De-Implementing Testing and Treating of Urine Cultures in Asymptomatic Patients

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Background: Successful deployment of strategies to reduce unnecessary testing and treatment is a critical component of improving care and minimizing harms. The Choosing Wisely Initiative has highlighted the importance of safely and effectively de-implementing unnecessary testing and treating practices. Positive urine cultures are a major driver of inappropriate antimicrobial use. Asymptomatic patients are often screened and positive urine cultures treated, despite new guidelines from national societies that patients without symptoms of urinary tract infection (UTI) should not have a urine culture performed and should not be treated with antibiotics even if the culture is positive. This inappropriate use of antibiotics can lead to preventable patient harms (e.g., C. difficile infection, antibiotic resistance) without any benefit. This proposal will develop and test a de- implementation strategy for reducing screening and treatment of urine cultures in asymptomatic surgical patients. Specific Aims: Aim 1: Develop a live database of the 15-facility CDC-CREATE Network to identify and to track organizational, provider, and patient level factors associated with preoperative urine testing and ASB treatment. Aim 2: Determine the current context of pre-operative urine testing and treating, and barriers and facilitators to de-implementation, using in-depth interviews at 5 facilities in our CDC-CREATE network. Aim 3: Develop a de-implementation tool and randomly select 5 intervention sites for pilot testing and compare rates of urine testing in 5 randomly selected control sites using time series analysis. Significance: This proposal meets the HSR&D Implementation Science priority area that addresses provider behavior and Secretary Shulkin's Priority 3: Focus Resources More Efficiently. It also addresses the Infectious Diseases Society of America #1 Choosing Wisely recommendation which says, “Don't treat asymptomatic bacteriuria with antibiotics.” The impact on Veteran's healthcare will be to focus resources towards evidence based practices that are associated with benefits (surgical prevention checklist) and away from potentially harmful practices (urine testing and treatment in asymptomatic patients). This innovative approach will translate new guidelines - to do less - into action using a theory based multi-pronged intervention. Methods: We will partner with the De-implementation Quality Enhancement Research Initiative (QUERI) and adapt their conceptual framework to achieve the proposal objectives. In addition, we will utilize our existing partnership with the CDC-CREATE network of sites to evaluate the context, facilitators and barriers to stopping urine culture practices in asymptomatic surgical patients and to pilot test a de-implementation strategy. We will use a mixed-methods approach, including analyses of data from the national VA databases (e.g. Corporate Data Warehouse), qualitative interviews, and piloting of a de-implementation strategy with a goal of wider dissemination in future work. We anticipate that the de-implementation strategy created and tested in this study will reduce urine testing and treatment in asymptomatic surgical patients. Implications and Next Steps: Our study will provide important insights into patient, provider, and hospital level factors, as well as organizational culture and broader external context (e.g., professional, social) associated with unnecessary urine testing and antibiotic treatment of surgical patients. Our study will develop a strategy to provide reliable, relevant data to the providers so they can do a critical assessment of the evidence against urine testing (unlearning) and adopt a substitute process to optimize the success of our de- implementation goal. Our next steps will be to test the intervention in a wider array of facilities and to work with the Antimicrobial Stewardship Task Force to disseminate our findings to VA antimicrobial stewardship teams nationwide. Our future goals are to disseminate the strategy nationally and to expand it to other patient settings, such as acute care and community living centers.