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Darren K. Pasay et al
Fig. 1. Monthly rates of antimicrobial prescriptions and urine cultures in control and intervention groups
These data were obtained from the AHS Clinical Analytics and Primary Data Support Service. To describe the characteristics of the residents who were
prescribed antimicrobials, information on residents’ age, urinary catheter use, whether there was a charted diagnosis ofUTI, presence of the minimumdiagnostic criteria for UTI (eg, fever, dysuria, hem- aturia, flank or suprapubic pain, newor increased urinary frequency, urgency, or incontinence), and timing of urine culture collection were retrieved from Meditech’s Enterprise Medical Record.
Sample size calculation and randomization
A mean difference of 0.2 in change in the urine culture testing and prescription rates between control and intervention sites, an average cluster bed size of 30 (per site), and an assumption that the intra- cluster correlation was 0.1, were used to determine that aminimum of 26 clusters (sites)would be required to be able to detect a statistical difference between treatment and control groups with 80% power and 5% significance for the primary outcomes. Power calculations for the secondary outcomes were not performed.
Statistical analysis
Awash-in monthwas assigned to each site,which indicatedwhen theUTI in LTC interventionwas implemented. Data collected for thewash-in monthwerenot used in
analyses.The nursing home served as the unit of allocation, intervention, and analysis. Change in the outcome variables between the baseline and post- intervention periods of the study were analyzed using the 2-tailed Fisher exact test. To assess the impact of the intervention over time, generalized least-squares linear regression was used to model the outcomes between the control and intervention sites by study month using pair differences in the matched pair of nursing homes. The analysis was conducted using R Studio soft- ware (RStudio, Boston, MA).
Results Study population
In total, 21 sites were allocated into each group. The mean number of beds, mean age, and percentage of females in the control and intervention groups were not significantly different (Table 1).
Urine cultures
In thebaseline period, theurine culture rateinthe controlgroup was 5.1 per1,000 RDlowerthan the intervention
group.Afterthe intervention, there was a statistically significant reduction in urine testing in the intervention group. Urine culture rates in the control group did not differ between the baseline and postin- tervention periods. In the intervention group, rates decreased the most in the months immediately after the intervention then gradually increased over time (regression coefficient, 0.05; 95% CI, 0.04–0.05) (Fig. 1 and Table 2).
Prescriptions
During the baseline period, prescription rates in the control and intervention groups were similar. After the intervention, there was a statistically significant reduction in the rates of antimicrobial prescribing in the intervention group. Prescribing rates in the con- trol group remained constant through the study period. Similar to urine culture rates, prescribing rates in the intervention group decreased themost in themonths immediately after the intervention and gradually increased toward the end of the study period (regres- sion coefficient, 0.02; 95% CI, 0.001–0.03) (Fig. 1 and Table 2).
Secondary outcomes
There were no differences in admissions to acute care or the emer- gency department between the groups (Table 2). During the base- line period, the mortality rate was 0.3 per 1,000 RD lower in the control group. Following the intervention, the mortality rate decreased by 0.2 per 1,000 RD in the intervention group and was unchanged in the control group. This study was not suffi- ciently powered to identify changes in mortality, and this outcome is likely due to chance.
Resident characteristics
Additional data were collected on the characteristics of 1,001 of 2,918 prescriptions (750 control, 251 intervention). At the time of prescription, a diagnosis of UTI (5.5%), fever (6.8%) or typical UTI symptoms (16%) was charted infrequently. Urine cultures processed within 72 hours prior to or 24 hours after the
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