Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship within Veterans Health Administration Emergency Department and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes

Abstract Background The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use, but evidence supporting safety are limited. We report the impact of Core Elements implementation within Veterans Health Administration sites. Methods A quasi-experimental controlled study assessed the effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARI). Outcomes included per-visit antibiotic prescribing, treatment appropriateness, potential benefits and complications of reduced antibiotic treatment, and change in ARI diagnoses over a 3-year pre-implementation and 1-year post implementation period. Logistic regression adjusted for covariates [OR (95% CI)] and a difference-in-differences analysis compared outcomes between intervention and control sites. Results From 2014-2019, there were 16,712 and 51,275 patient-visits in 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre-post implementation in intervention sites were 59.7% and 41.5%, respectively; in control sites they were 73.5% and 67.2%, respectively [difference-in-differences p<0.001]. The intervention site pre-post implementation odds ratio to receive appropriate therapy increased [1.67 (1.31, 2.14)] which remained unchanged within control sites [1.04 (0.91, 1.19)]. There was no difference in ARI-related return visits post-implementation [(-1.3% vs. -2.0%; difference-in-differences p=0.76] but all-cause hospitalization was lower within intervention sites [(-0.5% vs. -0.2%); difference-in-differences p=0.02]. The odds ratio to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention [1.27(1.21,1.34)] but not control [0.97(0.94,1.01)] sites. Conclusions Implementation of the Core Elements was associated with reduced antibiotic prescribing for uncomplicated ARIs and a reduction in hospitalizations. ARI diagnostic coding changes were observed.

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A Qualitative Study of Antibiotic Stewardship Implementation at Arizona Skilled Nursing Facilities

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.602 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s101-s101

Author(s):

Theresa LeGros ◽

Connor Kelley ◽

James Romine ◽

Katherine Ellingson

Keyword(s):

Nursing Homes ◽

Antibiotic Stewardship ◽

Population Level ◽

Skilled Nursing Facilities ◽

Care Transition ◽

Antibiotic Prescribing ◽

Nursing Facilities ◽

Skilled Nursing ◽

The Core ◽

Core Elements

Background: The CDC Core Elements of Antibiotic Stewardship (AS) include 7 evidence-based best practices adapted for a variety of healthcare settings, including nursing homes. We aimed to identify barriers and facilitators related to AS implementation in skilled nursing facilities (SNFs) within 18 months of the CMS mandate for AS implementation in SNFs, and to examine their relevance to the CDC’s Core Elements for Nursing Homes. Methods: We conducted 56 semistructured interviews with administrators, clinicians, and nonclinical staff at 10 SNFs in urban, suburban, rural, and border regions of Arizona. All interviews were recorded, transcribed, and imported into NVivo v12.0 software for constant comparative analysis by 3 researchers using a priori and emergent codes. After iterative coding, we confirmed high interrater reliability (κ = 0.8), finalized the code book, and used matrix coding queries to examine relationships and generate themes. Results: We identified 7 themes as “influencers” that were less (barrier) or more (facilitator) supportive of AS in SNFs. Intra- and interfacility communication were the most frequently described: respondents described stronger communication within the SNF and between the SNF and hospitals, labs, and pharmacies as critical to robust AS implementation. Other influencers included AS education, antibiotic tracking systems, SNF prescribing norms, human resources, and diagnostic resources. The Core Elements were reflected in all influencer themes except interfacility communication between SNFs and hospitals. Additionally, themes pertaining to systems emerged as critical to successful AS implementation, including the need to address: the interactions of multiple roles across the traditional SNF hierarchy, stewardship barriers from the lens of patient-level concerns (as opposed to population-level concerns), the distinction between antibiotic prescribing gatekeepers and stewardship gatekeepers, and care transition policies and practices. The Core Elements target many aspects of these systems themes—for example, they recognize the importance of creating a culture of stewardship. However, they do not address care transition policies or procedures beyond recommending that transfer-initiated antibiotics be tracked and verified. Conclusions: Because the interactions of various agents within and beyond the SNF can facilitate or inhibit stewardship in complex ways, our findings suggest the use of a systems approach to AS implementation that prioritizes communication within the SNF hierarchy, and between SNFs and hospitals, diagnostic facilities, and pharmacies. When followed, the CDC’s Core Elements can provide crucial guidance. However, SNFs need support to overcome the challenges of incorporating these elements into policy and practice. Additionally, more work is needed to understand and enhance stewardship-related care transition, which remains under-addressed by the CDC.Disclosures: NoneFunding: None

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Inpatient antibiotic utilization in the Veterans’ Health Administration during the coronavirus disease 2019 (COVID-19) pandemic

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1277 ◽

2020 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Thomas D. Dieringer ◽

Daisuke Furukawa ◽

Christopher J. Graber ◽

Vanessa W. Stevens ◽

Makoto M. Jones ◽

...

Keyword(s):

Antibiotic Use ◽

Veterans Health Administration ◽

Antibiotic Prescribing ◽

Veterans Health ◽

Health Administration ◽

Prescribing Practices ◽

Antibiotic Utilization ◽

Days Of Therapy

Abstract Antibiotic prescribing practices across the Veterans’ Health Administration (VA) experienced significant shifts during the coronavirus disease 2019 (COVID-19) pandemic. From 2015 to 2019, antibiotic use between January and May decreased from 638 to 602 days of therapy (DOT) per 1,000 days present (DP), while the corresponding months in 2020 saw antibiotic utilization rise to 628 DOT per 1,000 DP.

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Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1289 ◽

2020 ◽

pp. 1-8

Author(s):

James L. Lowery ◽

Bruce Alexander ◽

Rajeshwari Nair ◽

Brett H. Heintz ◽

Daniel J. Livorsi

Keyword(s):

Emergency Departments ◽

Respiratory Infections ◽

Antibiotic Use ◽

Veterans Health Administration ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Veterans Health ◽

Health Administration ◽

Urgent Care Centers ◽

Exacerbation Of Copd

Abstract Objective: Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs). Design: This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis. Results: There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001). Conclusions: Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

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Improving Patient Safety Through Antibiotic Stewardship: The Veterans Health Administration Leads the Way, Again

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2017.38 ◽

2017 ◽

Vol 38 (5) ◽

pp. 521-523 ◽

Cited By ~ 5

Author(s):

Arjun Srinivasan ◽

Lisa E. Davidson

Keyword(s):

Patient Safety ◽

Antibiotic Stewardship ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

The Way

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Antibiotic prescribing in mental health units across the Veterans’ Health Administration: How much and how appropriate?

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.432 ◽

2021 ◽

pp. 1-4

Author(s):

Jay J. Tieri ◽

Bruce Alexander ◽

Jason A. Egge ◽

Brett H. Heintz ◽

Daniel J. Livorsi

Keyword(s):

Mental Health ◽

Veterans Health Administration ◽

Accurate Diagnosis ◽

Antibiotic Prescribing ◽

Veterans Health ◽

Mental Health Clinicians ◽

Health Administration ◽

Major Area ◽

Mental Health Patients ◽

Tract Infections

Abstract We evaluated antibiotic-prescribing across 111 mental health units in the Veterans’ Health Administration. We found that accurate diagnosis of urinary tract infections is a major area for improvement. Because non–mental-health clinicians were involved in most antibiotic-prescribing decisions, stewardship interventions for mental health patients should have a broad target audience to be effective.

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An Intervention With Meaning

Crisis ◽

10.1027/0227-5910/a000433 ◽

2017 ◽

Vol 38 (6) ◽

pp. 376-383 ◽

Cited By ~ 2

Author(s):

Brooke A. Levandowski ◽

Constance M. Cass ◽

Stephanie N. Miller ◽

Janet E. Kemp ◽

Kenneth R. Conner

Keyword(s):

High Risk ◽

Qualitative Methodology ◽

Veterans Health Administration ◽

Veterans Health ◽

Safety Planning ◽

Health Administration ◽

Suicide Method ◽

Treatment Providers ◽

Interactive Nature ◽

Behavioral Health Treatment

Abstract. Background: The Veterans Health Administration (VHA) health-care system utilizes a multilevel suicide prevention intervention that features the use of standardized safety plans with veterans considered to be at high risk for suicide. Aims: Little is known about clinician perceptions on the value of safety planning with veterans at high risk for suicide. Method: Audio-recorded interviews with 29 VHA behavioral health treatment providers in a southeastern city were transcribed and analyzed using qualitative methodology. Results: Clinical providers consider safety planning feasible, acceptable, and valuable to veterans at high risk for suicide owing to the collaborative and interactive nature of the intervention. Providers identified the types of veterans who easily engaged in safety planning and those who may experience more difficulty with the process. Conclusion: Additional research with VHA providers in other locations and with veteran consumers is needed.

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