Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs

Bork, Jacqueline T.; Werzen, Alissa; Dave, Rohini; Morgan, Daniel J.; Talwani, Rohit; Decker, Brooke K.

doi:10.1007/s11908-020-00722-1

Cited by 2 publications

(3 citation statements)

References 115 publications

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“…In addition, the CDC reported a significant upward yearly trend in the percentage of national hospitals meeting all 7 core components of antibiotic stewardship since 2014 . These antibiotic stewardship efforts also extend beyond the inpatient setting, and better outpatient antibiotic prescribing practices could partially account for the concurrent reduction in CO-CDI rates that we observed …”

Section: Discussionmentioning

confidence: 82%

“…14 These antibiotic stewardship efforts also extend beyond the inpatient setting, and better outpatient antibiotic prescribing practices could partially account for the concurrent reduction in CO-CDI rates that we observed. 33,34 A third potential explanation for the decline we observed in HO-CDI rates relates to implementation of better diagnostic stewardship by the health care facilities in our cohort. 35 Solanky et al 36 showed that diagnostic stewardship had the most substantial association with reductions in HO-CDI rates among other interventions, including prompt isolation of patients with CDI, optimal environmental cleaning, hand hygiene, fluoroquinolone and proton-pump inhibitor stewardship, and the rejection of solid stool samples by the laboratory.…”

Section: Discussionmentioning

confidence: 97%

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Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

et al. 2021

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IMPORTANCEHealth care facility-onset Clostridioides difficile infection (HO-CDI) rates reported to the US Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) became a target quality metric for 2 Centers for Medicare & Medicaid Services (CMS) value-based incentive programs (VBIPs) in October 2016. The association of VBIPs with HO-CDI rates is unknown. OBJECTIVE To examine the association between VBIP implementation and HO-CDI rates. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series study evaluated HO-CDI rates among adults hospitalized from January 2013 to March 2019 at 265 acute-care hospitals. INTERVENTIONS Implementation of VBIPs in October 2016. MAIN OUTCOMES AND MEASURES Quarterly rates of HO-CDI per 10 000 patient-days, as reported to NHSN by participating hospitals, were evaluated. Generalized estimating equations were used to fit negative binomial regression models to estimate immediate program effect size (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital's predominant method of CDI testing (ie, nucleic acid amplification test [NAAT], enzyme immunoassay [EIA] for toxin, or other testing methods). RESULTSThe study cohort included 24 332 938 admissions, 109 371 136 patient-days, and 74 681 HO-CDI events at 265 hospitals (145 [55%] with 100-399 beds; 205 [77%] not-for-profit hospitals; 185 [70%] teaching hospitals; 229 [86%] in metropolitan areas). Compared with EIA, rates of HO-CDI were higher when detected by NAAT (adjusted incidence rate ratio [aIRR], 1.55; 95% CI, 1.40-1.70; P < .001) and other testing methods (aIRR, 1.47; 95% CI, 1.26-1.71; P < .001). There were no significant changes in testing methods used by hospitals immediately after VBIP implementation.Controlling for CDI testing method, VBIP implementation was associated with a 6% level decline in HO-CDI rates in the immediate postpolicy quarter (aIRR, 0.94; 95% CI, 0.89-0.99; P = .01) and a 4% decline in slope per quarter (aIRR, 0.96; 95% CI, 0.95-0.97; P < .001). Results were similar in a sensitivity analysis using a 1-year roll-in period accounting for the period after the announcement of the HO-CDI VBIP policy and prior to its implementation. CONCLUSIONS AND RELEVANCEIn this study, VBIP implementation was associated with improvements in HO-CDI rates, independent of CDI testing method. Given that CMS payment policies have not previously been associated with improvements in other targeted health careassociated infection rates, future research should focus on elucidating the specific processes that contributed to improvement in HO-CDI rates to inform the design of future VBIP interventions.

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Section: Discussionmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 97%

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

et al. 2021

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“…There have been many efforts to reduce unnecessary antibiotic prescribing for ARIs, often focused on changing clinician behavior within a given encounter [ 33 , 34 ]. Our results emphasize the importance of how care in 1 encounter drives a patient to seek care for subsequent ARIs.…”

Section: Discussionmentioning

confidence: 99%

Association of a Clinician’s Antibiotic-Prescribing Rate With Patients’ Future Likelihood of Seeking Care and Receipt of Antibiotics

Shi

Barnett

Jena

et al. 2020

Clinical Infectious Diseases

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Background One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients’ prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics when they have subsequent ARIs. Methods Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician’s antibiotic prescribing rate to the patients’ rates of ARI antibiotic receipt as well as their spouses’ rate of antibiotic receipt in the subsequent year. Results Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2-3.8, p<0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients’ spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6-7.7, p<0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits. Conclusions Receipt of antibiotics for an ARI increases the likelihood that patients and their family members will receive antibiotics for future ARIs.

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Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs

Cited by 2 publications

References 115 publications

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

Association of a Clinician’s Antibiotic-Prescribing Rate With Patients’ Future Likelihood of Seeking Care and Receipt of Antibiotics

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