Electronic Medical Records to Increase Adherence to the Choosing Wisely Recommendations

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

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)

Study Overview

• Status: Completed
• Conditions: Vitamin D Deficiency; Dementia; Viral Infection
• Intervention / Treatment: Behavioral: Audit and Feedback

Detailed 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.

• Study Type: Interventional
• Enrollment (Actual): 239
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Manitoba
    • Winnipeg, Manitoba, Canada, R3W0A8
      • University of Manitoba, Department of Family Medicine

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Audit and Feedback Group 1; 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.	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.
Experimental: Audit and Feedback Group 2; 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.	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.
No Intervention: Control; The control group received the standard feedback report with no information related to CWC.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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
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
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
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

Collaborators and Investigators

• Sponsor: University of Manitoba
• Collaborators: Manitoba Medical Service Foundation

Publications and helpful links

General Publications

• 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.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2016
• Primary Completion (Actual): January 1, 2017
• Study Completion (Actual): December 31, 2019

Study Registration Dates

• First Submitted: April 29, 2022
• First Submitted That Met QC Criteria: May 17, 2022
• First Posted (Actual): May 23, 2022

Study Record Updates

• Last Update Posted (Actual): May 23, 2022
• Last Update Submitted That Met QC Criteria: May 17, 2022
• Last Verified: April 1, 2022

More Information

Terms related to this study

• Keywords: Primary Health Care; Annual Screening
• Additional Relevant MeSH Terms: Infections; Nutrition Disorders; Avitaminosis; Deficiency Diseases; Malnutrition; Virus Diseases; Vitamin D Deficiency
• Other Study ID Numbers: HS19281(H2016:022)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No