Transforming Antibiotic Treatment Through Interprofessional Education in

Shared Decision Making

Kristina B. Blyer, MSN, RN, NE-BC

Maria Gilson deValpine, RN, MSN, PhD

Goal

u  The goal of this presentation is to describe the use of interprofessional education and collaboration in the implementation of shared decision making to address the appropriate use of antibiotics for respiratory tract infections.

Learning Objectives

u  By the end of this presentation participants will be able to identify the effectiveness of shared decision making to promote the appropriate use of antibiotics for respiratory tract infections.

u  By the end of this presentation participants will be able to identify methods for successful implementation of shared decision making using interprofessional education and collaboration.

u  By the end of this presentation participants will be able to identify lessons learned and needs for further development of shared decision making for interprofessional collaboration.

Disclosures

u  Information provided in this presentation is part of a research study conducted for a DNP Capstone project

u  Primary Author is Master Trainer Certified for the SHARE Approach which is funded by AHRQ (contract HHSA290 2012 000171 Task Order 1) and developed without commercial support

u  No conflicts of interest, relevant financial relationships, or sponsorships relevant to this activity

Background

u  According to the World Health Organization (2012) antibiotic resistance is a global health emergency which poses a serious threat to modern medicine; making the inability to treat common illnesses and injuries no longer a fantasy, but a real possibility

u  The unnecessary overuse of antimicrobials directly correlates to antibiotic resistance within a population. (World Health Organization, 2012)

u  Viral respiratory tract infections are a major cause of antibiotic use, even though there is no evidence to support their use for these infections (Kenealy & Arroll, 2013; World Health Organization, 2012).

WHO

Review of the literature

u  Patient perceptions and expectations are often the reason unnecessary antibiotics are prescribed (Altiner et al., 2007; Briel et al., 2007).

u  Shared decision making (with a focus on communication and patient expectations) shows promise for decreasing antibiotic use for respiratory tract infections in the college health setting. (Blyer and Hulton, 2015)

u  Interventions that support both interprofessional care and SDM (IP-SDM) have the potential to improve health care (Stacey et al., 2014)

u  IP-SDM is likely to result in health care decisions that are more likely to be carried out by the patient (Stacey et al., 2014)

National Importance

u  National Action Plan for Combating Antibiotic-Resistant Bacteria

u  2020 Goal to reduce inappropriate antibiotic use by 50 % in outpatient settings

u  Affordable Care Act

u  Calls for the use Shared Decision Making

u  Considered a “sleeper provision” (Oshima Lee & Emanuel, 2013)

Networking Austin, 2013

CDC, November 7, 2014

Description of Innovation

u  Shared Decision Making (SDM) is the interactional exchange of information and deliberation between a provider and a patient (Légaré et al., 2013)

u  Provider shares knowledge about a condition and treatment options (including risks and benefits)

u  Patient is an active participant who shares their values and preferences for treatment

u  Often utilizes decision aids

Description of Innovation

http://vimeo.com/35274883

Who is involved in shared decision making?

u  Patient

u  Provider (Physician, nurse practitioner, or physician assistant)

u  Decision coaches (Nurse, social worker, health educator)

u  Managers/support staff

u  Family members and care givers

u  Specialists

u  Pharmacist, dietitian, and more!

Setting for shared decision making

Any health care setting where

patient and family members make health care decisions

Problem Statement

Does the use of shared decision making within the college health setting increase

student decisional comfort with the appropriate use of antibiotics while

maintaining antibiotic prescribing rates for viral respiratory tract infections?

Population and Setting

u  James Madison University Student Health Center u  30,000 student visits per year

u  5,000 students seen for Respiratory Tract Infections per year

u  College Students u  English speaking

u  Age 18 or older

u  Patients being seen for signs/symptoms of a respiratory tract infection

u  Medical Providers u  Physicians

u  Nurse Practitioners

Design u  No use of decision aid

u  August 31, 2015 through December 18, 2015

u  Patient surveys completed after visits for respiratory tract infections

u  Training January 2016

u  SHARE Approach training (AHRQ, 2014)

u  Decision Aid “Taking an Antibiotic or Not” (Labrecque at al., 2010)

u  Electronic tablets for point-of-care patient engagement

u  Decision aids available for use

u  January 11, 2016 through May 6, 2016

u  Patient surveys completed after visits for respiratory tract infections

u  Provider Intent Survey immediately following shared decision making training, at study intervention mid-point, and at study conclusion

Implementation Ottawa Research Institute (2014) Process for the Implementation of Shared Decision Making Ottawa 5 step process for the

implementation of a decision aid 1) Identify the decision 2) Find patient decision aids 3) Identify barriers and explore ways to overcome them 4) Provide training 5) Monitor use and outcomes

Implementation Step 1-Find a Decision

Implementation Step 2- Find Decision Aid

u  Decision Aid Library Inventory (DALI) https://decisionaid.ohri.ca/cochinvent.php

u  Publically available

u  Evidence-based

u  Current

u  Meet definition of a patient decision aid

Implementation Step 2- Find Decision Aid

© Labrecque, LeBlance, Légaré, and Cauchon (2010)

Implementation Step 3- Identify Barriers and Overcome Them

Implementation Step 3- Common barriers

u  “I already do shared decision making”

u  “I don’t have enough time”

u  “What if I don’t agree with what the patient is asking for?”

u  Difficulty finding decision aids that providers agree to use

Implementation Step 3- Overcoming Barriers

u  Include the interprofessional team!

u  Allow providers, administration, pharmacists, and other team members to review and select decision aids

u  Provide tools for dealing with differences between patient and provider

u  Examples- teach back and conversation starters

u  Health educators and counselor are wonderful at teaching these methods to the team

Implementation Step 4- Implementation and Training

Physician (Medical Director)

Health Educator

Nurse Practitioner

Physician

Nurse Practitioner Physician

Assistant

Present not in picture- Pharmacist, 3 more Physicians, and Nurse Administrator

Implementation Step 5- Monitor use and outcomes

u  Sure Test ©

The SURE Test © O’Conner and Légaré, 2008

Implementation Step 5- Monitor use and outcomes

u  Other areas for data collection/analysis

u  Antibiotic prescribing rates

u  Visit length

u  Provider Feedback

u  Survey based on the Theory of Planned behavior

u  Survey on Decision Aid use

u  Survey on perceived use of Shared Decision Making

u  Qualitative feedback

Case Scenario- Putting Shared Decision Making Into Action

u  History: 21 year old female senior reports a sore throat starting 4 days ago. Now with nasal congestion and cough. Denies fever. Tried Sudafed yesterday and it “did nothing”.

u  Exam: Denies facial and/or tooth pain. Clear nasal discharge noted, nasal membranes have a glassy appearance without erythema or edema, throat and ears appear normal, mildly enlarged (non-tender) cervical nodes, and lungs are clear.

u  Note: Student is applying for graduate school and has to take the GRE exam tomorrow. Student states that she has to feel better because this test will affect the rest of her life! Her mother called the office before the student’s visit and states that her daughter always gets a sinus infection this time of year and that a Z-pack works best for her daughter.

Case Scenario- Putting Shared Decision Making Into Action

ü

ü

2% probability that this is a bacterial infection

Case Scenario- Putting Shared Decision Making Into Action

Sinus Infection

Case Scenario- Putting Shared Decision Making Into Action

Case Scenario- Putting Shared Decision Making Into Action

Case Scenario- Putting Shared Decision Making Into Action

Will make mom happy Time waiting for Rx to be filled

I will have to explain to my mom

Case Scenario- Putting Shared Decision Making Into Action

Results

u  Decisional Conflict

u  When the decision aid was not used students were 2.2 times more likely to have decisional conflict then when the decision aid was used [N=643; p=<.001; 95% CI (1.55, 3.12)]

u  Antibiotic prescribing rates

u  No Significant difference

u  Age, gender, and year in college were not significant

Results- In their own words

u  “Everything was explained well and I was given the option to have antibiotics or not (which is good)” -Student

u  “It clearly helped many students realize that antibiotics were not always indicated…” “It also was a good way to discuss possible side effect of antibiotics.”- Provider

u  “For many patients seeing the low probability of bacterial etiology in print seems to be eye opening for them. It made things easier for me to explain and for them to grasp.”- Provider

u  “I was able to explain benefits and risks better using the decision aids.”- Provider

Conclusion/Discussion

Implications

u  Further work should included:

u  Short- and long-term health outcomes of SDM and IP-SDM

u  The effectiveness of The SHARE Approach training in various clinical settings

u  Development/alteration of respiratory decision aids

u  Development of clinical “hands-on” training programs

u  Implementation of SDM and IP-SDM in varied clinical settings

u  Incorporation of SDM and IP-SDM into curriculum of all health professionals

Implications

u  IP-SDM Model

© Légaré F, Stacey D, and IP Team, 2010.

Questions?

References Agency for Healthcare Research and Quality. December 2014. The Share Approach Workshop Curriculum. Rockville, MD.

Altiner, A., Brockmann, S., Sielk, M., Wilm, S., Wegscheider, K., & Abholz, H. H. (2007). Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: A cluster-randomized intervention study. The Journal of Antimicrobial Chemotherapy, 60(3), 638-644.

Blyer, K., & Hulton, L. (2015). College students, shared decision making, and the appropriate use of antibiotics for respiratory tract infections: A systematic literature review. Journal of American College Health, 00-00. doi:10.1080/07448481.2015.1099105

CDC. (November 7, 2014). Retrieved from http://www.cdc.gov/ncird/div/dbd/newsletters/2014/fall/antimicrobial-resistance-menafrinet.html

Kenealy T & Arroll B. (2013). Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD000247.

Labreque, LeBlanc, Légaré, & Cauchon. (2010). Taking an antibiotic or not? Acute respiratory tract infections (ARI). Retrieved from http://decisionaid.ohri.ca/AZsumm.php?ID=1618

Légaré, F., Moumjid-Ferdjaoui, N., Drolet, R., Stacey, D., Härter, M., Bastian, H., … Thomson, R. (2013). Core Competencies for Shared Decision Making Training Programs: Insights From an International, Interdisciplinary Working Group. The Journal of Continuing Education in the Health Professions, 33(4), 267–273. http://doi.org/10.1002/chp.21197

Légaré, F., Stacey D, and IP Team. (2010). IP-SDM Model. https://decisionaid.ohri.ca/docs/develop/IP-SDM-Model.pdf

McDavid, J. C., Huse, I., & Hawthorn L. R. L., (2013). Program evaluation and performance measurement: an introduction to practice. Thousand Oaks, CA: Sage Publications.

Networking Austin. (2013). Retrieved from http://www.networkingaustin.com/small-business-tips/the-affordable-care-act-and-small-businesses-what-will-change-and-what-will-stay-the-same/

O’Conner and Légaré, 2008. The Sure Test ©. Retrieved from https://decisionaid.ohri.ca/docs/develop/Tools/DCS_SURE_English.pdf

Oshima Lee, E., & Emanuel, E. J. (2013). Shared decision making to improve care and reduce costs. N Engl J Med, 368(1), 6-8. doi:10.1056/NEJMp1209500Ottawa Hospital Research Institute. (2014). Patient decision aids: implementation toolkit. Retrieved from http://decisionaid.ohri.ca/implement.html

Stacey, D., Brière, N., Robitaille, H., Fraser, K., Desroches, S., & Légaré, F. (2014). A systematic process for creating and appraising clinical vignettes to illustrate interprofessional shared decision making. Journal of Interprofessional Care, 28(5), 453-459. doi:10.3109/13561820.2014.911157

World Health Organization. Antibiotics: handle with care 2015 campaign toolkit. Retrieved from http://www.who.int/entity/mediacentre/events/2015/world-antibiotic-awareness-week/waaw-toolkit.pdf?ua=1

World Health Organization department of Human Resources for Health. (2010). Framework for action on interprofessional education and collaborative practice. Geneva: WHO.