To collaborate or not? Does it make a real difference?
Study looks at collaboratives, compliance
The intervention is membership in a group collaborative. The five measures relate to antimicrobial prophylaxis in surgical patients. The endpoint: Did being part of the collaborative help facilities comply with the measures? The conclusion: No.
"My initial reaction was a bit of surprise," says John Gums, PharmD, professor of pharmacy and medicine at the University of Florida, who is working on VHA Inc.'s antimicrobial stewardship program, a collaborative of sorts to help hospitals manage their own antibiotic resistance patterns.
"I guess intuitively you would assume if you do more of something that you'll get a bigger result. In essence I think what they showed is by going above and beyond the minimum, it didn't seem to impact their outcomes," he says.
In the study, led by Stephen B. Kritchevsky, PhD, epidemiologist and professor in the department of internal medicine and gerontology and geriatric medicine at Wake Forest University, 44 hospitals were recruited and randomized into two groups of 22 hospitals. Hospitals in both groups received a comparative feedback report on their compliance with antimicrobial prophylaxis guidelines.1
The intervention group also participated in monthly phone calls to discuss prominent issues and ask experts questions and had two meetings to discuss progress in their efforts. Compliance on five Surgical Care Improvement Project (SCIP) measures, promulgated by The Joint Commission and the Centers for Medicare & Medicaid Services, were measured in the control and intervention groups.
The authors set out to study not the validity of the measures, but rather the quality improvement process itself. "I think that everyone is interested in knowing how best to achieve process improvement and there is very little research to demonstrate the efficacy of various strategies to improvement of complex processes that involve multiple departments and multiple systems," says Kritchevsky.
The collaborative model was chosen to compare to feedback alone because the group collaborative "seems to be the other sort of dominant or most popular and well known sort of alternative to comparative performance feedback," he says.
Measuring adoption of several methods of change, the study looked at the difference in adoption of these changes in the two groups and found no significant difference. In the discussion, the following changes were noted:
- proportion of doses given in the operating suite increased in the intervention group;
- proportion of doses given outside the surgical suite decline to less than 1% in both groups;
- responsibility for administering the doses shifted toward anesthesiologists, significantly more in the intervention group.
However, the groups improved their antimicrobial prophylaxis process performance to the same degree.
Gums says the study is really looking at yes/no questions — did you adopt this particular strategy or not? And it doesn't correlate the effectiveness of the individual processes to care, or to surgical-site infections, for that matter, he says. What he takes from the study is that the hospitals probably both improved documenting what they did because they knew they were being studied, and focusing on documenting your prophylaxis process is crucial. But trying to extrapolate the data to anything other than what the study is measuring would be unfortunate, he says.
Why is a study like this important?
Kritchevsky says, one reason "is there are ever-increasing sets of mandates about what levels of quality, what performance characteristics of certain kinds of care systems should be, and people can either get there efficiently or get there inefficiently, and it's hard to know, but you've got to make a decision on which way to go," and that's why research in this vein is needed more than ever, he says.
The study also says something about administration's relationship with the quality improvement department and its initiatives. Although hospital administration was not required to participate in the intervention, and if it had, Kritchevsky agrees that could have made a difference, he says anecdotally, the authors did see a correlation between success and buy-in from higher-level administration. With either group, he says, those with actively involved physicians who were respected among their management and peers seemed to improve more.
The Trial to Reduce Antimicrobial Prophylaxis Errors (TRAPE) was funded by a grant from the Agency for Healthcare Research and Quality, with additional support from the Centers for Disease Control and Prevention. Other sponsors and collaborators included The Joint Commission and the Society for Healthcare Epidemiology of America.
- Kritchevsky SB, Braun BI, Bush AJ, et al "The effect of a quality improvement collaborative to improve antimicrobial prophylaxis in surgical patients: a randomized trial" Ann Intern Med. 2008 Oct 7;149(7):472-80, W89-93.