The Effect of a Quality Improvement Collaborative to Improve Antimicrobial Prophylaxis in Surgical Patients: A Randomized Trial

摘要

Background: Quality improvement collaboratives are used to improve health care quality, but their efficacy remains controversial. nnObjective: To assess the effects of a quality improvement collaborative on preoperative antimicrobial prophylaxis. nnDesign: Longitudinal cluster randomized trial, with the quality improvement collaborative as the intervention. nnSetting: United States. nnParticipants: 44 acute care hospitals, each of which randomly sampled approximately 100 selected surgical cases (cardiac, hip or knee replacement, and hysterectomy) at both the baseline and remeasurement phases. nnIntervention: All hospitals received a comparative feedback report. Hospitals randomly assigned to the intervention group (n = 22) participated in a quality improvement collaborative comprising 2 in-person meetings led by experts, monthly teleconferences, and receipt of supplemental materials over 9 months. nnMeasurements: Change in the proportion of patients receiving at least 1 antibiotic dose within 60 minutes of surgery (primary outcome) and change in the proportions of patients given any antibiotics, given antibiotics for 24 hours or less, given an appropriate drug, and given a single preoperative dose and receipt of any of the 5 measures (secondary outcome). nnResults: The groups did not differ in the change in proportion of patients who received a properly timed antimicrobial prophylaxis dose (−3.8 percentage points [95% CI, −13.9 to 6.2 percentage points]) after adjustment for region, hospital size, and surgery type. Similarly, the groups did not differ in individual measures of antibiotic duration; use of appropriate drug; receipt of a single preoperative dose; or an all-or-none measure combining timing, duration, and selection. nnLimitations: Hospitals volunteered for the effort, thereby resulting in selection for participants who were motivated to change. Implementation of the surgical infection prevention measure reporting requirements by the Centers for Medicare & Medicaid Services and The Joint Commission may have motivated improvement in prophylaxis performance. nnConclusion: At a time of heightened national attention toward measures of antimicrobial prophylaxis performance, the trial did not demonstrate a benefit of participation in a quality improvement collaborative over performance feedback for improvement of these measures. nnEditors' NotesnContextnQuality improvement collaboratives are widely used to promote safety and quality initiatives.nnContributionnThis cluster randomized trial demonstrated that a quality improvement collaborative provided no added benefit over feedback alone for improving the quality of preoperative antimicrobial prophylaxis. nnCautionnHospitals volunteered and may have already been motivated to improve their practices. Mandatory reporting requirements may also have motivated improvements independent of the study interventions. nnImplicationnQuality improvement collaboratives are not necessarily effective ways to promote quality improvement.nn—The EditorsnnIncreased use of comparative clinical performance indicators has led to greater interest in the effectiveness of improvement strategies. “Audit and feedback,” the provision of comparative performance measure data, is a well-known strategy for hospital quality improvement, with demonstrated efficacy (1–3). Although comparative feedback is useful for establishing how well an individual or organization performs relative to peers, feedback reports typically do not provide detailed information on what aspects of the process need to be changed. Feedback can stimulate the desire to change but rarely provides the means (such as skills, tools, and strategies) to implement the change. Quality improvement collaboratives are a more recent innovation; they bring together groups of practitioners from different health care organizations in a series of meetings to share and implement practical solutions for rapid improvement of processes for which the gap between knowledge and practice in health care is substantial (4, 5). Although the collaborative learning model has been applied widely across a variety of topics, some consider the effectiveness of this model to be unproven and based largely on shared beliefs and anecdotal affirmations. The efficacy of collaboratives has yet to be firmly established in controlled studies (6–9). nnErrors in the timing, selection, and duration of antimicrobial prophylaxis can result in preventable surgical site infections (10). The salience of appropriate prophylaxis has increased dramatically since it became a priority topic in the Medicare quality improvement program in 2002. The Centers for Medicare & Medicaid Services (CMS)–sponsored National Surgical Infection Prevention (SIP) Project was designed to promote appropriate selection and timing of prophylactic antimicrobials to decrease the morbidity and mortality associated with postoperative surgical site infections (11). Quality improvement collaboratives have been used to promote antimicrobial prophylaxis process improvement. For example, to “jump-start” hospitals toward preventing surgical infection, the National SIP Project began with the National SIP Collaborative (12). nnBecause relatively few studies have rigorously evaluated quality improvement strategies targeting institutions rather than individuals (13–18), we performed a cluster randomized trial to determine whether hospitals receiving comparative feedback reports plus instruction on and support for process change through a quality improvement collaborative achieve greater improvements in the antimicrobial prophylaxis process than hospitals receiving feedback reports alone. The TRAPE (Trial to Reduce Antimicrobial Prophylaxis Errors) was designed to address this gap in evidence-based quality improvement research.