In this interview the author of a recent article investigating the impact of nudging in the microbiology laboratory is interviewed. The concept of modifying microbiology reporting and existing data on what impact it can have are discussed.
Interview with: Brad Langford, Pharm.D., ACPR, BCPS
Interview by: Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
[Last Updated: 4 December 2019]
Clinical infectious diseases is a complicated field that takes years of study to begin to master. The decisions made in each case are a result of considering pathogen, patient, and drug-specific factors. Often times these factors are at least partially subjective and many reasonable pathways to a successful clinical outcome are present.
Focusing just on pathogen data, microbiology results can be quite complicated. Sometimes the results are highly dependent on the lab technician running the test. Other times certain aspects of lab results may not be relevant to practice due to the particulars of a clinical case.
Given that microbiology results are so complex, it begs to question whether healthcare systems should implement restrictive reporting of microbiology results, so that physicians are led to make smarter patient care decisions.
Recently Dr. Langford and colleagues published an article in ICHE related to the topic of nudging in the microbiology laboratory, by selective reporting of results. The citation and link are:
This is a topic of interest to many people in the field and as such I thought it would be a good opportunity to interview him about what he had learned and get some insights. In this interview, we discuss the topic of nudging in the microbiology laboratory.
1. What motivated you and your team to investigate “nudging” in microbiology practices?
Our team had an interest in selective reporting starting ten years ago when we were battling many severe C. difficile infections (CDI) in our institution. Recognizing the role that high-risk antibiotics play in inciting CDI, one of the initiatives we implemented was to reduce fluoroquinolone over-prescribing by suppressing ciprofloxacin susceptibility results for pan-susceptible Enterobacteriaceae. We saw a significant drop in ciprofloxacin use and some improvements in resistance rates after the intervention. At the time we did not know it, but we were implementing a common approach referred to by behavioural economists as “nudging”- that is – manipulating choice architecture to guide decision making without compromising autonomy.
Some of us read the book “Nudge” by Thaler & Sunstein and it was eye opening to learn about the applications of nudging in all aspects of society. We were also influenced by a great narrative review on nudging in the microbiology laboratory by Dr. J. Katchanov and colleagues. This all prompted us to think, how else could we nudge clinicians to improve antimicrobial stewardship, particularly with help from the microbiology lab where there are a lot of opportunities to modify reporting practices.
For example, although IDSA and CLSI both recommend implementing selective-reporting, there is limited guidance on what to selectively report, in what situations, and how to implement it. So, we undertook a scoping review to see what others had done in this field and identify gaps for further research.
2. At the completion of your project, what were some findings that did not surprise you?
Selective or cascade reporting was by far the most common nudging strategy used throughout the studies we reviewed. This was not surprising, as strategic reporting of antimicrobial susceptibility results has been in place in microbiology laboratories for many years. But despite this, there’s wide heterogeneity in how labs have decided to implement selective reporting and the extent to which this strategy is used.
A recent European survey by Celine Pulcini and colleagues found that only 31% of countries had implemented selective reporting and there was wide intra- and inter-country variability.
3. Were there any findings form your project that did surprise you or that you found particularly interesting?
The “modified reporting” strategy is particularly interesting. It involves non-reporting of organism and susceptibility results for positive mid-stream urine culture results from admitted inpatients and instead providing a standard statement “The majority of positive urine cultures from inpatients without an indwelling urinary catheter represent asymptomatic bacteriuria. If you strongly suspect that your patient has developed a urinary tract infection, please call the microbiology laboratory.”
Two Canadian colleagues, Dr. J Leis and Dr. P Daley have done studies evaluating this approach and found a reduction in inappropriate treatment of asymptomatic bacteriuria without adverse outcomes, and a surprisingly low number of calls to the microbiology laboratory.
The use of comments adds a unique opportunity to guide decision making at the point of care. Studies by Dr. J McBride and Dr. M Musgrove have used comments in the microbiology report to help reduce prescribing of excessively broad spectrum therapy by simply adding the statement “no MRSA, no Pseudomonas” to respiratory cultures growing normal flora.
4. In what area do you perceive there is the most opportunity to implement nudging strategies via the microbiology laboratory?
Asymptomatic bacteriuria is a major driver of antibiotic overuse, particularly in the older inpatient and long-term care population. This is driven largely by urine culturing practices and the reflex reaction to treat a positive culture result despite a lack of symptoms. So, this presents the greatest opportunity to carefully craft the urine culture ordering process and result reporting to influence safer care.
Preventing unnecessary antibiotic use is also likely to reward stewards with the biggest bang for the buck (as opposed to de-escalation or modifying duration of therapy) – making asymptomatic bacteriuria a high-yield target for nudging.
5. What steps would you recommend undertaking to implement nudging strategies in a microbiology laboratory?
Nudging initiatives are typically collaborative and interdisciplinary. Key stakeholders include the antimicrobial stewardship team and the microbiologist and laboratory staff. Other team members could include infectious disease clinicians, infection control and front-line physicians, nurses, and pharmacists. Considering which nudging strategies might address problematic antibiotic prescribing practices is a good starting point. It’s important to clearly indicate the criteria by which a specific reporting process will be implemented (e.g., report amoxicillin-clavulanate only when isolate is resistant to amoxicillin, for all inpatients with urinary or respiratory isolates) and whether it can be automated or must be done manually. Have an evaluation plan ready that includes antibiotic use, patient outcomes and unintended consequences (e.g., calls to the microbiology laboratory).
Nudging is not a “one-size fits all” approach. For example, selective reporting can lead to confusion if targeted antibiotics are prescribed empirically before culture and susceptibility results are reported, leaving clinicians to wonder if their initial empiric therapy was adequate for the cultured organism. In these cases, adding comments to the report regarding preferred therapy or strategic arrangement of the susceptibility report (preferred agents in bold or at the top of the report) may be more appropriate strategies.
Sometimes “out of sight, out of mind” is a beneficial approach. So, there is a certain stealthiness to some nudging strategies. However keeping an open line of communication between the laboratory, antimicrobial stewardship program clinicians and prescribers and being open to opportunities for improvement and fine-tuning the report is of utmost importance.
6. What future research would you like to see done in this space?
The majority of nudging in microbiology research has been done in adult inpatient settings, so there are clearly opportunities to expand this population, especially given 80-90% of antibiotic use is occurs in the community setting.
Nudging is about more than simply de-escalation – there are many opportunities to improve the quality of prescribing, including when to start an antibiotic, which antibiotic, dose and route are most effective, and for how long to treat. So, as part of our NIMBLE (Nudging In MicroBiology Laboratory Evaluation) research program, led by Dr. Larissa Matukas, our team is exploring the breadth of these scenarios, and we are currently working on a case-based vignette study to determine what nudging approaches work best and in what types of scenarios.
Additionally more large, prospective multi-centre studies would help to increase the generalizability of this work and encourage more standardization in this field. So, our goal is to perform a multi-center prospective study to evaluate this question further.
Finally, nudging can apply to many aspects of antibiotic stewardship beyond the microbiology laboratory. This area is ripe for future research. The use of computerized physician order entry provides many opportunities to improve antibiotic prescribing through default choices, ordering of options and adding comments or additional information to aid decision making.
Disclosures: The views and opinions expressed in this article are those of the author and do not necessarily reflect the policy or opinions of any previous, current, or potential future employer.
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