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Antibiotic Stewardship National LAN Event –Reducing Inappropriate Antibiotic Prescribing in Outpatient Settings using Behavioral Interventions

Wednesday, August 29, 20183:00 – 4:30 PM ET

Accessing the Meeting

Welcome and Reminders

Kaylie DoyleTelligen

Event Lead

Marilyn ReiersonStratis HealthChat Manager

• Please be prepared for sharingand open discussion

• Slides and a recording fromtoday’s session can be found on:https://qioprogram.org/antibiotic-stewardship-national-lan-event-august-2018

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Agenda

• Continuing Education Details • Personal Narrative by Rosie Bartel• Topic Introduction by Dr. Katherine Fleming-Dutra• Speaker Presentations

– Dr. Daniella Meeker, Keck School of Medicine of the University of Southern California

– Dr. Larissa May, University of California – Davis• Facilitated Discussion• Wrap-up

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Learning Outcome

• The purpose of this session is to prepare healthcare quality improvement professionals to identify and implement effective healthcare strategies by exploring behavioral interventions for providers to reduce unnecessary antibiotic prescribing, while maintaining patient satisfaction with care.

• We expect that this experience will help participants demonstrate and promote successful delivery of care practices and identify opportunities for improvement, all of which may promote advances in care that impact the Medicare beneficiaries served by the work of the QIO Program.

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Things to Think About

Will you commit to being… • Attentive• Active participant• Actionable

Show your commitment by clicking the green checkmark!

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Continuing Education Credit

Continuing education credit is available for:• Physicians & Physician Assistants• Registered Nurses & Nurse Practitioners• Dietitians• Pharmacists & Pharmacy Technicians• Certificate of Attendance

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Instructions for Obtaining CE

• Attend the entire event• Complete the post-event assessment that will pop up at

the conclusion of the event• There is a separate evaluation required for CE that is

accessible through the post-event assessment• Once you submit your CE evaluation, you will be provided

with a certificate to retain for your records• For technical assistance, please email Nikki Racelis

(nikki.racelis@qinncc.hcqis.org)

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CE Information

Physicians:This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

AKH Inc., Advancing Knowledge in Healthcare designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants:NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

Pharmacists:AKH Inc., Advancing Knowledge in Healthcare is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.AKH Inc., Advancing Knowledge in Healthcare approves this knowledge-based activity for 1.5 contact hours (0.15 CEUs). UAN 0077-9999-18-027-L04-P; UAN 0077-9999-18-027-L04-T. Initial

Release Date: 8/29/2018

CE Information, Continued

Registered Nurses:AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.This activity is awarded 1.5 contact hours.

Nurse Practitioners:This activity has been planned and implemented in accordance with the accreditation Standards of the American Association of Nurse Practitioners

(AANP) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 030803This activity is accredited for 1.5 contact hour(s) which includes 0 hour(s) of pharmacology. Activity ID #218161

Dietitians:AKH Inc., Advancing Knowledge in Healthcare is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1.5 continuing professional education units (CPEUs) for completion of this program/material. CDR Accredited Provider #AN008. The focus of this activity is rated Level 2. Learners may submit evaluations of program/materials quality to the CDR at www.cdrnet.org.

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Disclosure of Financial Relationships & Commercial Support

• The planners and faculty do not have any relevantfinancial relationships to disclose.

• AKH Inc., CRW & Associates, and Telligen do not have anyrelevant financial relationships to disclose.

• No commercial support was received for this activity.

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Disclosure of Financial Relationships & Commercial Support

DisclosuresIt is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use and Investigational Product This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant's misunderstanding of the content.

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Method of Participation

• You must participate in the entire activity to receive credit.

• A statement of credit will be available upon completion of an online evaluation/claimed credit form.

• The link to the online evaluation will be provided after completion of the activity (within the post-event assessment).

• If you have questions about this CME/CE activity, please contact AKH Inc. at service@akhcme.com.

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Who’s in the room?

What entity or type of organization do you represent?

• CMS• Emergency Department• Urgent Care• Hospital• Nursing Home/Skilled Nursing Facility• Patient, Family, or Caregiver Representative• Pharmacy/Pharmacist• Provider/Practice• QIN-QIO• Other (please specify in chat)

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Session Goals

By the end of today’s call you will be able to…

• Explain why providers are prescribing antibioticsinappropriately

• Describe principles of decision science relevant toprescribing decisions

• Understand how implementation details impact programeffectiveness

• Utilize emerging stewardship toolkits for ED and outpatientsettings

Patient Advisor & Advocate

Rosie Bartel

Centers for Disease Control and Prevention

Katherine E. Fleming-Dutra, MDDeputy DirectorOffice of Antibiotic StewardshipDivision of Healthcare Quality Promotion

National Center for Emerging and Zoonotic Infectious Diseases

Outpatient Antibiotic Stewardship

Katherine Fleming-Dutra, MD

Deputy Director, Office of Antibiotic StewardshipPrevention and Response BranchDivision of Healthcare Quality PromotionNational Center for Emerging and Zoonotic Infectious DiseasesCenters for Disease Control and Prevention

Antibiotic Resistance

Annual excess direct healthcare cost: $20 billionAdditional annual cost of lost productivity: >$35 billion

CDC. Antibiotic resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/

CDC’s Response to Combat Antibiotic Resistance

CDC’s Office of Antibiotic StewardshipMission: To optimize antibiotic use in human healthcare to combat antibiotic resistance and improve healthcare quality and patient safety

Antibiotic Expenditures for Humans in the United States by Treatment Setting 2010-15: Total $56.0 billion

Approximately 85%–95% of human antibiotic use

by volume occurs in outpatient setting

Figure created from data from: Suda et al. Clin Infect Dis. 2017; cix773.Duffy et al. J Clin Pharm Ther. 2018; 43(1): 59-64.

At least 30% of outpatient antibiotics prescribed in U.S. doctor’s offices, hospital clinics and emergency departments are unnecessary

Unnecessary antibiotic use putspatients at avoidable risk of adversereactions, C. difficile infections, andfuture antibiotic-resistant infections.

Respiratory infections (e.g. colds,bronchitis, sinusitis, pharyngitis,otitis media) are major drivers ofunnecessary antibiotic use

Many more antibiotics areinappropriate in antibiotic selection,dosing or duration

Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. JAMA 2016 May 3;315(17):1864–73

Antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses (ARIs)* by outpatient setting — MarketScan, 2014

*Antibiotic-inappropriate ARIs include viral upper respiratory infections, bronchitis, bronchiolitis; influenza; nonsuppurative otitis media; viral pneumonia; asthma/allergy. Visits with additional diagnoses of concomitant bacterial infections (e.g. pneumonia, urinary tract infections, acute otitis media, sinusitis) were excluded.Palms D, Hicks L, Hersh AL, et al. JAMA Int Med. E-Publish Ahead of print July 16, 2018.

Core Elements of Outpatient Antibiotic Stewardship

Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1-12. https://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

antibioticuse@cdc.govhttps://www.train.org/cdctrain/training_plan/3697

Keck School of Medicine of the University of Southern California

Daniella Meeker, PhDAssistant Professor

Application of Behavioral Economics to Stewardship Programs in Ambulatory Settings

Overview

▷ Brief History of non-financial incentives▷ Four Stewardship Interventions Tested in

RCTs▷ Fatigue and antibiotic prescribing▷ Future: Availability & Salience

Non-Financial Incentives

Mission-based incentives: Tapping into providers' professional ethos

Establishing shared purpose

Reputational incentives: Internal peer comparisons

Public reporting

Eliminate informational barriers:

Comparative-effectiveness and cost-effectiveness research where gaps exist

“Just-in-time” information: clinical decision support and computerized order entry

What policies can improve the quality of decisions that are produced in healthcare?

History of non-financial incentives

2008Book

“Nudge” by Thaler & Sunstein

2014

White House Nudge Unit

2010

United Kingdom Nudge Unit

Formed

WH SBST

Nudge

UK BITResearch

Unstable Preferences:Self-control problems

Social normsHeuristics & Biases

2012

Behavioral Insights

Peer ComparisonWe look to others for how we should act.

JustificationsWe want others to approve of our behavior.

Public CommitmentsCommitments bind our future self to desires our present self wants to fulfill.

Decision FatigueDecision making gets worse with repeated decisions.

Choice PartitioningWe spread our choices over salient consumption options.

AvailabilityThe more easily we can call some scenario to mind, the more probable we will find it to be.

12.6%of outpatient visits result in an antibiotic prescription

50%of these are in appropriate

34,000,000inappropriate outpatient prescriptions per year

Methods: Enrollment

• Invited: 355 clinicians

• Enrolled: 248 (70%)– Consent– Education– Practice-specific orientation to intervention– Honorarium

Methods: Primary Outcome

• Antibiotic prescribing for non-antibiotic-appropriate diagnoses– Non-specific upper respiratory infections– Acute bronchitis– Influenza

• Excluded: chronic lung disease, concomitant infection, immunosuppression

• Data Sources: EHR and billing data

Results: Clinicians (N = 248)

Results: Visits (N = 16,959)

1.Peer Comparison

We look to others for how we should act.

Intervention 3: Peer Comparison

“You are a Top Performer”You are in the top 10% of clinicians. You wrote 0 prescriptions out of 21 acute respiratory infection cases that did not warrant antibiotics.

“You are not a Top Performer”Your inappropriate antibiotic prescribing rate is 15%. Top performers' rate is 0%. You wrote 3 prescriptions out of 20 acute respiratory infection cases that did not warrant antibiotics.

Main Results: Peer Comparison

p = <.001

2.Justifications

We want others to approve of our behavior.

Intervention 2: Accountable Justification

Patient has asthma.

Main Results: Justification

p < .001

Persistence

• Evaluated prescribing for 12 months after interventions were turned off

• Difference of differences comparing 18-month treatment period to 12-month follow-up period

Persistence of Effects

Persistence: Suggested Alternatives

Linder. JAMA 2017

Persistence: Accountable Justification

Linder. JAMA 2017

Persistence: Peer Comparison

Linder. JAMA 2017

Summary• Peer comparison showed greater persistence

than other interventions• Possible hypotheses

• Justification effects may depend on being prompted• Clinicians may have internalized being a “top

performer” into their self-image and continued to act accordingly

• If interventions are time-limited peer comparison may be the best option

Conclusions and Implications

Social motivation appears effective Interventions show durable effects post-

intervention

3.Public Commitment

Commitments bind the future self to desires the present self wants to fulfill.

Public Commitment

Public Commitment

Results: Public commitment

JAMA – Internal Medicine, 174, 425-431, 2014.

CDC funded Replications: IDPH & NYSDH

CDC Core Elements Outpatient Antibiotic Stewardship (2017)

EU Draft Guidelines for Antibiotic Stewardship

4.Decision Fatigue

Decision making gets worse with repeated decisions

“If you have to force yourself to do something you are less willing or able to exert self-control when

the next challenge comes around. — Daniel Kahneman

Big conceptBring the attention of your audience over a key concept using icons or illustrations

Decision Fatigue: Judicial Decisions Revert to Path of Least Resistance

Replication: Athena Research

https://insight.athenahealth.com/expert-forum-decision-fatigue-antibiotics/

5.Availability

The more easily we can call some scenario to mind, the more probable we will find it to be.

1. Penicillins are one of the most common causes of adverse drug events in ambulatory practice.18

2. Antibiotics are the second most common cause of adverse drug events in the elderly.19

3. Antibiotics are one of the most common causes of adverse drug events following hospital discharge 20

4. Adverse events from antibiotics often cause hospital admissions.21

5. Antibiotics are one of the most common classes of medication associated with malpractice claims.22

6. 5% to 25% of patients will develop antibiotic-associated diarrhea.14

7. Clostridium difficile is an increasingly recognized adverse event following antibiotic treatment.15

8. About 2% of patients who take an antibiotic will develop a skin reaction.16

9. About 1 in 5000 patients who receive an antibiotic will have an anaphylactic reaction.17

5.Applying AvailabilityGoing Beyond Education and Statistics

Beyond Education: Potentiating Availability with Cognitive Factors

• Feedback promotes availability of information. Additionally, rare adverse events are over-weighted cognitively. Feedback on a single patient had an adverse event, especially a severe event, this will increase availability of antibiotic risks.

• Beyond simple education on risks, consider audits and personalized case review that demonstrate evidence of risks in your practice.

Coming Soon:AHRQ Safety Program

Steps for Antibiotic Stewardship

1. Improve teamwork and communication2. Educate staff on how improving antibiotic use is a safety issue3. Identify defects with current antibiotic use4. Learn from defects and develop solutions5. Partner with a senior executive

https://safetyprogram4antibioticstewardship.org/

AcknowledgementsFunded by the National Institutes of Health (RC4AG039115)

University of Southern CaliforniaJason N. Doctor, PhD (PI)Dana Goldman, PhDJoel Hay, PhDRichard CheslerTara Knight

University of California, Los AngelesCraig R. Fox, PhDNoah Goldstein, PhD

RANDMark Friedberg, MD, MPPDaniella Meeker, PhDChad Pino

Partners HealthCare, BWH, MGHJeffrey Linder, MD, MPHYelena KleynerHarry Reyes NievaChelsea BonfiglioDwan Pineros

Northwestern UniversityStephen Persell, MD, MPHElisha Friesema

Cope Health SolutionsAlan Rothfeld, MDCharlene ChenGloria RodriguezAuroop RoyHannah Valino

Thank you!Questions?

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Facilitated Discussion

Chat in your questions and comments.

Press *1 on your telephone key pad to enter the teleconference queue.

University of California – Davis

Larissa May, MD, MSPH, MSHSDirector of Emergency Department Antibiotic StewardshipProfessor, Emergency Medicine

MITIGATE ANTIMICROBIAL STEWARDSHIP TOOLKIT

A guide for practical implementation in adult and pediatric emergency department and urgent care settings

Presented By:Larissa May, MD, MSPHDirector of ED and Outpatient Antibiotic Stewardship, UC Davis Health

INTRODUCTION• This guide is written for healthcare providers and administrators

interested in designing quality improvement programs in antimicrobial stewardship.

• This guide outlines how facilities can implement individualized, effective, and practical antimicrobial stewardship programs in acute care (emergency department and urgent care) settings.

•• Acknowledgements• Allyson Sage• Benjamin Mooso• Katherine Fleming Dutra• Lauri Hicks• Reagan Miller• Richard Kravitz• Sara Cosgrove

• This work was supported by CDC’s investments to combat antibiotic resistance under award number 200-2016-91939; **Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

PRINCIPLES: CORE ELEMENTS

Commitment: Demonstrate dedication to and

accountability for optimizing antibiotic prescribing and

patient safety.

Action for policy & practice:Implement at least one

policy or practice to improve antibiotic prescribing, assess

whether it is working, and modify as needed.

Tracking & reporting:Monitor antibiotic

prescribing practices and offer regular feedback to

clinicians, or have clinicians assess their own antibiotic

prescribing practices themselves.

Education & expertise:Provide educational

resources to clinicians and patients on antibiotic

prescribing, and ensure access to needed expertise

on optimizing antibiotic prescribing.

TOOLS

Provider Education

Patient Education

Provider Commitment-Enhanced Patient Education

Program Champion

Department Feedback

Personalized Feedback

COMPONENTS

Clinical Champion The "face" of the intervention. Lead the interventions, serve as a resource for education, serve as liaison between the department and administration.

Institutional Leadership (Chief Quality Officer or Chief Medical Officer) Sponsor the program and provide institutional administrative and programmatic support for implementation and evaluation.

Departmental Director Refine standard operating procedure and develop provider enrollment procedures (electronic, in-person).

Information Technology Specialist Data extraction for performance reports. Framework for regular personalized feedback for peer comparison.

Nursing Leadership Guide clinical workflow review and refine standard operating procedure.

Program Manager Develop monitoring plan to ensure interventions are delivered with fidelity, and record modifications.

PRE-IMPLEMENTATION

1. Identify key stakeholders and potential champions

2. Conduct stakeholder interviews and engagement

3. Conduct surveys

4. Compile data

PRE-IMPLEMENTATIONTable 1. Intervention Components

Component Definition Provider Education Educational presentations, smartphone apps, CDC Be Antibiotics Aware

brochures. Patient Education CDC Be Antibiotics Aware posters in waiting rooms, Choosing Wisely

brochures, discharge handouts. Provider Commitment Physician-worn “flair” (pens, pins, badge reels, etc.) that are thematically

consistent with the CDC Be Antibiotics Aware posters and brochures. Departmental Feedback

Monthly aggregate of antibiotic prescribing practices for ARI from electronic health record data provided to departmental leadership.

Provider Feedback and Education

Case-based educational rounds with a stewardship consulting service (if available). Alternatively, ED pharmacists can provide consultations for patient-related issues.

Peer Comparison using Personalized Audit and Feedback

Personalized monthly performance rankings with each physician receiving a designation of being a “top performer” (top decile) or “not a top performer” for appropriate antibiotic Rx for ARI delivered by email.18*

*Peer comparison will be distinct from traditional audit-and-feedback interventions in its comparison with top-performing peers instead of group performance, and its validated benefit of delivery of positive reinforcement to top performers. Norms will be computed within each setting within each site.

Launch Do’s and Don’ts Do send out announcement email letting staff know when program will be starting

Don’t pick a week where staff might be out (conferences, retreats, etc.)

Do bring awareness to the program by presentations or holding information sessions

Don’t start on a weekend

Do have extra flair and materials Don’t begin activities without prior announcement and engagement of stakeholders

Data Extraction

Peer Comparison• Feedback helps clinicians monitor own behavior and make changes based

on their real prescribing habits • Monthly email intervention EHR data about inappropriate prescription

rates• Clinicians are ranked from highest to • Rankings are typically only shared with the program team and

administration, however sites may choose to share rankings with all clinicians.

• Clinicians with the lowest inappropriate prescribing rates (the top-performing 10th percentile) will be informed that they are a “top performer” in a congratulatory email.

• Remaining clinicians will be told that they are “not a top performer”. • Emails include the #/proportion of inappropriate antibiotic Rx written for a

month for non-antibiotic-appropriate ARI cases and proportion written by Top Performers.

• Be specific in the language used for provider feedback

Toolkit is Evidence Based

• Study Objective: To evaluate the comparative effectiveness of patient and provider education adapted for the acute care setting (adapted intervention) to an intervention with behavioral nudges and individual peer comparisons (enhanced intervention), on reducing inappropriate antibiotic use for ARI in EDs and UCCs.

Toolkit is Evidence Based• Methods: Pragmatic, cluster randomized clinical trial conducted in

three academic health systems (1 pediatric-only, 2 serving adults and children) that included five adult and pediatric EDs and 4 UCCs.

• Sites were block randomized by health system• Providers at each site assigned to receive the adapted or enhanced

intervention. • Implementation science strategies were employed to tailor

interventions at each site. • Main outcome was the proportion of antibiotic inappropriate ARI

diagnosis visits that received an antibiotic. • We estimated a hierarchical mixed effects logistic regression model

for visits that occurred between November and February for 2016-2017 (baseline) and 2017-2018 (intervention), controlling for organization and provider fixed effects.

• Results to be presented at IDWeek 2018

Pre and Post Intervention Provider Knowledge, Attitudes, and Beliefs on Antibiotic Stewardship

• *The first of each pair of questions below is pre-intervention and the second is post-intervention

Summary

• Overall, inappropriate prescribing rates during ourcluster randomized trial decreased by approximately33% in our population of academic ED and UCCproviders

• Absolute change was modest 0.7% (0.2 – 1.2%).• No significant difference-in-differences between

reductions in unnecessary antibiotic prescribingbetween two intervention methods

• Demonstrated the effectiveness of behavioral andeducational interventions in reducing inappropriateantibiotic prescribing in the ED and UCC

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Facilitated Discussion

Chat in your questions and comments.

Press *1 on your telephone key pad to enter the teleconference queue.

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Individual Reflection

What are your key takeaways?

Did you hear any approaches or tactics that you could apply to your efforts in avoiding unnecessary

antibiotic prescribing?

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Call to Action

• Identify one behavioral intervention to avoid unnecessaryantibiotic prescribing.

• Identify a community partner you can engage in yourefforts.

• Complete the post-event assessment upon exiting WebEx:https://www.surveymonkey.com/r/HY5DYB3

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Call For Future Topics

• We want to hear from you!• Do you have a need or desire to hear about a certain topic?• Submit your ideas in chat or email us at:

QINNCC@area-d.hcqis.org

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Thank you!

This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC-02246-08/08/18