Evaluering av et tilpassbart antibiotikastyringsprogram skreddersydd for franske sykehjem (ORANEAT)

Nursing homes in the experimental group will receive the ORANEAT antibiotic stewardship program.

The ORANEAT multifaceted customizable antibiotic stewardship program includes (i) a contextual diagnostic regarding AMS in the targeted NH; (ii) based on the results of the contextual diagnostic, a bundle of tools selected from an AMS-toolkit including actions and tools suited to French NH setting and covering the main CDC domains of AMS in NHs; and (iii) implementation support relying on French structures involved in tackling AMR (i.e., CRAtb and CPias).

Nursing homes in the control group will not receive the ORANEAT antibiotic stewardship program ("usual care").

Overall antibiotic prescription rate expressed in Defined Daily Doses (DDD)/1000 resident-days/month.

Measured using data from the Health Insurance reimbursement database.

As part of a sensitivity analysis:

Overall antibiotic prescription rate expressed in number of prescriptions/1000 resident-days/month.

Measured using data from the Health Insurance reimbursement database.

Broad-spectrum antibiotic prescription rate expressed in Defined Daily Doses (DDD)/1000 resident-days/month. Broad-spectrum antibiotics include quinolones and 3rd-generation cephalosporins. Measured using data from the Health Insurance reimbursement database.

Proxy indicators reflecting the appropriateness of antibiotic use in nursing homes (Asquier-Khati et al. 2023, doi:10.1093/jacamr/dlad037). These proxy indicators assess the appropriateness of prescriptions for urinary tract infections, seasonal variations in prescriptions, repeated prescriptions of fluoroquinolones, cephalosporins' route of administration, duration of treatment, rate of second-line antibiotics, and co-prescriptions with non-steroidal anti-inflammatory drugs.

Number of hospital admissions/1000 resident-days and number of deaths/1000 resident-days among nusing home residents.

Measured using data from the Health Insurance reimbursement database.

Overall antibiotic prescription rate expressed in Defined Daily Doses (DDD)/1000 resident-days/month.

As part of a sensitivity analysis: Overall antibiotic prescription rate expressed in number of prescriptions/1000 resident-days/month.

Measured using data from the Health Insurance reimbursement database.

Nursing homes' staff resources (number of coordinating physicians, nurses, assistant nurses and general practitioners).

Measured using data collected by the research team through ad hoc standardized activity reports.

Characteristics of the geographic areas of the nursing homes (type of area: rural/semi-urban/urban; access to general practioners in the area according to the Local Potential Accessibility Index, which considers the number of general practioners, their level of activity, the age of the population, and the distance to GPs' offices within the municipality ).

Measured using data from administrative public databases.

Number of nursing homes included / number of nursing homes invited to participate in the intervention group * 100, by stratum.

Measured using data collected by the research team through ad hoc standardized activity reports.

For each profesionnal category (nursing home coordinating physician or nurse, nurses, assistant nurses and referring general practitioners), participation rate (%) in the contextual diagnostic questionnaire of the ORANEAT program (first component of the program), calculated as as the number of completed questionnaires divided by the total number of professionals in that category x 100.

Proportion of nurses and assistant nurses attending at least one training session; proportion of referring general practitioners contacted at least once regarding the ORANEAT program by the external or the internal facilitators; number of tools distributed (number of copies provided to the nursing home, for each tool); proportion of nursing homes that developed at least one tool as part of the "tool development" action of the ORANEAT program.

Measured using data collected by the research team through ad hoc standardized activity reports.

Number of tools used / number of tools included in the bundle of tools, for each bundle.

Measured using data collected by the by the research team through ad hoc standardized activity reports.

Number of categories of the antimicrobial stewardship tools/actions implemented in the nursing home according to the contextual diagnostic tool of the ORANEAT program and their evolution over 12 months. Categories are defined according to the Centers for Disease Control and Prevention (CDC) core elements of antibiotic stewardship for nursing homes.

Data collected through the questionnaires of the contextual diagnostic.

Score of exposure to each component of the ORANEAT program. This composite measure will capture the intensity of exposition to each component of the program in each nursing home (i.e., the contextual diagnosis, the exposition to the tools/actions, and the implementation strategies).

Measured using data collected by the research team through ad hoc standardized activity reports, the questionnaires of the contextual diagnostic and annual activity reports from the local antimicrobial stewardship teams.

Number of tools used for each target population. Measured using data collected by the by the research team through ad hoc standardized activity reports.

Number of meetings with the internal and external facilitators held as part of the implementation support of the ORANEAT program (third component of the program).

Measured using data collected by the by the research team through ad hoc standardized activity reports.

Average time (days) between validation of the pack with the internal facilitators and the date when all tools are reported as used.

Measured using data collected by the by the research team through ad hoc standardized activity reports.

Number of tools withdrawn from the bundle of tools or modified (in form and/or content) or added / number of tools initially proposed (for each bundle of tools and overall).

Measured using data collected by the by the research team through ad hoc standardized activity reports.

Users' experiences with the ORANEAT program assessed among coordinating physicians/nurses, nurses, assistant nurses and general practitioners using a questionnaire UREMs (User Reported Experience Measures) adapted from PREMs (Patient Reported Experience Measures) developed by the research team. This questionnaire was designed to measure the users reported experience of the intervention. A score ranging from 0 to 100 will be calculated; higher score means better experience.

Sustainability of the ORANEAT program assessed among coordinating physicians/nurses, nurses, assistant nurses and general practitioners using the NoMAD questionnaire (questionnaire based on the normalization process theory [NPT], measuring the normalization of complex healthcare interventions - Finch et al. 2018 - doi: 10.1186/s12874-018-0591-x). The NoMAD questionnaire includes three general items on the intervention answered on an 11-point Likert scale ranging from 0 to 10, and 20 items representing the four key constructs of NPT: coherence (4 items), cognitive participation (4 items), collective action (7 items), and reflexive monitoring (5 items) answered on a 5-point Likert scale ranging from strongly agree to strongly disagree. Mean scale scores will be calculated for each NoMAD construct as well as for the overall scale (20 items); higher scores mean higher degree of normalization.

Number of urine cultures prescribed/1000 resident-days/month. Measured using data from the Health Insurance reimbursement database.

Nursing home professionals' (coordinating physicians/nurses, nurses, assistant nurses and general practitioners) knowledge, attitudes, practices and motivation towards AMS. For each component (knowledge, attitudes, practices and motivation), a score ranging from 0 to 100 will be calculated; higher scores means more favorable position towards AMS.

Data collected through the questionnaires of the contextual diagnostic.

Cost associated with the work provided by the professionals responsible for the implementation support, with printing and sending the ORANEAT program tools to the nursing homes, etc.

Measured using data collected by the by the research team through ad hoc standardized activity reports.

Observations, semi-structured interviews, focus groups with professionals involved in the implementation of the ORANEAT program (coordinating physicians/nurses, nurses, assistant nurses, general practitioners, professionals responsible for the implementation support…).