1. Assessment of the Effect of Behavioral Change Strategies on Knowledge Translation and Pharmacist Interventions for Antimicrobial Stewardship: PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Nicole Bruchet Sarah Murray Tasha Ramsey

2. Background Priority disease states are prevalent and associated with significant burden to patients and health system – ED visits, hospitalizations, prolonged length of stay Pharmacists resolving priority disease DTPs improves quality of drug therapy and reduces health care utilization and costs Makowsky MK, et al. Med Care 2009;47:642-650. Gillespie U, et al. Arch Intern Med 2009;169:894-900. Makowsky MK, et al. Med Care 2009;47:642-650. Gillespie U, et al. Arch Intern Med 2009;169:894-900.

3. Background Disease state educational modules (DSEMs) for priority diseases were implemented to support pharmacists in providing high value interventions To guide interventions, key pharmacist interventions (KPIs) proven to reduce mortality, morbidity, health utilization were developed with DSEMs

4. Background AIMS study showed that DSEMs increased DSEM DTP and KPI resolution, but opportunity for improvement still exists DSEM-KT study showed that multifaceted behavioral change strategies improved IH pharmacist knowledge and care for heart failure Slavik RS, Slavik VC, Hamilton B. AIMS Study 2012. Slavik RS, Murray S, Gorman SK, Bruchet N, Dalen D, Hamilton B. DSEM-KT Study 2013. Slavik RS, Slavik VC, Hamilton B. AIMS Study 2012. Slavik RS, Murray S, Gorman SK, Bruchet N, Dalen D, Hamilton B. DSEM-KT Study 2013.

5. Background Accreditation Canada states “organizations have a program for antimicrobial stewardship” Goals of antimicrobial stewardship are to ensure effective treatment of infections while minimizing unintended collateral damage from antimicrobial use Clinical pharmacists positioned to provide a significant contribution to antimicrobial stewardship as part of routine pharmaceutical care © Accreditation Canada, 2012. Required Organizational Practices 2012.

6. 1.Initiate appropriate antibiotics. 2.Discontinue empiric antibiotics that are not indicated. 3.De-escalate antibiotics based on C&S data and clinical response. 4.Perform IV to PO step-down of antibiotics. 5.Promote appropriate duration of antibiotic therapy. Background Pneumonia and UTI Key Pharmacist Interventions Interior Health Pharmacy Services

7. Objective To evaluate the impact of a multifaceted professional behavioral change strategy on IH pharmacist knowledge translation and interventions for pneumonia and UTI

8. Methods Design Prospective quasi-experimental, one group, pre/post study Setting Tertiary (KGH, RIH); regional (PRH, VJH, EKH, KBH); community (SOH, SLH, KLH, OMH, CMH) pharmacy departments across IH (July 1/13 to June 30/14)

9. Methods Inclusion Criteria IH clinical pharmacists and residents were administered a PRE and POST therapeutics quiz to assess knowledge translation DTP data during the PRE intervention phase (July 1 to Dec 31/13) and the POST intervention phase (Jan 1 to June 30/14) were included to assess behavioral change

10. Methods Intervention Bundle of proven multifaceted professional behavioral change strategies provided over a 8-week period – Audit and feedback – Local opinion leaders – Educational meeting – Educational outreach – Printed education materials – Reminders

11. Methods Primary Outcome The change in the proportion of DSEM DTPs resolved for pneumonia + UTI from PRE to POST phase Secondary Outcomes The change in the proportion of DSEM KPI resolved for pneumonia + UTI from PRE to POST phase Change in pharmacists’ quiz scores on pneumonia + UTI KPI therapeutics from PRE to POST phase The change in the proportion of DSEM DTPs resolved for heart failure by IH pharmacists

12. Study Schema Knowledge Intervention PRE phase Behavioral Change Strategies 1. Audit and feedback 2. Local opinion leaders 3. Educational meetings 4. Educational outreach 5. Printed education materials 6. Reminders Quiz DTP/DSEM DTP KPI/DSEM KPI POST phase BehaviorKnowledgeBehavior DTP/DSEM DTP KPI/DSEM KPI

13. Results InterventionProvided * Exposed † 1. Audit and feedback100%90% 2. Local opinion leaders100%82% 3. Educational meeting43%78% 4. Educational outreach62%75% 5. Printed education material100%95% 6. Reminders100%78% Legend * Based on information provided and initial attendance recorded † Based on study participant POST intervention questionnaire

14. Results Knowledge Quiz Scores p < 0.05 (paired and unpaired t-test)

15. Results OutcomePREPOSTp-valueRRI (95% CI) ARI (95% CI) 1° Combo DTP/ DSEM DTP 1067/6000 (17.8%) 862/3196 (27.0%) < 0.0551.7% (40.0 to 64.2%) 9.3% (7.4 to 11.0%) 2° Combo KPI/ DSEM KPI 457/3754 (12.2%) 411/2083 (19.7%) < 0.05 62.1% (43.1 to 83.5%) 7.6% (5.6 to 9.6%) 2 o HF DTP/ DSEM DTP 856/6000 (14.3%) 293/3196 (9.2%) < 0.05 RRR 35.7% (27.0 to 43.5%) ARR 5.1% (3.7 to 6.4%) Legend PRE: Jul 1/13 to Dec 31/13 POST: Jan 1/14 to Mar 31/14 Combo: Pneumonia + UTI RRI: Relative risk increase ARI: Absolute risk increase CI: Confidence interval

16. Conclusions Significant improvement in knowledge translation for pneumonia + UTI therapeutics Significant improvement in proportion of DSEM DTPs resolved for pneumonia + UTI Significant improvements in proportion of DSEM KPI resolved for pneumonia + UTI Significant reduction in proportion of DSEM DTPs resolved for heart failure