A Statewide Collaborative Quality Initiative to Improve Antibiotic Duration and Outcomes in Patients Hospitalized With Uncomplicated Community-Acquired Pneumonia

Abstract

Background Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Methods Prospective collaborative quality initiative including patients hospitalized with uncomplicated CAP who qualified for 5-day antibiotic duration. Between 2/23/2017 and 2/5/2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance. Change in outcomes, including appropriate receipt of a 5 (±1) day antibiotic duration and 30-day post discharge composite adverse events (i.e., mortality, readmission, urgent visit, antibiotic-associated adverse events), were assessed over time (per 3-month quarter) using logistic regression controlling for hospital clustering. Results 41 hospitals and 6,553 patients were included. The percentage of patients treated with an appropriate 5±1 day duration increased from 22.1% (predicted probability 20.9%, 95% CI: 17.2%, 25.0%) to 45.9% (predicted probability 43.9%, 95% CI: 36.8%, 51.2%; adjusted odds ratio [aOR] 1.10 per quarter, 95% CI: 1.07-1.14). 30-day composite adverse events occurred in 18.5% (1,166 /6,319) of patients and decreased over time (aOR 0.98 per quarter, 95% CI: 0.96-0.99) due to a decrease in antibiotic-associated adverse events (aOR 0.91 per quarter, 95% CI: 0.87-0.95). Conclusions Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and lower adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional CQIs with data collection and benchmarking, sharing of best practices, and pay-for-performance may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria

“…In 2017, HMS began collecting data on hospitalized medical patients treated for urinary tract infection (UTI; see eFigure 1 in Supplement 1 for timeline). To improve patient care, HMS uses 3 quality improvement pillars: (1) data with benchmarking, (2) sharing of best practices, and (3) pay-for-performance data . First, HMS collects patient-level data from each hospital through medical record review by nurse abstractors employed by individual hospitals but trained and supported by HMS.…”

Antibiotic Stewardship Strategies and Their Association With Antibiotic Overuse After Hospital Discharge: An Analysis of the Reducing Overuse of Antibiotics at Discharge (Road) Home Framework

“…Since 2017, HMS has collected detailed medical record data on a sample of hospitalized, non-critically ill medical patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) at each hospital [ 4 , 5 , 8 , 11 ]. These data are then fed back to hospitals in the form of hospital benchmarking and pay-for-performance metrics [ 12 ]. HMS does not specify which stewardship strategies hospitals should perform; thus, each hospital conducts antibiotic stewardship according to their local or system antibiotic stewardship and/or quality committees.…”

Transitions of care: An untapped opportunity for antimicrobial stewardship

“…On a statewide scale, Vaughn et al directed 41 centers in Michigan in an intervention for reporting and benchmarking antibiotic prescribing for community‐acquired pneumonia. Over the study period, duration of antibiotic and frequency of adverse events decreased 36 . The clinical impact on safety and patient‐centered outcomes will prove to be critical in future efforts in advocacy for ASP TOC support, with authors reporting improvements in quality or prescribing, adverse events, and even possibly readmissions 28,31,36 …”

“…Over the study period, duration of antibiotic and frequency of adverse events decreased 36 . The clinical impact on safety and patient‐centered outcomes will prove to be critical in future efforts in advocacy for ASP TOC support, with authors reporting improvements in quality or prescribing, adverse events, and even possibly readmissions 28,31,36 …”

“…36 The clinical impact on safety and patient-centered outcomes will prove to be critical in future efforts in advocacy for ASP TOC support, with authors reporting improvements in quality or prescribing, adverse events, and even possibly readmissions. 28,31,36 In a mixed-method approach, Giesler et al reviewed process outcomes to describe impact of a pilot TOC intervention on antimicrobial use at discharge following "timeouts" on a hospitalist floor. The authors also assessed the feasibility, acceptability, adherence, and awareness surrounding the intervention.…”