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The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study

Published:January 02, 2018DOI:https://doi.org/10.1016/j.jcjq.2017.07.007

      Background

      Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs.

      Methods

      Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes.

      Results

      Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems.

      Conclusion

      The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.
      Antimicrobial-resistant organisms account for more than two million infections and 23,000 deaths annually in the United States.
      • Centers for Disease Control and Prevention (CDC)
      Antibiotic Resistance Threats in the United States, 2013.
      Studies from diverse settings estimate that between 25% and 50% of antibiotic use in hospitals is suboptimal or unnecessary.
      • Fridkin S.
      • et al.
      Vital signs: improving antibiotic use among hospitalized patients.
      • Hecker M.T.
      • et al.
      Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity.
      • Vora N.M.
      • Kubin C.J.
      • Furuya E.Y.
      Appropriateness of gram-negative agent use at a tertiary care hospital in the setting of significant antimicrobial resistance.
      • Willemsen I.
      • et al.
      Appropriateness of antimicrobial therapy measured by repeated prevalence surveys.
      Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely impacts morbidity, mortality, length of stay and cost.
      • Costelloe C.
      • et al.
      Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis.
      • MacDougall C.
      • et al.
      Hospital and community fluoroquinolone use and resistance in Staphylococcus aureus and Escherichia coli in 17 US hospitals.
      • Patel G.
      • et al.
      Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies.
      • Schultz L.
      • et al.
      Economic impact of redundant antimicrobial therapy in US hospitals.
      • Swaminathan M.
      • et al.
      Prevalence and risk factors for acquisition of carbapenem-resistant Enterobacteriaceae in the setting of endemicity.
      Hospital antimicrobial stewardship programs (ASPs) can reduce inappropriate antimicrobial use, length of stay, Clostridium difficile infection, rates of resistant infections and cost.
      • Baur D.
      • et al.
      Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.
      • Feazel L.M.
      • et al.
      Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis.
      • Karanika S.
      • et al.
      Systematic review and meta-analysis of clinical and economic outcomes from the implementation of hospital-based antimicrobial stewardship programs.
      Major professional societies and the Centers for Disease Control and Prevention (CDC) have developed guidance for ASPs in acute care, nursing homes, and outpatient settings.
      • Barlam T.F.
      • et al.
      Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.
      • Centers for Disease Control and Prevention
      Core Elements of Hospital Antibiotic Stewardship Programs.
      • Centers for Disease Control and Prevention
      The Core Elements of Antibiotic Stewardship for Nursing Homes.
      • National Quality Forum (NQF)
      National Quality Partners Playbook: Antibiotic Stewardship in Acute Care.
      • Sanchez G.V.
      • et al.
      Core elements of outpatient antibiotic stewardship.
      In addition to guidelines, there have been changes to policies, regulation, and accreditation standards to promote the optimal use of antibiotics. For example, in 2015, President Obama announced the National Action Plan for Combating Antibiotic-Resistant Bacteria, which outlines activities to mitigate antibiotic resistance, including adoption and enhancement of ASPs.
      • The White House
      National Action Plan for Combating Antibiotic-Resistant Bacteria.
      Further, beginning in 2017, The Joint Commission required hospitals to establish an ASP for accreditation,
      • The Joint Commission
      Prepublication Requirements: New Antimicrobial Stewardship Standard.
      and the Centers for Medicare & Medicaid Services (CMS) proposed a rule change in the infection control Condition of Participation that would require all hospitals in the United States to implement an ASP.
      • Federal Register
      Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care.
      Implementation of ASP practices can be difficult. As of 2014, only 39% of hospitals in the United States reported having an ASP that met all recommended elements of stewardship programs, and only 55% had any ASP infrastructure.
      • Pollack L.A.
      • et al.
      Antibiotic stewardship programs in U.S. acute care hospitals: findings from the 2014 National Healthcare Safety Network Annual Hospital Survey.
      Previous data from international and American settings suggest that resource limitations, lack of executive leadership support, and cultural barriers regarding antimicrobial prescribing are major challenges for successful ASP implementation.
      • Ashiru-Oredope D.
      • et al.
      Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus.
      • Broom J.
      • et al.
      Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study.
      • Jeffs L.
      • et al.
      A qualitative analysis of implementation of antimicrobial stewardship at 3 academic hospitals: understanding the key influences on success.
      • Pakyz A.L.
      • et al.
      Facilitators and barriers to implementing antimicrobial stewardship strategies: results from a qualitative study.
      However, it is not known how leading ASPs are evolving strategies to overcome these barriers in the face of technological innovation and ongoing regulatory and accreditation requirements. We used qualitative methods to identify and describe characteristics of leading ASPs and novel strategies for stewardship.

      Methods

      This is a key-informant interview study of ASP leaders in the United States. Study methods and findings are reported using the COREQ criteria for reporting qualitative research.
      • Tong A.
      • Sainsbury P.
      • Craig J.
      Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.

      Research Team

      The research team consisted of infectious diseases (ID)–trained physicians [S.N.K., D.P.C., M.S.S.] and pharmacists [A.S.L.], as well as health services researchers with qualitative research expertise [E.L.A., E.J.C]. Two members of the team [A.S.L., M.S.S.] are leaders of an ASP.

      Study Design

      We conducted interviews with key informants at hospital-based ASPs in the United States. Purposive sampling was used to select programs recognized for leadership in the field of antimicrobial stewardship through a combination of literature review, U.S. News hospital ranking,
      • U.S. News & World Report
      U.S. News Hospitals Rankings and Ratings.
      and diverse geographic distribution. Program directors at each center were approached by e-mail and asked to identify physicians or pharmacists who were leaders of the ASP efforts. Thematic saturation was reached after interviews with 12 individuals at four centers. The characteristics of the four sites and the interview subjects are described in Table 1.
      Table 1Characteristics of Antimicrobial Stewardship Program Sites
      Site 1Site 2Site 3Site 4
      TypeAcademicAcademicAcademic and CommunityAcademic
      No. of beds> 750> 750250–500500–750
      Total no. of interviews
       Physicians1111
       Pharmacists3311
      Geographic regionNortheastMidwestMidwestSoutheast
      Two co-investigators [A.S.L., M.S.S.] conducted semistructured interviews of ASP leaders at the participating medical centers between February and August 2016. Each interview consisted of two interviewers and one to three participants. Multiparticipant interviews were conducted at two of the four sites when needed to best accommodate interviewees' work schedules. Groups were selected to avoid joint interviews with supervisors and supervisees, and facilitated to encourage group exchange. The interviews were conducted using an interview guide that was developed by the research team and focused on ASP implementation, program structure, strengths, weaknesses, barriers, facilitators, lessons learned, and future directions (Sidebar 1). The interview process was iterative, and data from early interviews influenced the questions asked in later interviews.
      Interviews were approximately 30–60 minutes in length and were tape-recorded and transcribed using a commercial transcription service.
      Semistructured Interview Questions
      • 1.
        Tell me about your ASP.
        • a.
          Strategies
        • b.
          Resources
          • i.
            FTEs
          • ii.
            Capital
        • c.
          Leadership support
        • d.
          IT involvement/support
      • 2.
        What do you see as the major strengths? The major weaknesses?
        • a.
          How do you measure program success?
        • b.
          IT
        • c.
          Institutional culture
      • 3.
        Can you tell me about some of the successes you've had? Any failures?
      • 4.
        What have been the major facilitators to a successful program? The major barriers?
        • a.
          Communication with providers
        • b.
          Leadership support
        • c.
          IT resources
      • 5.
        What changes would you like to make over the next several years?
        • a.
          Reporting requirements
        • b.
          Benchmarking
      • 6.
        How do you educate clinicians about stewardship program activities?
        • a.
          What seems to be effective or ineffective?
      • 7.
        What lessons might you give to other hospitals that are trying to improve their stewardship programs?
      ASP, antimicrobial stewardship program; FTE, full-time equivalent; IT, information technology.
      The Institutional Review Board at Weill Cornell Medicine granted an exemption from approval.

      Data Analysis

      De-identified interview transcripts were coded using conventional and directed content analysis.
      • Hsieh H.F.
      • Shannon S.E.
      Three approaches to qualitative content analysis.
      Prior to coding the first transcript, a codebook was developed with areas of interest on the basis of prior literature and topical expertise of the research team.
      • Saldaña J.
      The Coding Manual for Qualitative Researchers.
      Investigators updated the codebook over the course of data analysis to reflect new content from transcript data. Two transcripts were initially coded independently by four investigators [S.N.K., E.L.A., E.J.C., M.S.S.], and researchers found few discrepancies in their application and interpretation of codes. Subsequently, the remaining transcripts were coded independently by pairs of investigators. Pairs were selected so that each pair contained one ID specialist and one investigator with expertise in qualitative data analysis. Discrepancies in coding were reconciled by discussion and consensus during in-person team meetings. Codes were analyzed for themes using both inductive and deductive reasoning, which were also discussed during monthly meetings. Representatives from each program were provided the opportunity to offer feedback on the findings, and among participants that responded, findings were validated and no additional themes were raised. All data were coded in NVivo 11 (QSR International [Americas] Inc., Burlington, Massachusetts).

      Results

      We found three main themes that emerged from the data: the first theme related to the changing structure of ASPs. The second involved the integration of information technology (IT) into program activities, and the third theme was barriers to the effective use of IT.

      Stewardship Programs Are Expanding Beyond Traditional Roles and Personnel

      The traditional model of ASP consists of interventions conducted by a small group of physician and/or pharmacy leaders on the ASP team, typically with specialized training in ID. Our respondents described an evolution outside that model, in which generalist clinical pharmacists and physicians from disciplines outside of ID were engaged in improving antimicrobial prescribing or empowered to perform stewardship activities. As one respondent stated:I think that we in stewardship also need to decentralize some of the responsibility, which doesn't mean give up the central responsibility…. If we continue to do what we do but also empower unit-level people to actually work with us and do stewardship on a day-to-day basis, I think that's more powerful and can extend the reach of stewardship.
      One program allowed generalist clinical pharmacists to perform antibiotic prior authorizations, and “if the physicians don't take their recommendations, then they kick it up to our stewardship team.” Another program adopted a “train the trainer” model in which unit-based pharmacists were provided education on antimicrobial stewardship that they could then use to make interventions and educate providers.
      A collaborative, multidisciplinary approach was identified as particularly important when trying to affect physician groups that may have traditionally been resistant to stewardship interventions. Respondents stressed that that ASPs should not create an “antibiotic police scenario or a dictatorship” and advised against a “top-down, heavy handed approach.” Programs involved providers from a broad array of specialties, including surgery, critical care, oncology, emergency medicine, and hospital medicine. This multidisciplinary involvement was seen as essential to disseminate, promote, and adopt ASP guidelines—as a respondent stated, “If prescribers within a given specialty are involved in coming up with something, then they're more likely to sell it to their colleagues.”
      As the personnel involved in stewardship are changing, ASPs' communication with frontline providers is also evolving. Whereas ASP recommendations at all four programs were conveyed verbally, two programs had also begun clinical documentation in the medical chart. Malpractice liability was cited as a potential concern because ASP recommendations involved chart review rather than direct patient contact and could be misinterpreted by prescribers as ID consultation. Both programs consulted with the hospital legal department before designing progress note templates. These programs incorporated a standardized disclaimer statement to clarify that recommendations were based solely on chart review and that ID consults should be obtained as indicated.
      Finally, when discussing program structure, our respondents discussed the need for ASPs to model from the structure of infection control programs, but also to differentiate themselves as independent entities. Infection control programs have historically shared personnel, space, and budget with ASPs and often have aligned goals and strategies. For example, one respondent at a multisite health care system drew inspiration from its infection prevention program's hierarchical structure, in which central infection control staff would coordinate activities with local infection control staff at individual hospitals within the system. Another respondent stated that “infection control has been able to … shift some of the responsibility to more of the unit level or provider level,” and that this model should be emulated by ASPs.
      Despite many areas of overlap, respondents stated that without being structurally independent from infection control programs, ASPs tended to lose priority when allocating resources. A respondent who led both the infection control program and the ASP at his hospital discussed their budget allocation, as follows:It sort of gets lumped in with infection control. I think even the infection control payment is low. So if you throw stewardship on top of that, I think it's under-resourced on a physician level.
      However, respondents cited new accreditation requirements from The Joint Commission and a proposed rule change from CMS as offering ASPs greater “leverage to request more resources,” and the potential to evolve into a distinct program, separate from infection control, from the perspective of hospital administration.

      Information Technology Has Improved Efficiency of ASP Operations and Enabled Innovative Strategies

      Dedicated antimicrobial stewardship software was present at each of the programs and was used for generating alerts for stewardship personnel to identify opportunities for intervention, communication between members of the stewardship team, documentation of interventions, and data analysis. Examples of alerts included opportunities for de-escalation, patients who were receiving ineffective antibiotic therapy, positive blood cultures, and multidrug-resistant organisms. One pharmacist stated that software alerts directed at ASP personnel were “game-changing,” and found it “rewarding when you get a critically ill patient on appropriate therapy faster and improve their outcomes.” While alerts for ASP personnel to identify potential interventions were viewed as an invaluable tool, one ASP leader urged caution in using IT alerts directed at frontline providers, in view of the potential for alert fatigue, as follows:Anything that kind of interferes with their day-to-day work flow they're going to work around …. I think the IT systems that work best are those that are trying to deliver meaningful information that the clinicians find useful.
      In addition to improving the efficiency of traditional ASP strategies, IT enabled innovative stewardship approaches. One example is the introduction of syndrome-specific interventions. Whereas passive guideline development for specific infections has been a long-standing strategy of ASPs, our respondents were actively contacting and recommending optimal management strategies to frontline providers. Care bundles for specific infections allowed ASPs to make recommendations beyond antibiotic selection and encouraged adherence to evidence-based guidelines. Examples of infections for which this strategy was used, and for which national guidelines could be used to create an institution-specific management strategy, included Staphylococcus aureus bacteremia and Candida fungemia. These interventions included assistance in selecting duration of therapy, dose optimization, further diagnostic evaluation, and policies requiring ID consultation. One program measured outcomes for such an approach to Staphylococcus aureus bacteremia, and found that they were “numerically decreasing mortality” and “significantly [reducing] readmissions.”
      To identify patients with a given clinical syndrome for targeted management, IT played a critical role. Three programs implemented these interventions on the basis of the results of new microbiological methods for rapid identification of bacterial species and genetic resistance markers. IT systems would generate a real-time notification to an ASP team member, who could then advise the treating physicians on antibiotic selection and other aspects of management. While IT systems were useful for identifying patients with specific microbiologic results, their utility in identifying common clinical syndromes, such as pneumonia or cellulitis, remained limited, which hampered programs' ability to develop interventions for these infections.
      In another case, IT directly facilitated enhanced information delivery to frontline providers, allowing for better-informed antimicrobial prescribing. One program developed an interactive, dynamic, Web-based antibiogram to replace the traditional static antibiogram annually developed by the ASP. Providers could access the program using a smartphone-enabled platform and view antimicrobial susceptibility information for specific specimen source and for facility- and unit-level data. This program reported seeing a dramatic increase in clinicians using the antibiogram, as follows:We found that previously our website that listed our more traditional table antibiogram had about 30 hits per month, but when we implemented something that people found more useful to individual patient care, we have 3,000 hits a month.
      In addition to facilitating communication, programs also used technology-based approaches to augment traditional strategies to control prescribing. For example, automatic discontinuation of antibiotics after a predefined number of days was seen as a commonly used intervention with a potential for error, in which antimicrobials would “fall off,” or be discontinued prematurely. To mitigate this possibility, one program offered a separate “long term antibiotic order set” if a longer duration was needed, which included antibiotic duration and commonly ordered laboratory monitoring. Another program created a daily list of patients for whom antibiotics were stopped without being discontinued, to allow the ASP to review it for potential errors. Although none of the four programs had instituted a formal antibiotic time-out, one program planned to implement one in the near future. The proposed time-out would be “physician-driven,” would automatically pull in laboratory, culture, and radiology results, and would provide the physician with options for de-escalation, escalation, stopping antibiotics, or continuing therapy for a defined duration. This technology-driven approach would require providers to reassess antibiotic appropriateness and duration in a structured fashion.

      Barriers to Information Technology Integration Included Interoperability Between Software Systems and Adequate Resources for Data Analysis

      Poor interoperability between software systems within an institution was seen as a barrier to efficient use of IT. Clinical microbiology software, electronic heath records, pharmacy software, and dedicated stewardship software were often each used for some components of ASP activities. Lack of integration between stewardship software and the electronic health record (EHR) was viewed as a particularly important barrier because of poor communication of recommendations and the additional effort needed to duplicate documentation in multiple places. Ideally, these systems would enable a more seamless flow of information between frontline providers, general pharmacists, and ASP team members. Respondents also expressed concerns with the accuracy of antibiogram data when stewardship software was used for this purpose because of failure to accurately reflect susceptibility results reported from a microbiology database. The importance of being “in one system” was seen as a solution to many interoperability problems, although none of the hospitals in our study had a unified software suite.
      Even with dedicated stewardship software, participants identified lack of resources to produce and analyze data reports. One respondent cited a “several-month turnaround time.” Another respondent stated that antibiotic use data were “the messiest data there is” and that they “don't have the dedicated support that [they] need.” Another respondent commented, “one of the biggest challenges is linking improved antibiotic utilization to improvement in resistance trends.” To overcome this, programs were developing mechanisms to provide more customized data feedback to unit-based pharmacists or individual prescribers. Compared with aggregate hospital data, unit-specific or individual prescriber data were viewed as a more meaningful way to “link process, performance, and outcomes measures” and to “benchmark prescribers against each other … to help affect antibiotic prescribing.” However, this type of individualized data were even more difficult to obtain than hospital-level data. Commercial software products designed for stewardship were nonetheless seen as an invaluable aid: Prior to acquiring software support, analysis and documentation were done manually, a time-consuming process.

      Discussion

      Our study provides valuable insights on program implementation at a sample of leading ASPs across the United States. ASPs are expanding to new roles and personnel by integrating unit-based pharmacists and multidisciplinary clinical teams. IT is both assisting with traditional interventions and enabling new ones, but even leading programs struggle to use technology optimally for data analytics because of limited resources and interoperability issues.
      ASPs have traditionally operated within an organizational model in which a single physician or pharmacy champion is responsible for improving antibiotic prescribing at an institution. Our results suggest an evolving role for the ASP in empowering an array of physicians across disciplines and pharmacists across hospital units to champion stewardship program activities and objectives. Prior studies support the effectiveness of unit-based pharmacist implementation of ASP care bundles.
      • Gorman S.K.
      • Slavi R.S.
      Should traditional antimicrobial stewardship (AMS) models incorporating clinical pharmacists with full-time AMS responsibilities be replaced by models in which pharmacists simply participate in AMS activities as part of their routine ward or team-based pharmaceutical care?.
      • Carreno J.J.
      • et al.
      Evaluation of pharmacy generalists performing antimicrobial stewardship services.
      • Wenzler E.
      • et al.
      An automated, pharmacist-driven initiative improves quality of care for Staphylococcus aureus bacteremia.
      As the new regulatory and accreditation requirements for hospital ASPs coincide with a looming shortage of ID–trained physicians,
      • Walensky R.P.
      • Del Rio C.
      • Armstrong W.S.
      Charting the future of infectious disease: anticipating and addressing the supply and demand mismatch.
      the role of non-ID-trained staff in performing traditional ASP activities is of interest. Our findings suggest that a “train the trainer” model was a successful strategy to enhance the ASP's impact at these medical centers. From a national policy perspective, ID physician and pharmacy professional societies may consider adopting a similar strategy to support a training infrastructure in which generalist physicians and pharmacists may receive competency training in ASP leadership and implementation to advance antimicrobial stewardship principles where ID–trained expertise is in short supply.
      IT for antibiotic stewardship was shown in a recent meta-analysis to improve antimicrobial use.
      • Baysari M.T.
      • et al.
      The effectiveness of information technology to improve antimicrobial prescribing in hospitals: a systematic review and meta-analysis.
      In our study, dedicated IT systems for stewardship facilitated clinical decision support and identification of opportunities for intervention and communication, and allowed for the development of novel strategies. Through real-time alerting of (1) critical microbiological results that necessitate escalation of therapy and (2) important ID syndromes that may warrant diagnostic interventions or specialist consultation, suboptimal management could be identified expediently. This allowed the ASP to more efficiently and effectively assist in guiding provider behavior, even when that behavior was not reduction or de-escalation of antimicrobial prescription, and was reportedly well-received by frontline providers. These findings underscore the importance of developing quality metrics that can capture appropriate or improved antibiotic use rather than merely decreases in antibiotic use and cost.
      Our data also highlight structural limitations with existing stewardship IT systems—specifically, the inability to generate meaningful outcomes data and the inability to interface effectively with other IT systems in the same institution, particularly the EHR. Dedicated IT support is recommended in national guidelines
      • Barlam T.F.
      • et al.
      Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.
      • Centers for Disease Control and Prevention
      Core Elements of Hospital Antibiotic Stewardship Programs.
      but is not explicitly addressed in proposed regulatory and accreditation requirements. Despite the successful deployment of dedicated software, our respondents continued to feel that there was limited support for data analysis, a finding that is consistent with a 2014 study of barriers to implementation.
      • Pakyz A.L.
      • et al.
      Facilitators and barriers to implementing antimicrobial stewardship strategies: results from a qualitative study.
      This limitation was a major barrier to tracking antibiotic use, delivering provider-specific feedback, and meaningful outcome reporting although programs were working toward developing this analytic capacity. Currently, the CDC's National Health Safety Network supports an Antimicrobial Use and Resistance module, which allows hospitals to voluntarily report antimicrobial use data. However, as of March 2017, only 251 facilities had submitted data.
      • Centers for Disease Control and Prevention
      National Healthcare Safety Network (NHSN): Surveillance for Antimicrobial Use and Antimicrobial Resistance Options.
      In June 2016 CMS proposed a rule for reporting hospital antimicrobial use data to the Hospital Inpatient Quality Reporting Program;
      • Federal Register
      Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; and Technical Changes Relating to Costs to Organizations and Medicare Cost Reports.
      however, our findings suggest that implementation would be challenging even at leading institutions.
      Although ASPs have been a recommended best practice for more than a decade, their formal integration into the hospital quality and patient safety movement is a new development. We found important parallels between the strategies used by ASPs and hospital infection control programs for affecting behavior change and in developing program structure but also a need for independent resources. Given the increasing regulatory and accreditation focus on ASPs, ASP leadership will likely face increasing demands from hospital leadership to report process measures and outcomes as well as negotiate for resources. CMS incentives linked to avoiding certain hospital-acquired infections and public reporting have positively affected leadership support for hospital infection control programs, though the effect of this intervention on outcomes remains controversial.
      • Hoff T.
      • et al.
      Making the CMS payment policy for healthcare-associated infections work: organizational factors that matter.
      • Lee G.M.
      • et al.
      Perceived impact of the Medicare policy to adjust payment for health care-associated infections.
      • Liu H.
      • et al.
      Impact of state reporting laws on central line-associated bloodstream infection rates in U.S. adult intensive care units.
      • McHugh M.
      • et al.
      Medicare's payment policy for hospital-acquired conditions: perspectives of administrators from safety net hospitals.
      While new regulatory incentives may improve hospital leadership support for ASPs, measurement of ASP–related quality measures and outcomes for public reporting requires further study and validation, particularly given the continued resource challenges for robust ASP–related data analysis reported here.

      Limitations

      One important limitation of this study was the focus on academic medical centers that were leaders in the ASP field. Our findings may not be representative of the experience in different hospital settings. Understanding barriers to hospitals with poorly functioning ASPs is an important area for future investigation. Another limitation is that our interviews focused on ASP physician and pharmacist leadership and did not include the perspective of other key stakeholders, such as hospital executives and prescribing clinicians. Additional qualitative research to understand the attitudes of these groups would further inform implementation strategies.

      Conclusion

      Our findings demonstrate the evolution of ASPs from a top-down structure to a more diffuse approach with multispecialty provider involvement and shared responsibility for antimicrobial prescribing under the ASP's leadership. Further study of the role and training required for non-ID physicians and pharmacists to perform stewardship activities and affect clinical outcomes is warranted. As IT systems for stewardship become more commonplace, technology-driven interventions may augment or even replace more traditional ASP strategies, in addition to enabling new ones. These perspectives will help ASPs in setting program priorities in an era in which quality metrics and regulatory and accreditation requirements are linked to successful ASP implementation.
      Funding. Funding for the study was provided by Gary Barnett, who had no role in study design, data collection, data analysis, or manuscript preparation.
      Acknowledgments. The authors acknowledge the study participants for their time and generosity in providing site visits and interviews.
      Conflicts of Interest. All authors report no conflicts of interest.

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      Biography

      Shashi N. Kapadia, MD, MS, is Instructor of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York City, and Instructor of Healthcare Policy and Research, Weill Cornell Medicine.
      Erika L. Abramson, MD, MS, is Associate Professor of Pediatrics, Weill Cornell Medicine, and Associate Professor of Healthcare Policy and Research, Weill Cornell Medicine.
      Eileen J. Carter, RN, PhD, is Assistant Professor of Nursing, Columbia University Medical Center School of Nursing and NewYork-Presbyterian Hospital, New York City.
      Angela S. Loo, PharmD, is Clinical Pharmacy Manager of Infectious Diseases, NewYork-Presbyterian Hospital/Weill Cornell.
      Rainu Kaushal, MD, MPH, is Chair of Healthcare Policy and Research, Weill Cornell Medicine.
      David P. Calfee, MD, MS, is Professor of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, and Professor of Healthcare Policy and Research, Weill Cornell Medicine.
      Matthew S. Simon, MD, MS, is Assistant Professor of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, and Assistant Professor of Healthcare Policy and Research, Weill Cornell Medicine.