93. Developing Urinary Tract Infection Clinical Vignettes for the Nursing Home Setting: A Mixed-Methods Approach

Background Little is known about how providers choose antibiotics for nursing home residents when concerned about urinary tract infections. To better assess this in a simulated setting, we used a mixed-methods approach to develop robust clinical vignettes. Methods First, we developed 7 vignettes and distributed them to resident physicians as a survey, randomizing participants’ response type to rank-order or free-text entry. Second, we shared 5 vignettes with nursing home prescribers and conducted semi-structured interviews that asked providers to explain their thinking out loud (Think Aloud structure). Interviews were continued until content saturation was achieved. Two authors (LT & RJ) determined appropriateness of decisions about antibiotic initiation and antibiotic choice; two authors (LT & JI) coded feedback on the vignettes with adjudication by a third (RJ). Results Of 23 residents (11 rank-choice; 12 free-response) that participated in the pilot survey, only 6 (26%) completed 7 vignettes, with a mean completion of 69.4%. Completion of all vignettes was similar between groups, however, greater attrition at the first question was observed in respondents randomized to rank-choice (4/11) compared to free-response (6/12). Of the original 7 vignettes, 5 free-response cases were chosen for further development. We conducted semi-structured interviews with 7 nursing home prescribers, 4 of whom were physicians. The prescribers had a median age 39 (range 34 to 54) and a median of 10 years of post-graduation experience. Figure 1 summarizes appropriateness of respondents’ answers regarding antibiotic initiation and antibiotic choice. The most common inappropriate choice was a fluoroquinolone. Vignettes were edited iteratively based on participant feedback on each case’s realistic characteristics, missing necessary clinical data, formatting changes, and clarity (Figure 2). Figure 1. Appropriateness of antibiotic initiation and antibiotic choice per clinical vignette. Figure 2. Example of vignette editing process based on Think Aloud interview responses Conclusion This mixed-methods approach effectively captured prescribers’ feedback about length, response method, and case characteristics for our clinical vignettes. Responses assessed differences in prescribers’ decision to initiate antibiotic treatment and antibiotic choice. The refined vignettes will be used in a national survey. Disclosures Robin L. Jump, MD, PhD, Pfizer (Individual(s) Involved: Self): Consultant