Electronic Medical Records to Increase Adherence to the Choosing Wisely Recommendations

Dementia Clinical Trial

Official title:

The Use of Electronic Medical Records to Change Clinician Behaviour and Increase Adherence to the Choosing Wisely Recommendations

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT05385445
• Other study ID #: HS19281(H2016:022)
• Status: Completed
• Phase: N/A
• Start date: January 1, 2016
• Est. completion date: December 31, 2019

Study information

• Verified date: April 2022
• Source: University of Manitoba
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Audit and Feedback (A&F), a strategy aimed at promoting modified practice through performance feedback, is a method to change provider behaviour and reduce unnecessary medical services. This study aims to assess the use of A&F to change:

1. antibiotic prescribing for viral infections

2. antipsychotic prescribing to patients with dementia

3. routine measure of vitamin D in low risk adults

4. annual screening blood tests (without direct indication by the risk profile of the patient)

Description:

The investigators conducted a clustered randomized trial of primary care providers in Manitoba, Canada participating in the Manitoba Primary Care Research Network (MaPCReN) to assess the impact of A&F interventions to change prescribing and screening rates.

In January 2016, MaPCReN included 239 providers in 46 practices across Manitoba, representing ~20% of Manitoba primary care providers. MaPCReN recruits consenting primary care providers (family physicians, nurse practitioners and community pediatricians) that receive semi-annual feedback reports for practice reflection and quality improvement. Feedback reports provide practice-level details including disease prevalence and clinical characteristics of patients, reported in comparison to other providers at the same practice, health region and provincially

Investigators implemented an A&F cycle reporting on practice behaviours related to four Choosing Wisely Canada (CWC) recommendations.

A) "Don't use antibiotics for upper respiratory infections that are likely viral in origin, such as influenza-like illness, or self-limiting, such as sinus infections of less than seven days of duration." • Bacterial infections of the respiratory tract are rare and usually only secondary complications from initial viral infections. Antibiotics are rarely indicated for upper respiratory illness and patients may suffer adverse effects from antibiotics.

B) Don't routinely measure Vitamin D in low risk adults.

• Routine supplementation of vitamin D is recommended for people living in Northern climates regardless of measured laboratory levels. There is no indication for ordering vitamin D unless a patient is suffering severe renal or metabolic disease.

C) Don't do annual screening blood tests unless directly indicated by the risk profile of the patient.

• There is minimal value in ordering routine blood tests in asymptomatic patients and in fact some "routine" screening tests such as prostate-specific antigen (PSA) is in fact recommended against due to the likelihood of producing false positive results. This may lead to additional and unnecessary testing.

D) Don't prescribe antipsychotics to treat behavioural and psychological symptoms of dementia.

• There are some instances where patients with behavioural symptoms of dementia require antipsychotic medicines although these instances are rare. These medicines should be used judiciously given for this indication because they provide limited benefit and may cause serious side effects including premature death

MaPCReN personnel randomly assigned numbers to clinics for randomization. Number of physicians practicing at each clinic was controlled during randomization.

The intervention "Group 1" received the standard feedback report with a one-page summary of the CWC recommendations of interest. Group 1 did not receive any data specific to their prescribing. Intervention "Group 2" received the standard feedback report, CWC recommendation summary and practice-specific data related to their prescribing rates for the CWC recommendations of interest, compared to rates for other providers at their clinic, in their health region and in the province. The control group received the standard feedback report with no information related to CWC.

The A&F intervention took place between January 2016 and January 2017. Retrospective Electronic Medical Record (EMR) data from the MaPCReN repository was assessed between January 2014-December 2019 to assess changes in prescribing rates during and immediately following the A&F intervention (2016/17), as well as assess continued change in practice after the A&F (2018/19) compared to prescribing rates prior to the A&F (2014/15). There were seven clinics not included in the 2018/19 analysis due to a change in EMR vendor that may have compromised data quality.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 239
• Est. completion date: December 31, 2019
• Est. primary completion date: January 1, 2017
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: N/A and older

Eligibility

Inclusion Criteria:

• All primary care providers participating in the Manitoba Primary Care Research Network (MaPCReN), the Manitoba practice-based network of the Canadian Primary Care Sentinel Surveillance Network.

Exclusion Criteria:

• Primary care providers not participating in MaPCReN

Related Conditions & MeSH terms

• Dementia
• Viral Infection
• Virus Diseases
• Vitamin D Deficiency

Intervention

Behavioral:
• Audit and Feedback
The investigators conducted a clustered randomized trial of primary care providers in Manitoba, Canada participating in the Manitoba Primary Care Research Network (MaPCReN) to assess the impact of Audit & Feedback interventions to change prescribing and laboratory ordering.

Locations

Country	Name	City	State
Canada	University of Manitoba, Department of Family Medicine	Winnipeg	Manitoba

Sponsors (2)

Lead Sponsor	Collaborator
University of Manitoba	Manitoba Medical Service Foundation

Country where clinical trial is conducted

Canada, 

References & Publications (1)

Singer A, Kosowan L, Katz A, Jolin-Dahel K, Appel K, Lix LM. Prescribing and testing by primary care providers to assess adherence to the Choosing Wisely Canada recommendations: a retrospective cohort study. CMAJ Open. 2018 Dec 10;6(4):E603-E610. doi: 10.9778/cmajo.20180053. Print 2018 Oct-Dec. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change in antibiotic prescribing for upper respiratory infections that are likely viral in origins	Investigators assessed baseline prescribing (before the intervention, 2014/2015), and compared this to during the intervention (2016/2017) and following the intervention (2018/2019)	12 months
Primary	Change in prescribing of antipsychotics to treat behavioural and psychological symptoms of dementia.	Investigators assessed baseline prescribing (before the intervention, 2014/2015), and compared this to during the intervention (2016/2017) and following the intervention (2018/2019)	12 months
Primary	Change in Vitamin D laboratory testing	Investigators assessed baseline ordering (before the intervention, 2014/2015), and compared this to during the intervention (2016/2017) and following the intervention (2018/2019)	12 months
Primary	Change in PSA ordering (annual screening)	Investigators assessed baseline ordering (before the intervention, 2014/2015), and compared this to during the intervention (2016/2017) and following the intervention (2018/2019)	12 months