvement in appropriate duration of therapy (77% vs 89% inappropriate, P = 0.039)
  • Higher drug-drug interaction rate in the intervention group (8% vs 1%, P = 0.046)
  • Trend toward more inappropriate dosing in intervention homes (32% vs 25%) 

3. Health system outcomes:

• Antibiotic classes most associated with inappropriateness: quinolones, penicillins, and cephalosporins
  • Quinolones were most frequently prescribed inappropriately in both groups (25.3% vs 22.8%)
  • Use of penicillins was significantly lower in the intervention group (P = 0.023) 
• The intervention had limited reach to prescribers (mostly engaged nursing staff)
• Authors suggest that adding consultant pharmacists might enhance intervention effectiveness

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Summary Conclusion:

This randomised quality improvement study found a modest, non-significant trend toward improved antibiotic prescribing for cystitis in older nursing home residents. Significant improvements were noted in prescription duration, but not in overall appropriateness. The study highlights the need for stronger engagement of prescribing providers, including the potential role of pharmacists in antimicrobial stewardship. The findings support scaling up such interventions with enhanced multidisciplinary involvement.

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