Taking a Ride on the Stewardship Side of Long-term Care: The Cadillac and the Camry | Geriatrics | JAMA Network Open | JAMA Network
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Invited Commentary
Infectious Diseases
September 11, 2019

Taking a Ride on the Stewardship Side of Long-term Care: The Cadillac and the Camry

Author Affiliations
  • 1Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
  • 2Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas
  • 3Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 4Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
JAMA Netw Open. 2019;2(9):e199515. doi:10.1001/jamanetworkopen.2019.9515

The trial protocol described by Ford et al1 should inspire awe in implementation scientists and perhaps a little bit of envy. The Improving Management of Urinary Tract Infections in Nursing Institutions Through Facilitated Implementation (IMUNIFI) Study will be a cluster randomized trial of an antibiotic stewardship bundle for urinary tract infection (UTI) in 20 or more nursing homes. The investigators are tackling a major question in an area of considerable clinical importance: how does one best implement antibiotic stewardship interventions in nursing homes? They will explore this question by combining 3 implementation strategies: external facilitation, peer-learning collaboratives, and peer comparison feedback. This enhanced implementation approach will be compared with usual implementation, which consists of a kickoff meeting followed by unlimited online access to the toolkit and training resources. All sites in both groups will be required to input data through a web-based portal on a monthly basis. The 2 primary clinical outcome measures are well-defined: (1) number of urine cultures and (2) antibiotic prescriptions for suspected UTI, both standardized by resident-days. The investigators require nursing homes to submit 3 months of baseline data prior to randomization, thus ensuring all sites are engaged and capable of collecting study data. Appropriate balancing measures are in place, tracking number of transfers to hospitals or emergency departments and also the number of resident deaths. The study will measure key implementation outcomes related to toolkit adoption through surveys, participation in coaching calls, and qualitative interviews. In terms of quality, this study is truly the Cadillac of antibiotic stewardship implementation trials.

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